Redefining ‘optimal medical therapy’ for vascular patients

Vascular and endovascular surgeons are frequently the only specialists other than primary care involved in the longitudinal care of their patients afflicted with clinically active vascular disease. As such, while scrutinizing the longitudinal and periprocedural outcomes in their patients, involvement in the management and counseling of the patients and their primary care providers in their cardiovascular risk factor modification has become a logical sequence of their overall care. The ongoing effort of understanding procedural and patient outcomes towards quality improvement has led to significant standardization of vascular interventions along the whole spectrum of care—from preoperative evaluation to postoperative surveillance.

The term “optimal medical therapy” (OMT) is often used within this framework to describe the standard pharmacological management of vascular patients. In practice, this equates to an antiplatelet agent, usually aspirin, and an aggressive first-line cholesterol-lowering medication, typically a statin. However, this one-size-fits-all approach to pharmacologic management of cardiovascular risk factors may be insufficient in improving long-term outcomes. Recent data from the Vascular Quality Initiative (VQI) raises concerns about the efficacy of the current paradigm. A recent analysis of survival rates for patients with chronic-limb threatening ischemia (CLTI), with 87% on aspirin and 86% on a statin, reported a dismal 30% five-year survival rate.¹ The majority of these patients were on OMT, yet their longevity was dismal. This raises the question: does the use of statins and aspirin represent OMT? Clearly, the definition of OMT needs to be reconsidered and possibly redefined to improve the longevity and outcomes of this patient population.

The primary cardiovascular risk factors that vascular surgeons and primary care physicians currently focus on include smoking, dyslipidemia (particularly hypercholesterolemia), hypertension, chronic kidney disease (CKD) and diabetes. In most practices, vascular surgeons may take a few minutes during a clinic visit to discuss with the patient a plan for individual risk-factor modification. The first focus is often on smoking. But smoking cessation is notoriously difficult—less than 10% of smokers who tried quitting were successful in 2022.² Many surgeons will offer general advice to patients to use the Quitline or a nicotine patch, but few are organized to provide targeted resources or a well-structured plan. Often, hypertension and CKD are acknowledged as they relate to periprocedural considerations, but the management is deferred to the patient’s medical providers. Similarly, lipid panels to evaluate whether patients are meeting their low-density lipoprotein (LDL) targets, and hemoglobin A1C levels may be noted, but these are also deferred to the patients’ medical providers. As such, though it may be noted, surgeons often fail to take a broader view of the patient’s metabolic health in their assessments and planning of their procedures.

Metabolic syndrome is one of the strongest predictors of cardiovascular outcomes—it is associated with higher rates of death, stroke and myocardial infarction.^3–5 These predictors, which can be considered to reflect “optimal metabolic health,” are quantified by five metrics: systolic blood pressure, fasting blood glucose, high-density lipoprotein (HDL) cholesterol levels, triglyceride levels and waist circumference (body mass index). Current cross-sectional population studies have identified that only 10–20% of the American population is metabolically healthy.⁶ The rates are alarmingly low, even in normal-weight individuals. A recent report calculated that 60% of the U.S. population would be eligible for “weight-loss drugs” like Ozempic.⁷ This would obviously be higher in patients with vascular disease.

To identify patients with metabolic syndrome, one of the most important things to quantify and target is insulin resistance. This hallmark of metabolic syndrome can be easily quantified in a clinic setting, either through a HOMA-IR (homeostatic model assessment for insulin resistance), which is based on fasting glucose and insulin, or through a surrogate marker like the triglyceride to high-density lipoprotein ratio (TG/HDL). A TG/HDL ratio above 1.5 suggests metabolic syndrome, and a ratio above 4 strongly predicts extensive coronary disease.⁸ Many patients have lipid panels readily available, and those that have significant insulin resistance or dyslipidemia—especially in the setting of early onset of cardiovascular disease or recurrent treatment failures—may benefit from targeted counseling. This centers on high-yield dietary changes and involves focus on simple, practical diet modifications to reduce refined carbohydrates and increase healthy fats and proteins. Most patients are very receptive to this type of counseling and, over time, with these changes can reverse their insulin resistance and stop their diabetes medications with simple lifestyle changes.⁹

As vascular surgeons have the privilege of following their patients longitudinally and have their patients as a captive audience, this presents a unique opportunity to make a greater impact on patient outcomes by altering their risk factors, including metabolic syndrome. Vascular surgeons are more than just proceduralists—they are advocates for comprehensive, long-term care and want their patients to have the best possible outcomes. We can work closely with primary care providers to better optimize medication management, particularly when LDL cholesterol and blood pressure targets are not met.

In addition, we can advocate to check lipoprotein(a) levels, especially in precocious patients with atherosclerosis or those with very positive family history, as 20% of the population will be positive, and it is becoming the most potent predictor of adverse outcomes.¹⁰ Patients can be counseled on dietary changes and we can advocate for daily exercise programs. Those who may benefit from GLP-1 receptor agonists and SGLT-2 inhibitors can be identified and referred to endocrinologists or other medical providers trialing these medications for our patients with diabetes and CKD in whom mortality and renal protective benefits have been demonstrated.¹¹

The key takeaway is that OMT needs to be redefined into a broader concept in patients with vascular disease, encompassing optimal metabolic health, rather than simply a checklist of medications. Managing vascular patients requires an integrated approach to address the underlying metabolic abnormalities that drive vascular disease progression. The focus should be expanded to include not only traditional medications but also lifestyle modifications, especially diet, exercise and emerging therapies that target the root causes.

Ultimately, by adopting a more comprehensive approach to managing vascular patients, both short-term outcomes and long-term survival rates can be improved.

There is much to gain for our patients as vascular specialists need to embrace this new path forward—one where the patient’s care provided is truly “optimal” in every sense of the word.

References

1. Levin, S. R. et al. Five Year Survival in Medicare Patients Undergoing Interventions for Peripheral Arterial Disease: a Retrospective Cohort Analysis of Linked Registry Claims Data. Eur. J. Vasc. Endovasc. Surg. 66, 541–549 (2023).
2. VanFrank, B. et al. Adult Smoking Cessation — United States, 2022. MMWR. Morb. Mortal. Wkly. Rep. 73, 633–641 (2024).
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4. Lakka, H.-M. The Metabolic Syndrome and Total and Cardiovascular Disease Mortality in Middle-aged Men. JAMA 288, 2709 (2002).
5. Sundström, J. et al. Clinical value of the metabolic syndrome for long term prediction of total and cardiovascular mortality: prospective, population based cohort study. BMJ 332, 878–882 (2006).
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7. Shi, I. et al. Semaglutide Eligibility Across All Current Indications for US Adults. JAMA Cardiol. (2024). doi:10.1001/jamacardio.2024.4657
8. Sultani, R. et al. Elevated Triglycerides to High-Density Lipoprotein Cholesterol (TG/HDL-C) Ratio Predicts Long-Term Mortality in High- Risk Patients. Hear. Lung Circ. 29, 414–421 (2020).
9. Unwin, D. et al. Insights from a general practice service evaluation supporting a lower carbohydrate diet in patients with type 2 diabetes mellitus and prediabetes: a secondary analysis of routine clinic data including HbA1c, weight and prescribing over 6 years. BMJ Nutr. Prev. Heal. 3, 285–294 (2020).
10. Nordestgaard, B. G. et al. Lipoprotein(a) as a cardiovascular risk factor: current status. Eur. Heart J. 31, 2844–2853 (2010).
11. Bhattarai, M. et al. Association of Sodium-Glucose Cotransporter 2 Inhibitors With Cardiovascular Outcomes in Patients With Type 2 Diabetes and Other Risk Factors for Cardiovascular Disease. JAMA Netw. Open 5, e2142078 (2022).

Sophie Wang, MD, Lars Stangenberg, MD, Glenn LaMuraglia, MD, and Allen Hamdan, MD, are Boston-based vascular surgeons.