DocWire News interviews Geoffrey D. Barnes, MD, a vascular specialist and assistant professor of medicine at the University of Michigan Health System, about the most recent news and updates in the world of atherosclerotic disease, and particularly peripheral artery disease (PAD) and coronary artery disease (CAD).
An edited transcript of Dr. Barnes’ comments is included below.
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DocWire News: What currently are the most exciting developments in atherosclerotic disease?
Dr. Geoffrey Barnes: As a cardiologist and a vascular medicine specialist, I’m really excited about some of the advances in atherosclerosis, particularly some of the new treatments. We have been targeting cholesterol as well as thrombosis for a long time. We were really limited to just statin therapy and aspirin, or maybe clopidogrel, but now we have an increasing number of pharmaceutical therapies that can target cholesterol management, as well as multiple pathways of thrombosis. It’s really moved the field forward and given us many more treatment opportunities to improve care for our patients.
Are there any new regulatory changes or updates that have impacted the specialty?
For patients with PAD, there have been two recent regulatory changes or upcoming changes that I think are particularly impactful. The first has been a really thorough review of drug-coated balloons and the safety of using drug-coated balloons for patients with PAD. We got a signal a little over a year ago suggesting that there may have been increased harm with their use, but now a number of really large and well-conducted real-world studies have identified that use of drug-coated balloons is actually safe and highly effective for patients with PAD. The other area that I think is exciting and is sort of an emerging regulatory field is the use of dual-pathway inhibition, meaning targeting multiple pathways for thrombosis (a platelet pathway and coagulation pathway), for patients with PAD. We’ve had data for chronic PAD, but we also now have new data for patients who have recently undergone revascularization. So we’re waiting to see how the FDA will rule view that data on whether we can use dual-pathway inhibition, like a combination of a very low-dose factor 10a inhibitor like rivaroxaban in addition to aspirin to help prevent limb-related, events (as well as overall cardiovascular events).
What interesting new CAD/PAD therapies or guideline-recommended treatments being employed?
The guidelines that we use for PAD at this point are somewhat outdated. They’re almost five years old, and there’s been a lot of new evidence that has been published since then. I think the field really has moved beyond the current ACC/AHA guidelines for things like use of dual pathway inhibition, where we can use a low dose rivaroxaban in addition to aspirin for patients with stable PAD and perhaps even patients who have recently undergone revascularization. Similarly, we now have data on PCSK9 inhibitors to show how they can be beneficial for some of our highest-risk patients with PAD and polyvascular disease. As to whether there are also advantages for some of the other therapies, I’m thinking things like SGLT2 inhibitors and others remain to be incorporated into clinical practice and guidance.
How has the pandemic affected your practice and have you changed your care delivery because of it?
The COVID-19 pandemic has really caused me to rethink some of the ways I care for my patients. First, it’s made me even more thoughtful about the testing that I do, and in making sure that when I recommend a test to a patient it’s really necessary, since it means they’re going to have to interact with the health care system and all. I’ve been very thoughtful and judicious about when I employ ankle brachial indices, cross-sectional imaging with CT, and things like that. I need to justify that testing to my patient. And second, it’s opened up a new and creative way for us to interact with patients. How do we use tele-health to make patients feel more comfortable getting healthcare, thereby increasing our access and our reach to patients who have peripheral artery disease? It’s an under-recognized condition. Through telehealth, we’ve had to be creative about how we examine and consult with patients who have pad. We can’t do a physical exam. How do I find other ways to look for signs and symptoms? And then once a patient’s diagnosed, how do we follow them longitudinally? Can telehealth be a strategy for increasing that follow-up interaction and that ability to longitudinally follow patients? So those have been two really interesting developments and changes in my practice as a result of COVID-19.
What is your most important takeaway for practitioners in this subspecialty?
When it comes to atherosclerotic disease, I think it’s incredibly important that we as clinicians appreciate the prevalence that PAD has. It is often under-recognized and yet is an important risk factor for both morbidity and mortality in patients. So looking for PAD is so important, and once we find it, we now have even more options for treating those patients. […] Lastly, let’s think more creatively about how we care for our patients and about telehealth, which has really grown and expanded due to COVID-19. It offers us a great opportunity to use tele-health to increase access for our patients, identify their clinical problems, and help them with longitudinal management.