Date of Award

January 2024

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Carlos Mena-Hurtado

Abstract

For patients with peripheral artery disease (PAD) and symptoms of intermittent claudication, treatment is geared towards maximizing health status and minimizing disease progression. We aimed to phenotype health status trajectories over the first 12 months of specialty care and examine factors associated with nonresponsiveness to treatment. Adults with new or worsening exertional leg symptoms presenting to vascular clinics in the United States, Australia, and Netherlands 2011-2015 were included. Patients with non-compressible ankle-brachial index, critical limb ischemia, barriers to consent, or lacking at least one follow-up interview were excluded. The Peripheral Artery Questionnaire (PAQ; range 0-100, higher = better) was used to capture disease-specific health status at baseline and during 3-, 6-, and 12-month follow-up visits. Latent trajectory modeling was used to delineate latent trajectory subgroups based on heterogeneity in longitudinal PAQ scores. Trajectories were classified as either "Responsive" or "Nonresponsive" by achievement of a mean ≥10-point improvement by the 12-month visit. Medical and psychosocial factors associated with a Nonresponsive trajectory were assessed by hierarchical multivariable logistic regression with a random effect for site. Of 2,917 eligible patients, 1,204 (41.3%) were included in the final cohort. The cohort was 62.5% male with a mean age of 67.5±9.4. Latent trajectory modelling revealed 5 subgroups: the High (n=401, 33.3%), Intermediate (n=400, 33.2%), Low (n=150, 12.5%), Sustained Response (n=98, 8.1%), and Transient Response (n=155, 12.9%) groups with +16.8, +59.4, +24.0, +8.6, and +7.6 score changes at 12-months, respectively. Following a Nonresponsive trajectory (Low or Transient Response) was associated with depressive symptom burden, however the effect did not remain significant after sequential adjustment for age, sex, race, country, baseline PAQ, and revascularization. Individuals with new or worsening PAD symptoms receiving specialty care exhibit diverse recovery trajectories. Roughly 1 in 4 experiences no meaningful improvement in health status at 12 months. Addressing psychosocial factors alongside medical comorbidities in an integrated care system may improve outcomes in PAD.

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This is an Open Access Thesis.

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