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Circulation. 2018 Apr 3;137(14):1435-1446. doi: 10.1161/CIRCULATIONAHA.117.032361. Epub 2018 Jan 12.

Association of Statin Dose With Amputation and Survival in Patients With Peripheral Artery Disease.

Author information

Division of Vascular Surgery and Endovascular Therapy, Department of Surgery (S.A., A.K., L.P.B.)
Emory School of Medicine, and Department of Epidemiology, Rollins School of Public Health (S.A., Z.O.B.), Emory University, Atlanta, GA.
Surgical Service Line (S.A., L.P.B.).
Division of Vascular Surgery and Endovascular Therapy, Department of Surgery (S.A., A.K., L.P.B.).
Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN (R.R.D.).
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (P.P.G.).
Division of Cardiology (P.W.F.W.).
Epidemiology and Genomic Medicine (P.W.F.W.), Atlanta VA Medical Center, Decatur, GA.



Statin dose guidelines for patients with peripheral artery disease (PAD) are largely based on coronary artery disease and stroke data. The aim of this study is to determine the effect of statin intensity on PAD outcomes of amputation and mortality.


Using an observational cohort study design and a validated algorithm, we identified patients with incident PAD (2003-2014) in the national Veterans Affairs data. Highest statin intensity exposure (high-intensity versus low-to-moderate-intensity versus antiplatelet therapy but no statin use) was determined within 1 year of diagnosis of PAD. Outcomes of interest were lower extremity amputations and death. The association of statin intensity with incident amputation and mortality was assessed with Kaplan-Meier plots, Cox proportional hazards modeling, propensity score-matched analysis, and sensitivity and subgroup analyses, as well, to reduce confounding.


In 155 647 patients with incident PAD, more than a quarter (28%) were not on statins. Use of high-intensity statins was lowest in patients with PAD only (6.4%) in comparison with comorbid coronary/carotid disease (18.4%). Incident amputation and mortality risk declined significantly with any statin use in comparison with the antiplatelet therapy-only group. In adjusted Cox models, the high-intensity statin users were associated with lower amputation risk and mortality in comparison with antiplatelet therapy-only users (hazard ratio, 0.67; 95% confidence interval, 0.61-0.74 and hazard ratio, 0.74; 95% confidence interval, 0.70-0.77, respectively). Low-to-moderate-intensity statins also had significant reductions in the risk of amputation and mortality (hazard ratio amputation, 0.81; 95% confidence interval, 0.75- 0.86; hazard ratio death, 0.83; 95% confidence interval, 0.81-0.86) in comparison with no statins (antiplatelet therapy only), but effect size was significantly weaker than the high-intensity statins (P<0.001). The association of high-intensity statins with lower amputation and death risk remained significant and robust in propensity score-matched, sensitivity, and subgroup analyses.


Statins, especially high-intensity formulations, are underused in patients with PAD. This is the first population-based study to show that high-intensity statin use at the time of PAD diagnosis is associated with a significant reduction in limb loss and mortality in comparison with low-to-moderate-intensity statin users, and patients treated only with antiplatelet medications but not with statins, as well.


amputation; hydroxymethylglutaryl-CoA reductase inhibitors; mortality; peripheral arterial disease; propensity score; vascular medicine; veterans health

[Available on 2019-04-03]

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