Guideline‐directed statin intensification in patients with new or worsening symptoms of peripheral artery disease

Abstract

Background

The ACC/AHA cholesterol guidelines recommend patients with peripheral artery disease (PAD) be treated with a moderate to high‐intensity statin. The extent to which patients with new or worsening PAD symptoms are offered guideline therapy is unknown.

Hypothesis

There is significant variability in rate of guideline‐directed statin intensification across clinical practices.

Methods

In the PORTRAIT registry, patterns of statin therapy were assessed in 1144 patients at 16 PAD specialty clinics between June 2011 and December 2015 before and after an evaluation for new or worsening claudication symptoms. We documented whether patients were treated with a guideline statin as well as the incidence of statin intensification. Statin intensification was defined as transitioning from no statin or low‐intensity statin to moderate or high‐intensity statin treatment. Patient factors associated with intensification were examined. Site and provider‐level variation in intensification was summarized using an adjusted median odds ratio (aMOR).

Results

Among 1144 patients, 810 (70.8%) were initially on guideline therapy compared to 334 (29.2%) that were not. In the latter, 103 (30.8%) received intensification following evaluation. Patients with typical symptoms displayed greater odds of intensification (OR 3.74; 95% CI: 1.23‐11.41) while older patients had lower odds of intensification (OR 0.60/decade; 95% CI: 0.41‐0.88). Site variability for statin intensification was observed across sites (aMOR = 3.15; 95% CI 1.22‐9.60, [P = 0.02]) but not providers (aMOR = 1.89; 95% CI 1.00‐3.90, [P = 0.14]).

Conclusions

Most patients evaluated at a PAD specialty clinic for new or worsening claudication symptoms arrived on guideline statin therapy. Only 31% not receiving appropriate therapy underwent statin intensification. These findings highlight an important opportunity to optimize medical therapy for patients with PAD.

1. INTRODUCTION

The primary goals in treating patients with symptomatic peripheral artery disease (PAD) are symptom relief and cardiovascular risk management, including use of a moderate to high‐intensity statin.1 Statins' ability to prevent cardiovascular death underscores their importance in PAD,2, 3, 4, 5, 6, 7 a highly prevalent atherosclerotic condition associated with an increased risk for adverse cardiovascular events (ie, myocardial infarction, stroke)8 exceeding that observed in coronary artery disease or cerebrovascular disease alone.9

The 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol guidelines have highlighted moderate to high‐intensity statins as a Class 1A recommendation for all patients with PAD.1 Despite these recommendations, statins are known to be under‐prescribed in clinical practice.10, 11 Evidence of suboptimal use of statins comes primarily from cross‐sectional,2, 3 procedural,12 and administrative databases.11 A unique opportunity to assess whether clinicians capitalize on key cardiovascular prevention strategies is at the time a patient with PAD presents to a specialty care clinic for further evaluation of new or worsening PAD symptoms. To date, however, little is known about optimization of guideline‐directed statin therapy in patients with new or worsening PAD symptoms.

Within the Patient‐Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories (PORTRAIT) registry—a prospective, multi‐center cohort of patients with PAD—we examined statin intensification rates (transitioning from no statin or low‐intensity statin to moderate or high‐intensity statin therapy) following PAD evaluation at a specialty clinic for new or worsening PAD symptoms. We then assessed patient factors associated with statin intensification after PAD evaluation as well as provider and site‐level variability in statin intensification. Describing the adoption of the ACC/AHA 2013 cholesterol guidelines in patients actively being evaluated at a PAD specialty clinic represents an important opportunity to identify subgroups that are currently not receiving optimal care and identify target areas to improve the quality of PAD care.

2. METHODS

2.1. Data source and study population

PORTRAIT is an international, prospective observational registry of patients referred to a specialty provider with a new diagnosis or exacerbation of PAD and its study design has been previously described.13 In brief, consecutive patients with objective evidence of symptomatic PAD were enrolled at 16 specialty PAD clinics between June 2011 and December 2015. All patients had a resting ankle‐brachial index (ABI) of ≤0.90 or a significant drop in post‐exercise ankle pressure of ≥20 mmHg. Patients with non‐compressible ankle‐brachial indices (ABI ≥ 1.30), lower‐limb revascularization in the 12 months prior to the PAD visit, and inability to provide written informed consent were excluded. Symptomatic PAD—typical and atypical—was defined using the San Diego intermittent claudication questionnaire, which describes the presence, location, and character of symptoms in each affected leg.14 Typical symptoms were recognized as lower extremity pain only on exertion, with resolution of discomfort within 10 minutes of rest. Atypical symptoms referred to extremity pain either at rest or on exertion that usually did not limit activity nor resolve within 10 minutes of rest.15, 16

Patients were enrolled at the PAD specialty clinic (general cardiology, interventional cardiology, interventional radiology, or vascular surgery) before a treatment plan was established. A baseline interview was conducted by trained personnel to obtain information about patients' quality of life, symptoms and functioning, and socio‐economic background. Clinical information (medical history, PAD history, and medications) was abstracted from patients' medical records using standardized case record forms. PORTRAIT investigators obtained IRB approval from all participating centers that recruited patients. Informed consent was obtained from all participants.

2.2. Statin treatment information and definition of statin intensification

Trained data abstractors gathered information from the medical records about whether or not patients were on a statin as well as statin dosing information before and no later than 1 month after their PAD evaluation (Figure 1). The categorization of statin intensity (low, moderate, high) is outlined in Supporting information Table S1. Being on guideline‐directed statin therapy, per the 2013 ACC/AHA cholesterol guidelines, was defined as being on a moderate to high‐intensity statin.1 Those patients without documentation of a statin prescription or prescribed a low‐intensity statin were classified as not being on guideline‐directed therapy. We defined statin intensification as transitioning from no statin or low‐intensity statin to moderate or high‐intensity statin therapy.

Figure 1.

Statin intensity data collection timeline

Patients with statin‐related contraindications to treatment, including those with prior adverse symptoms (ie, myalgia) or end‐organ injury were prospectively identified from the medical records if contraindications were described before or during the PAD evaluation. Patients were excluded from the denominator if such contraindications were documented.

2.3. Other measures

Information about patients' baseline PAD‐specific health status was collected using the Peripheral Artery Questionnaire (PAQ). The PAQ is a disease‐specific, sensitive, and validated health status measure that quantifies the following patient domains: physical function, symptoms, symptom stability, social limitation, treatment satisfaction, and quality of life. A total of 20 items are included in this multi‐dimensional health assessment, with one item identifying the symptomatic extremity and the remaining 19 comprised of variable Likert response scales. Applying a standardized scoring algorithm, a summary score (range of 0‐100, with higher scores indicating better health status) can be calculated by combining all scales except the Treatment Satisfaction and Symptom Stability Scales.17

2.4. Statistical analysis

Demographic and patient characteristics of those who were and were not on guideline‐directed statin treatment before and after the PAD evaluation were described using Student's t tests for continuous variables and nonparametric (χ ²) tests for categorical variables. Rates of statin intensification were calculated.

Next, a hierarchical multivariable logistic regression model with a random effect for site was constructed to identify correlates of statin intensification among those patients not on guideline‐directed statin treatment before their PAD specialty clinic visit. Per the number of patients that received statin intensification, we limited our model to 10 patient predictors based upon prior literature18, 19 and clinical relevance: age, sex, race (Caucasian vs non‐Caucasian), insurance status (any vs none), high‐school educational level or greater, presentation with typical claudication symptoms, history of depression, history of coronary artery disease (composite outcome of percutaneous coronary intervention, coronary artery bypass grafting, or myocardial infarction), patient health status as assessed by the Peripheral Artery Questionnaire (PAQ) summary score, and country of enrollment. Out of 16 participating sites, one was excluded from the model as all patients (n = 3) were already on guideline‐directed statin therapy prior to the PAD visit. To verify whether rates of statin intensification differed before vs after the release of the guideline statement in December 2013, a sensitivity analysis was performed comparing the proportion of patients intensified to guideline statin therapy before and after December 2013.

A median odds ratio (MOR) was calculated to quantify provider and site‐level variability in statin intensification among patients not on guideline‐directed statin treatment before their PAD specialty clinic encounter. A MOR estimates the average relative difference in two randomly selected patients receiving appropriate statin intensification when treated at two random sites or by two random providers.20 These were calculated as smoothed rates,21 adjusting for the volume of patient sites enrolled. Both unadjusted and adjusted rates were calculated. We treated site and provider as random effects through a three‐level adjusted logistic regression model (patient‐provider‐site). The adjusted model included the same covariates as described for the logistic regression model.

The percentage of missing data for baseline covariates was small (less than 1%), with only two data fields having missing information (symptom presentation and education level). Accordingly, no data imputation methods were used. All statistical analyses were performed using SAS version 9.4 software (SAS Institute Inc., Cary, North Carolina) and R version 3.3.2 software. Two‐sided P values less than 0.05 were considered statistically significant. The lead author had full access to all the data in the analysis and takes responsibility for its integrity and the data analysis.

3. RESULTS

A total of 1275 patients were enrolled in the PORTRAIT registry. Our analytical cohort consisted of 1144 patients, with an overview of exclusions provided in Figure 2.

Figure 2.

Patient flowchart (N = 1144)

3.1. Guideline‐directed statin treatment before and after PAD evaluation

Of 1144 patients with a new diagnosis or exacerbation of PAD, 810 (71%) were on guideline‐directed statin treatment before their initial PAD evaluation. Before the PAD evaluation, as compared with those who were not on guideline‐directed statin therapy, patients who were on guideline therapy were more likely to have completed high school and to be of non‐white race. They were also more likely to have a history of dyslipidemia, tobacco abuse, hypertension, diabetes, chronic kidney disease, myocardial infarction, heart failure, and stroke (Table 1).

Table 1.

Patient characteristics before and after initial visit (N = 1144)

	Guideline‐directed therapy before visit			Guideline‐directed therapy after visit
	Yes 810 (%)	No 334 (%)	P value	Yes 913 (%)	No 231 (%)	P value
Male	515 (63.6%)	213 (63.8%)	0.95	580 (63.5%)	148 (64.1%)	0.88
Age	67.8 ± 9.2	67.2 ± 9.7	0.31	67.4 ± 9.3	68.5 ± 9.7	0.12
White	395 (48.7%)	218 (65.3%)	<0.001	481 (52.7%)	132 (57.1%)	0.22
Insurance	587 (72.5%)	274 (82.0%)	<0.001	680 (74.5%)	181 (78.4%)	0.22
≥HS education	590 (73.6%)	198 (59.8%)	<0.001	633 (70.1%)	155 (67.4%)	0.43
Never smoker	81 (10.0%)	33 (9.9%)	<0.001	85 (9.3%)	29 (12.6%)	0.05
ABI	0.7 ± 0.2	0.7 ± 0.2	0.27	0.7 ± 0.2	0.7 ± 0.2	0.91
Typical symptoms	646 (85.9%)	260 (85.0%)	0.693	727 (86.7%)	179 (81.7%)	0.06
Rutherford category
Mild	170 (21.3%)	73 (23.4%)	0.259	199 (22.1%)	44 (19.5%)	0.33
Moderate	411 (51.4%)	152 (46.3%)		454 (50.4%)	109 (48.2%)
Severe	218 (27.3%)	103 (31.4%)		248 (27.5%)	73 (32.3%)
Pain‐free walking distance (meters)	138.2 ± 123.1	104.2 ± 149.5	0.04	126.2 ± 129.6	116.5 ± 161.8	0.66
History of PVI	108 (13.3%)	16 (4.8%)	<0.001	112 (12.3%)	12 (5.2%)	0.002
History of CHF	96 (11.9%)	27 (8.1%)	0.06	98 (10.7%)	25 (10.8%)	0.97
History of DLD	734 (90.6%)	203 (60.8%)	<0.001	794 (87.0%)	143 (61.9%)	<0.001
History of HTN	678 (83.7%)	244 (73.1%)	<0.001	744 (81.5%)	178 (77.1%)	0.13
History of TIA/CVA	110 (13.6%)	26 (7.8%)	0.005	114 (12.5%)	22 (9.5%)	0.21
History of MI	191 (23.6%)	35 (10.5%)	<0.001	193 (21.1%)	33 (14.3%)	0.02
History of PCI	216 (26.7%	42 (12.6%)	<0.001	219 (24.0%)	39 (16.9%)	0.02
History of CABG	192 (23.7%)	41 (12.3%)	<0.001	197 (21.6%)	36 (15.6%)	0.04
History of CKD	106 (13.1%)	23 (6.9%)	0.002	109 (11.9%)	20 (8.7%)	0.16
History of depression	107 (13.2%)	39 (11.7%)	0.48	112 (12.3%)	34 (14.7%)	0.32
History of DM	310 (38.3%)	84 (25.1%)	<0.001	324 (35.5%)	70 (30.3%)	0.14
Iliac disease	161 (42.7%)	94 (49.5%)	0.13	205 (44.9%)	50 (45.5%)	0.91
Femoral disease	266 (70.6%)	133 (70.0%)	0.89	316 (69.1%)	83 (75.5%)	0.19
Distal disease	43 (11.4%)	19 (10.0%)	0.61	50 (10.9%)	12 (10.9%)	0.99
PAQ summary score	48.9 ± 22.2	48.0 ± 21.4	0.49	49.4 ± 21.9	45.8 ± 22.1	0.02
LDL collected within 12 months prior to screening	519 (64.1%)	208 (62.3%)	< 0.001	599 (65.6%)	128 (55.4%)	< 0.001
LDL‐C level	86.6 ± 34.0	120.6 ± 40.1	<0.001	93.4 ± 38.9	110.0 ± 36.5	<0.001
Site characteristics non‐academic	80 (13.9%)	11 (6.5%)	0.03	81 (13.5%)	10 (6.8%)	0.03
Specialty			<0.001			0.05
Int. cardiology	387 (47.8%)	99 (29.6%)		404 (44.2%)	82 (35.5%)
Cardiology	95 (11.7%)	45 (13.5%)		102 (11.2%)	38 (16.5%)
Vascular surgery	252 (31.1%)	174 (52.1%)		328 (35.9%)	98 (42.4%)
Country			<0.001			0.21
United States	579 (71.5%)	170 (50.9%)		603 (66.0%)	146 (63.2%)
Netherlands	182 (22.5%)	130 (38.9%)		250 (27.4%)	62 (26.8%)
Australia	49 (6.0%)	34 (10.2%)		60 (6.6%)	23 (10.0%)

Abbreviations: CABG, coronary artery bypass graft surgery; CHF, congestive heart failure; CKD, chronic kidney disease; DLD, dyslipidemia; DM, diabetes mellitus; HTN, hypertension; Int. cardiology, interventional cardiology; LDL‐C, low density lipoprotein cholesterol; MI, myocardial infarction; PAQ, peripheral artery questionnaire; PCI, percutaneous intervention; PHQ‐8, personal health questionnaire depression scale; PVI, peripheral vascular intervention.

Results are expressed as n (%) or mean ± SD.

After the initial evaluation, 913 (79.8%) patients were on guideline‐directed statin therapy as opposed to 231 patients receiving low‐intensity (5.2%) or no statin therapy (14.9%). Patients receiving guideline‐directed statin therapy were more likely to have a history of dyslipidemia and myocardial infarction. While there was significant variability as to the treatment provider and site of patients originally presenting on guideline therapy, these differences were attenuated after initial evaluation. All other comorbidities and functional assessments were similar between groups (Table 1). Detailed statin intensity rates before and after PAD evaluation are provided in the Appendix S1, where the percentage of patients on varying statin intensity therapy before ([15.3%; no], [5.2%; low], [51.4%; moderate], and [28.1%; high]) and after ([24.6%; no], [4.5%; low], [43.8%; moderate], and [27.1%; high]) initial evaluation are described (Figure S1). Moreoever, statin intensification outcomes for patients initially not prescribed a statin (Figure S2) or a low‐intensity statin (Figure S3) are shown. Importantly, three out of five patients initially without a statin and all patients on a low‐intensity statin remained undertreated.

3.2. Patient correlates of statin intensification

A total of 334/1144 (29.2%) patients were eligible to receive statin intensification, as they either had not been on a statin before (n = 281) or were receiving a low‐intensity statin (n = 53). Among those eligible, an additional 103 (31%) received statin intensification during their PAD visit. Patients with typical (vs atypical) symptoms were more likely to receive statin intensification following PAD evaluation (OR 3.74, 95% CI 1.23; 11.41) while older patients had a lower odds of receiving guideline‐directed therapy (OR 0.60, 95% CI 0.41; 0.88) (Figure 3).

Figure 3.

Patient predictors of statin intensification after initial visit (N = 334)

3.3. Sensitivity analysis comparing statin intensification before and after guideline publication

Intensification rates were 45.9% (78 out of 170) before the release of 2013 ACC/AHA guidelines, whereas intensification rates only reached 15.2% (25 out of 164) following the publication of the guidelines (P test for trend <0.001).

3.4. Site and provider variability for statin intensification

For the 15 enrolling sites with documentation of statin intensification, rates of statin intensification ranged from 4% in the lowest performing site to 74% in the highest performing site (Figure 4). At the provider level, performance rates ranged from 4% to 77% (Figure S4). An unadjusted median odds ratio (MOR) was calculated for site variability (MOR 3.16 [95% CI 1.76; 7.69, P = 0.001]) and provider variability (MOR 2.06 [95% CI 1.00 (CI does not cross 1.00); 3.62, P = 0.04]) indicating that, for patients with identical characteristics presenting to one site vs another site (or one provider vs another), there was a 2‐ to 3‐fold odds of statin intensification. In the fully adjusted model for country and patient‐level factors, site variability remained significant (MOR 3.15 [95% CI 1.22; 9.60, P = 0.02]) while provider variability became non‐significant (MOR 1.89 [95% CI 1.00; 3.90, P = 0.14]).

Figure 4.

Heterogeneity of guideline‐directed statin intensification across PORTRAIT sites (patient N = 334)

4. DISCUSSION

While 7 out of 10 patients presenting to a specialty clinic for PAD evaluation were already on guideline‐directed statin therapy, only a third of those not on guideline therapy were appropriately treated at the time of their visit. Patients who were older were less likely to receive statin intensification, while individuals with typical symptoms were more likely to experience appropriate titration. Finally, there was substantial and unexplained site and provider‐level variability in statin intensification rates where as few as 4% and as many as 74% of patients had statin intensification across individual PORTRAIT sites. Site variability remained significant, even after adjusting for country and patient‐level factors. These findings highlight the importance of systematic efforts to monitor and titrate the intensity of statin therapy for patients with PAD.

Our findings represent a relatively unique observation in a referral population comprised of PAD patients. First, we present data on statin prescription and intensification prospectively collected in a multinational PAD cohort focusing on patients with new or worsening PAD symptoms only, which gave us a chance to review active prescription behavior across PAD specialty care providers. Prior evidence came primarily from retrospective and administrative studies: statins were shown to be markedly underused in mixed cohorts of patients with PAD.10, 11, 22 Statin prescription was only noted in 62% of the patient cohort studied in REACH,23 and Berger et al documented the persistent underuse of statins in PAD patients treated at multispecialty outpatient clinics.24 Finally, an analysis examining the adoption of the 2013 ACC/AHA cholesterol guidelines described an underwhelming trend of moderate and high‐intensity statin use in a heterogeneous cohort of patients with clinical atherosclerotic cardiovascular disease—a 62.7% prescription rate before guideline publication compared with 67.0% rate after publication—signifying only a modest improvement.25 Collectively, while these prior studies have historically emphasized an overall underuse of statins in patients with PAD, these data may reflect the practice of physicians who were not explicitly considering how best to manage patients with PAD. Our contemporary data offers insight into the current management of PAD patients as they present with new or worsening symptoms to a PAD specialty clinic and describes missed opportunities for statin intensification.

At the patient level, differences in clinical and socio‐demographic characteristics before and after specialist evaluation were similar. In line with prior work,26, 27 participants with a history of cardiovascular disease and risk factors were more likely to be appropriately treated with statin therapy. Among those eligible to receive statin intensification, patients that were older were less likely to be appropriately treated, and those with typical symptoms were more likely. While providers may display more caution when considering prescribing a moderate to high intensity statin in the elderly,28 recent evidence suggests that patients ≥75 years with clinical atherosclerotic cardiovascular disease are more likely to experience a survival benefit from guideline‐directed statin therapy compared with lower‐intensity statin treatment.29 Furthermore, all of the patients enrolled in PORTRAIT had confirmed PAD as verified by their ankle‐brachial index, and by definition share an increased cardiovascular risk,30 regardless of the nature of the symptomatology of their PAD. Accordingly, there was no clinical plausibility to preferentially offer guideline‐directed statin therapy to patients reporting typical (as opposed to atypical) symptoms.

When describing variability in statin intensification rates there was dramatic variability across sites, even after adjusting for country and patient‐level factors, that was largely unexplained. Prior work suggests that there are many reasons healthcare providers may miss the opportunity to appropriately intensify statin therapy11, 31: lack of clinician familiarity with the 2013 ACC/AHA guidelines,32 clinician disagreement with guideline recommendations,33 and medical and patient‐centered contraindications to statin eligibility.25 In the case of PAD, where multiple disciplines can be treating the disease, there may be an unclear understanding about who should be responsible for initiating the statin intensification for patients with PAD. Our sensitivity analyses comparing intensification rates before and after the release of the 2013 ACC/AHA guidelines were not reflecting an uptake of the guidelines following the publication, as intensification rates were actually lower following the release, further questioning provider familiarity and confidence in implementing the guidelines.34, 35 Importantly, our results showed that, even after taking into consideration patient‐specific and medical contraindications to statin therapy, there remained significant variability across sites.

Future work should further document additional barriers as it relates to guideline adoption in the context of PAD management. From a quality of care perspective, efforts should look into applying system‐based quality initiatives (eg, EMR alert systems) and programs that provide feedback on physicians' performance regarding guideline‐based medications as examples of strategies to optimize cardiovascular risk management in PAD. Our findings demonstrated there only to be significant site‐level variability, upholding the contemporary belief that an organizational practice culture that supports efforts to improve PAD care may be one of the most important factors influencing the quality of health care delivered and an important predictor of statin intensification.36 However, there are currently limited strategies to identify other key determinants of hospital‐level outcomes, and much of this variability in performance needs to be further explored.37, 38, 39

Our results must be interpreted in the context of the following potential limitations. First, while PORTRAIT is a prospective observational registry, there is potential for residual confounding. Therefore, there may be other reasons, besides those that we captured in the registry, that might help explain our findings: quality programs that centers had in place, physician and patient attitudes, and beliefs about statin intake. Second, even though patients were recruited from two non‐US countries ‐ the Netherlands and Australia—with different health care systems and policies, we verified that their national guidelines40 (Dr. John Beltrame, MD, personal communication, 2017) are consistent with the ACC/AHA guidelines as it concerns prescribing statin therapy in this high‐risk population. Third, the majority of centers that were recruiting patients for this study were selected based upon prior collaboration with the coordinating center and may not necessarily be representative for other PAD specialty clinics. Fourth, PORTRAIT enrollment occurred between 2011 and 2015 while the ACC/AHA guidelines were published in 2013, which could have explained a potentially slower uptake of the latest guidelines.41 Finally, while LDL‐C might be a significant contributor to providers' consideration of statin therapy titration, a large proportion of patients in our dataset did not have baseline LDL‐C levels recorded. These findings are relevant given prior recommendations of using statins to primarily target pre‐specified low‐density lipoprotein cholesterol concentrations instead of using statins more widely as a strategy to curb global cardiovascular risk.41

5. CONCLUSION

To conclude, real world data from the PORTRAIT study found that, while most patients referred to a specialty PAD provider were on an appropriate intensity statin, the majority of patients presenting off guideline‐directed statin therapy remain undertreated. This suggests that a substantial proportion of providers miss a significant opportunity to appropriately initiate or titrate statin therapy upon initial patient evaluation. The elderly were at increased risk of missing out on appropriate statin therapy while patients presenting with typical claudication symptoms were at lower risk, thereby highlighting significant treatment gaps in care. There was site‐level treatment variation, reflecting marked discrepancies in how health institutions address cardiovascular risk in the PAD population.

CONFLICTS OF INTEREST

Dr. P. Chan consults for Optum Rx. Dr. J. Spertus consults for Janssen, is involved in a research contract with Abbott Vascular, and holds the copyright for the PAQ questionnaire. Drs. D. Safley and W. Hiatt report no relevant financial disclosures. Dr. K. Smolderen receives research support by Merck and Boston Scientific.

Supporting information

FIGURE S1 Overview of patients (%) by statin intensity categories (no statin, low, moderate, high intensity) Before and after the initial PAD visit (N = 1144)

FIGURE S2 Prescription rates (%) and dosage for statins in patients without a statin prior to the initial PAD visit (n = 281)

FIGURE S3 Prescription rates (%) and dosage for statins in patients on a low‐intensity statin prior to the initial PAD visit (n = 53)

FIGURE S4 Heterogeneity of guideline‐directed statin intensification across PORTRAIT providers (patient N = 334)

TABLE S1 Statin potency definitions a low, moderate, and high‐intensity statin per the ACC/AHA 2013 cholesterol guidelines

Khariton Y, Patel KK, Chan PS, et al. Guideline‐directed statin intensification in patients with new or worsening symptoms of peripheral artery disease. Clin Cardiol. 2018;41:1414–1422. 10.1002/clc.23087