Dr Marc Bonaca Discusses the Significance of VOYAGER-PAD Trial Findings in Cardiology

March 28, 2020

VOYAGER-PAD helps to underscore that peripheral artery disease is a different disease state than coronary disease and different than stroke. Although they're all unified by an underlying biology of atherosclerosis, the character and the nature of that disease is different, said Marc P. Bonaca, MD, MPH, cardiologist and vascular medicine specialist who serves as the Executive Director of CPC Clinical Research and CPC Community Health.

VOYAGER-PAD helps to underscore that peripheral artery disease is a different disease state than coronary disease and different than stroke. Although they're all unified by an underlying biology of atherosclerosis, the character and the nature of that disease is different, said Marc P. Bonaca, MD, MPH, cardiologist and vascular medicine specialist who is affiliated with the University of Colorado School of Medicine and serves as the Executive Director of CPC Clinical Research and CPC Community Health.

Transcript

What findings from VOYAGER-PAD will be of greatest interest to cardiologists?

That's a great question. [With] VOYAGER-PAD really there are a couple of different audiences. There's the vascular practitioner—many of the vascular surgeons or interventional radiologists, they know that limb outcomes are really critical and the patency of the interventions are important. I think for them, the results will be compelling. I think for cardiologists there has been often the notion that patients with PAD [peripheral artery disease] are just sort of another high-risk subgroup of cardiology trials–so high risk of heart attack and stroke.

That is true, but I don't think in the cardiology community that things like acute limb ischemia are actually more frequent than heart attack and stroke, and just as bad or worse. So I think, for the broader community, understanding the epidemiology of this disease state—how high the risk is, the role that limb events play, the role of prothrombin thrombosis, and that will be really critical. Then I think the broad benefits of rivaroxabon for those events that are happening in this population will be a key observation.

VOYAGER helps to underscore that PAD is a different disease state than coronary disease and different than stroke. Although they're all unified by an underlying biology of atherosclerosis, the character and the nature of that disease is different. The population in VOYAGER is very sick—a lot of comorbidity. You can tell just from the mortality rate, how sick the population is, yet only 11% ever had a plaque rupture event or myocardial infarction.

So it's just very different than an ACS [acute coronary syndrome] population. I hope that VOYAGER is the first of many trials that will be dedicated to examining this distinct population and the relevant outcomes in this population to understand how to improve outcomes. There have been many cardiology trials and very few PAD trials, and even fewer that have been positive. So, I think we need more work in this field, and I hope VOYAGER leads the way for that.

If more patients with PAD could be successfully treated with medication, what would this mean for population health? What would it mean for savings in Medicare and health systems?

I think some of the key features for peripheral artery disease and for the clinicians that take care of it is that these patients, they're never seen once right, especially after intervention. These patients come back frequently with complications of the intervention, but also complications of their disease, including cardiovascular disease—it’s a very high risk group and that’s very costly. If you look at what's likely to happen to these patients, about 1 in 4 over the next 2 or 3 years needs another procedure on their limbs.

So medical therapies that reduce the risks not only of heart attack and stroke, but also of limb outcomes and the need for recurrent revascularisation have a big impact on cost. So, if you think of the cost benefits of preventing heart attack and stroke, this is about 2-fold that and an important driver of utilization in this population. So, I think any medical therapy that can reduce the need for recurrent limb interventions as well as other heart outcomes will save money.