Letter by Malyar et al Regarding Article, “Supervised Exercise Versus Primary Stenting for Claudication Resulting From Aortoiliac Peripheral Artery Disease: Six-Month Outcomes From the Claudication: Exercise Versus Endoluminal Revascularization (CLEVER) Study”

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HomeCirculationVol. 126, No. 7Letter by Malyar et al Regarding Article, “Supervised Exercise Versus Primary Stenting for Claudication Resulting From Aortoiliac Peripheral Artery Disease: Six-Month Outcomes From the Claudication: Exercise Versus Endoluminal Revascularization (CLEVER) Study” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Malyar et al Regarding Article, “Supervised Exercise Versus Primary Stenting for Claudication Resulting From Aortoiliac Peripheral Artery Disease: Six-Month Outcomes From the Claudication: Exercise Versus Endoluminal Revascularization (CLEVER) Study” Nasser M. Malyar, MD, Matthias Meyborg, MD and Holger Reinecke, MD, PhD Nasser M. MalyarNasser M. Malyar Division of Angiology Department of Cardiology and Angiology University Hospital Muenster Muenster, Germany (Malyar, Meyborg, Reinecke) Search for more papers by this author , Matthias MeyborgMatthias Meyborg Division of Angiology Department of Cardiology and Angiology University Hospital Muenster Muenster, Germany (Malyar, Meyborg, Reinecke) Search for more papers by this author and Holger ReineckeHolger Reinecke Division of Angiology Department of Cardiology and Angiology University Hospital Muenster Muenster, Germany (Malyar, Meyborg, Reinecke) Search for more papers by this author Originally published14 Aug 2012https://doi.org/10.1161/CIRCULATIONAHA.112.100594Circulation. 2012;126:e101To the Editor:We read with great interest the eagerly awaited results of the first prospective, multicenter, randomized, controlled trial presented by Murphy et al1 comparing the benefit of optimal medical care, supervised exercise (SE), and stent revascularization (ST) on both walking outcomes and measures of quality of life in patients with claudication resulting from aortoiliac peripheral artery disease.The 6-month results of the Claudication: Exercise Versus Endoluminal Revascularization (CLEVER) study confirm unequivocally the beneficial effect of SE on walking measures. The authors concluded that SE shows a superior clinical benefit compared with ST. However, from our point of view, the presented data do not justify such a firm conclusion exclusively in favor of SE. Because the results of this trial will have a marked impact on the decision making of how to treat patients worldwide with claudication resulting from aortoiliac peripheral artery disease, one has to put the results of the CLEVER study in perspective: The main goal of current therapeutic strategies in patients with claudication resulting from aortoiliac peripheral artery disease is to release symptoms, regain lost ambulatory function, and to improve the overall quality of life. Even though the primary end point of the study (ie, improvement in peak walking time on a treadmill) was greatest for SE, it is noteworthy that the increase in treadmill performance is not equal to the patients' perceived performance in everyday life, and even less an improvement in quality of life. It is also essential to concern the value and efficacy of interventional measures in patients with claudication resulting from aortoiliac peripheral artery disease in terms of improvement of quality of life. In CLEVER, in terms of daily ambulatory activity as well as in most of the disease-specific quality of life measures, ST resulted in a significantly greater benefit than SE. At the 6-month follow-up, the claudication-free rate after ST was double the rate in the exercise group (42% versus 21%). Moreover, Walking Impairment Questionnaire (WIP) pain severity (P =0.014), WIQ walking distance (P =0.029), Peripheral Artery Questionnaire (PAQ) symptoms (P =0.002), and PAQ quality of life (P =0.006) were all significantly better in patients treated with ST.Another important aspect of a recommended intervention measure is its practicability in a broader spectrum of patients. SE requires consequent daily discipline, patience, strict adherence, and, of course, supervision of all these patients. Compared with one-stop ST, SE requires much greater logistic efforts. Moreover, SE is generally not reimbursed by health insurance companies despite substantial evidence for the clinical benefit of exercise programs. In this context, it would have been interesting to evaluate the effect of a combined strategy (ie, SE after ST). At our institution, we recommend exercise training (preferably supervised, but if not available, at least home-based exercise) to all our patients with manifest atherosclerotic disease, and of course also in those who have undergone ST.We congratulate Murphy and colleagues on this landmark study, but we conclude from CLEVER that ST is, in many ways, superior—and more practicable—than SE in most patients with claudication resulting from aortoiliac peripheral artery disease. Without a doubt, the pros and cons of available strategies should be elucidated for each individual patient, concerning her or his specific complaints and needs.Malyar Nasser M., MDMatthias Meyborg, MDHolger Reinecke, MD, PhD Division of Angiology Department of Cardiology and Angiology University Hospital Muenster Muenster, GermanyDisclosuresHolger Reinecke has received speaker honoraria from Sanofi-Aventis, Daiichi-Sankyo, The Medicine Company, Cordis, and Novartis. He has also received research grants from the German Federal Ministry for Education and Research (BMBF).