Effect of physical inactivity and tobacco use on mortality and morbidity in revascularized patients with peripheral arterial disease: A nationwide cohort study

Importance Physical activity (PA) and tobacco use are key health behaviours in patients with peripheral arterial disease (PAD). Limited studies are available on effects of those behaviours in PAD after revascularization, including Asian countries where tobacco use is high. Objective To investigate the effects of PA and tobacco use on adverse clinical outcomes in patients with PAD after revascularization. Design Retrospective cohort study Setting Population-based study using the Korean National Health Insurance Service (NHIS) database Participants Patients who had received revascularization for PAD between 2010-2015 were included. They were categorized as active or inactive based on the number of days per week they engaged in PA and as current or non-tobacco users (self-report). Exposures PA and tobacco use. Main outcomes The primary outcome was all-cause mortality. Secondary outcomes included major adverse outcome (a composite of all-cause mortality, myocardial infarction, and stroke) and major adverse limb event (MALE, a composite of amputation and recurrent revascularization). Results The cohort comprised 8324 patients (mean age, 64.7 years; 76.9% male). Among them, 32.7% were inactive and 26.4% were tobacco users. Active patients had significantly better outcomes than inactive patients [all-cause mortality adjusted hazard ratio (adjHR) = 0.766 (0.685 – 0.855), major adverse outcome adjHR = 0.795 (0.719 – 0.878), MALE adjHR = 0.858 (0.773 – 0.953)]. Tobacco users had significantly poorer outcomes than non-users [all-cause mortality adjHR = 1.279 (1.124 – 1.456), major adverse outcome adjHR = 1.263 (1.124 – 1.418), MALE adjHR = 1.291 (1.143 – 1.458)]. Conclusions and Relevance Even after receiving revascularization for PAD, a sizable proportion of patients were inactive and used tobacco, leading to adverse clinical outcomes. These modifiable risk factors are systematically addressed in cardiac rehabilitation; in line with current guideline recommendations, more needs to be done to ensure cardiac rehabilitation participation in patients with PAD.