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Supervised Exercise Therapy and Revascularization for Intermittent Claudication: Network Meta-Analysis of Randomized Controlled Trials

Saratzis A, Paraskevopoulos I, Patel S, Donati T, Biasi L, Diamantopoulos A, Zayed H, Katsanos K
JACC: Cardiovascular Interventions 2019 12(12):1125-1136

Bibliography

PubMed
PMID 31153838
DOI
10.1016/j.jcin.2019.02.018
Funding
No dedicated study funding is reported beyond the authors' institutional affiliations. Dr Saratzis is partly funded by the National Institute for Health Research and the Academy of Medical Sciences.
Competing interests
Dr Saratzis receives honoraria and reimbursements from Amgen, Regeneron, and Medyria Medical. All other authors reported no relationships relevant to the contents of this paper. Medyria Medical makes vascular access devices, which is tangential to but not the direct subject of this analysis (supervised exercise therapy and angioplasty); disclosed here for transparency.

Study snapshot

DesignNetwork meta-analysis (systematic review plus Bayesian mixed-treatment comparison) of randomised controlled trials
ModelAdult humans with intermittent claudication due to peripheral arterial disease
Sample2,983 patients across 37 randomised controlled trials (83 treatment arms): best medical therapy alone (n=688), supervised exercise therapy (n=1,189), percutaneous angioplasty (n=511), angioplasty plus supervised exercise (n=395)
InterventionBest medical therapy (BMT) alone vs supervised exercise therapy (SET) vs percutaneous transluminal angioplasty (PTA) vs PTA combined with SET
DurationMean weighted follow-up 12 months (95% CI: 9-23 months)
EndpointsMaximum walking distance (MWD) at latest follow-up (primary); Patient-reported quality of life using validated tools (secondary, Cohen's D effect size)

What the study showed, in plain terms

This 2019 network meta-analysis pooled 37 randomised trials to work out the best first-line treatment for intermittent claudication, the leg pain caused by poor circulation from peripheral artery disease. Supervised exercise therapy alone (structured, supervised walking programmes) meaningfully improved walking distance and quality of life compared with medication alone. Combining supervised exercise with an angioplasty procedure to open the narrowed artery produced the biggest improvement of all, but supervised exercise by itself, without any procedure, still clearly outperformed medication-only management.

Key findings

  • Compared with best medical therapy (BMT) alone, supervised exercise therapy (SET) increased maximum walking distance by 180 metres (95% credible interval 130-230m), an 87% proportional gain.
  • Angioplasty (PTA) combined with SET produced the largest improvement: +290m versus BMT alone (95% CrI 180-390m, p<0.001), and +110m versus SET alone (95% CrI 16-200m, p<0.001).
  • Angioplasty alone, without supervised exercise, produced a smaller walking-distance benefit (+85m vs BMT) than supervised exercise alone (+180m vs BMT); exercise therapy outperformed the procedure on its own.
  • Quality-of-life improvement (Cohen's D) followed the same pattern: PTA+SET was superior to other strategies (Cohen's D 1.8 vs BMT), with SET alone also improving quality of life (Cohen's D 0.63 vs BMT).
  • The authors conclude PTA combined with SET is the optimal first-line strategy where a patient can exercise, but that SET should be part of standard care regardless of whether a procedure is also offered, and that angioplasty without supervised exercise support should be avoided where possible.

What this study can and cannot tell us

Patient-level data were not available, so the authors could not perform meta-regression to explore how individual patient characteristics (age, diabetes, disease severity) might modify the treatment effect, an important gap given other research shows diabetes can blunt exercise-related walking improvements.

None of the component trials were double-blinded or sham-controlled, an inherent limitation of comparing exercise and procedural interventions, and quality-of-life tools varied across trials (standardised here using Cohen's D for comparability). One included trial was rated high risk of bias on formal quality assessment; the rest were moderate risk. The lead author discloses paid relationships with a vascular device manufacturer and two pharmaceutical companies, a relevant transparency point when weighing this analysis's procedural (angioplasty) recommendations specifically.

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