Abnormal ankle-brachial index and risk of cardiovascular or all-cause mortality in patients with chronic kidney disease: a meta-analysis

Association of Ankle-Brachial Index with Quality of Life and Survival Outcomes in Hemodialysis Patients

Background/Objectives: Ankle-brachial index (ABI) is frequently measured in hemodialysis patients due to their high cardiovascular risk, while its potential role as a screening tool for assessing overall physical function and health-related quality of life (QOL) remains unclear. This study aimed to evaluate the association of the ABI with QOL and survival in hemodialysis patients. Methods: This study included 346 hemodialysis patients, categorized into two groups based on their ABI (≤0.9 vs. >0.9). Clinical parameters, QOL (measured using SF-36 and KDQOL questionnaires), and survival outcomes were analyzed. Results: There were 66 (19.1%) patients with an ABI ≤ 0.9 in this study population. Patients with an ABI ≤ 0.9 exhibited significantly older ages, longer dialysis durations, higher prevalence of diabetes mellites and cardiovascular disease, elevated N-terminal pro-brain natriuretic peptide levels, and higher calcitriol use but lower phase angle, skeletal muscle mass index values, health-related QOL domains, and several kidney disease-specific QOL domains compared to those with an ABI > 0.9. Kaplan-Meier analysis revealed significantly higher cumulative mortality in the ABI ≤ 0.9 group (6.6 vs. 2.5 per 100 patient-years, p < 0.001). Conclusions: A low ABI is significantly associated with decreased QOL and higher mortality risk in hemodialysis patients. While traditionally used for PAD screening, the ABI may serve as a practical tool for predicting QOL decline and survival outcomes. Interestingly, the ABI was also linked to muscle attenuation and volume overload. ABI assessment could aid in early risk stratification and guide multidisciplinary interventions, including exercise programs, nutritional support, and cardiovascular risk management, to improve patient care and outcomes.

Skin Perfusion Pressure Outperforms Ankle-Brachial Index in Predicting Mortality and Cardiovascular Outcomes in Hemodialysis Patients

AIMS

Skin perfusion pressure (SPP) and ankle-brachial index (ABI) are useful in screening for peripheral arterial disease in patients undergoing hemodialysis (HD). We compared the prognostic abilities of the SPP and ABI in predicting the composite outcomes of mortality and atherosclerotic vascular events.

METHODS

This single-center prospective cohort study enrolled 258 patients undergoing HD. The patients with SPP and ABI measurements were divided into tertiles. Log-rank tests, Cox regression analyses, and discrimination parameters were used for comparisons.

RESULTS

Over a median follow-up period of 3.7 (1.4-5.0) years, 119 composite events were recorded. The incidence rates of composite events were 27.5, 13.3, and 9.1 per 100 person years, respectively, across the SPP tertiles (log-rank: p＜0.001), and 23.2, 13.2, and 11.6 per 100 person years across the ABI tertiles (p=0.003). With the 3rd tertiles as references, the 1st tertiles of the SPP and ABI were significantly associated with the composite outcome (adjusted hazard ratio [aHR]: 2.58, 95% confidence interval [CI]: 1.57-4.23 and aHR: 1.70, 95% CI: 1.06-2.73, respectively). Adding the tertiles of the SPP to a predictive model with established risk factors significantly improved the model performance. This improvement was larger than that of the ABI in terms of net reclassification (0.330 vs. 0.275) and integrated discrimination (0.045 vs. 0.012). Furthermore, in patients with a normal ABI, the 1st SPP tertile (＜71 mmHg) was significantly associated with the outcome (aHR, 1.97; 95% CI, 1.13-3.41) when compared to the 3rd tertile.

CONCLUSIONS

Even patients with a normal ABI have a poor prognosis if their SPP levels are low. SPP outperformed ABI in predicting mortality and cardiovascular outcomes in HD patients.

Association between ankle-brachial blood pressure index and erectile dysfunction in US adults: a large population-based cross-sectional study

Background

Erectile dysfunction (ED) is a very common condition among adult men and its prevalence increases with age. The ankle-brachial blood pressure index (ABPI) is a noninvasive tool used to assess peripheral vascular disease (PAD) and vascular stiffness. However, the association between ABPI and ED is unclear. We aimed to explore the association between ABPI and ED in the US population.

Methods

Our study used data from two separate National Health and Nutrition Examination Survey (NHANES) datasets (2001-2002 and 2003-2004). Survey-weighted logistic regression models were used to explore the association between ABPI as a continuous variable and quartiles with ED. We further assessed the association between ABPI and ED using restricted cubic regression while selecting ABPI thresholds using two-piecewise Cox regression models. In addition, we performed subgroup analyses stratified by BMI, race, marital status, diabetes, and hypertension.

Main outcome measure

ABPI was calculated by dividing the mean systolic blood pressure at the ankle by the mean systolic blood pressure at the arm.

Results

Finally, 2089 participants were enrolled in this study, including 750 (35.90%) ED patients and 1339 (64.10%) participants without ED. After adjusting for all confounding covariates, logistic regression analyses showed a significant association between ABPI and ED (OR=0.19; 95% CI, 0.06-0.56, P=0.01); with ABPI as a categorical variable, compared with the lowest quartile, the OR and 95% CI for the second quartile were 0.58 (0.34-0.97; P = 0.04).Besides, splines indicated that there was an L-shaped relationship between ABPI levels and the risk of ED. Piecewise Cox regression demonstrated the inflection point at 1.14, below which the OR for ED was 0.06 (0.02-0.20; P < 0.001), and above which the OR was 2.79 (0.17-4.53; P = 0.469).

Conclusion

In our study, lower ABPI was independently associated with ED risk. In addition, the lowest ABPI level associated with ED risk was 1.14, below this level, lower ABPI was associated with higher ED risk.

Predictive Value of the Ankle-Brachial Index for All-Cause and Cardio-Cerebrovascular Mortality

The present study explored the relationship between the ankle-brachial index (ABI) (>.9) and all-cause or cardio-cerebrovascular mortality. Participant details were obtained from the National Health and Nutrition Examination Survey 1999-2004. The association between baseline ABI and the risk of mortality was evaluated by a priori defined quartile categories and on a continuous scale (per .1-unit change) with Cox regression models adjusted for demographic and traditional risk factors. A total of 7087 individuals (age: 59.6 ± 12.8 years) were included; 3612 (51.0%) were male. After an average follow-up of 12.2 years, 1926 deaths occurred. Kaplan-Meier analysis showed that the lowest ABI quartile (<1.06) was associated with the highest risk of all-cause, cardio-cerebrovascular and cancer mortality (all P < .001). However, after adjusting for potential confounders, ABI ranging between 1.06 and 1.12 was associated with the lowest risk of all-cause mortality (hazard ratio .88, 95% confidence interval .78-1.00, P < .05) compared with the reference group (<1.06). Besides, splines showed the relationship was nonlinear (P < .05) and the inflection point was 1.11. In conclusion, the level of ABI associated with the lowest risk of all-cause mortality was 1.11, under which a lower ABI was independently associated with an increased risk of all-cause mortality.

Dose-Response Association of Low and Normal Ankle Brachial Index With the Risk of Cardiovascular Disease Morbidity and Mortality

We quantitatively evaluated the dose-response association of low and normal ankle brachial index (ABI) with the risk of morbidity and mortality from cardiovascular diseases (CVDs). PubMed, Embase, and Web of Science were systematically searched for cohort studies. Random effects or fixed effects models were used to estimate the pooled relative risks (RRs) and 95% confidence intervals (95% CIs). Generalized least squares regression was used to assess study-specific dose-response associations per 0.1 ABI decrease. Restricted cubic splines were used to evaluate linear or nonlinear trends. Twelve cohort studies (57 031 participants) were included in this meta-analysis. For low vs normal ABI levels, the pooled RRs were 2.03 (95% CI, 1.72-2.41; I² = 52.9%; p_{heterogeneity}=0.030) and 2.29 (95% CI, 1.98-2.64; I² = 39.5%; p_{heterogeneity} =0.158) for CVD morbidity and CVD mortality, respectively. For per 0.1 ABI decrease from 1.40 the risk for CVD morbidity and CVD mortality increased by 8% (1.08, 95% CI 1.04-1.11) and 11% (1.11, 95% CI 1.07-1.15), respectively. Restricted cubic splines showed inverse linear associations for CVD morbidity and CVD mortality. As a non-invasive index, lower ABI was significantly associated with the increased risk of morbidity and mortality from CVDs in an inverse linear manner.

Accuracy of Ankle-Brachial Index, Toe-Brachial Index, and Risk Classification Score in Discriminating Peripheral Artery Disease in Patients With Chronic Kidney Disease

The accuracy of ankle-brachial index (ABI) and toe-brachial index (TBI) in discriminating lower extremity peripheral artery disease (PAD) has not been evaluated in patients with chronic kidney disease (CKD). We measured ABI, TBI, and Doppler ultrasound in 100 predialysis patients with CKD without revascularization or amputation. Leg-specific ABI was calculated using higher systolic blood pressure (SBP) in posterior tibial or dorsalis pedis artery divided by higher brachial SBP; alternative ABI was calculated using lower SBP in posterior tibial or dorsalis pedis artery. PAD was defined as ≥50% stenosis detected by Doppler ultrasound. PAD risk classification score was calculated using cardiovascular disease risk factors. The area under the curve (AUC, 95% confidence interval [CI]) for discriminating ultrasound-diagnosed PAD was 0.78 (0.69 to 0.87) by ABI, 0.80 (0.71 to 0.89) by alternative ABI, and 0.74 (0.63 to 0.86) by TBI. Sensitivity and specificity were 25% and 97% for ABI ≤0.9, 41% and 95% for alternative ABI ≤0.9, and 45% and 93% for TBI ≤0.7, respectively. AUC (95% CI) of PAD risk classification score was 0.86 (0.78 to 0.94) with sensitivity and specificity of 95% and 60% for risk score ≥0.10, 76% and 76% for risk score ≥0.25, and 43% and 95% for risk score ≥0.55. Combining risk score with ABI, alternative ABI, and TBI increased AUC (95% CI) to 0.89 (0.82 to 0.96), 0.89 (0.80 to 0.98), and 0.87 (0.78 to 0.96), respectively. In conclusion, current ABI and TBI diagnostic criteria have high specificity but low sensitivity for classifying PAD in patients with CKD. PAD classification risk score based on cardiovascular disease risk factors improves the accuracy of PAD classification.

Ankle-brachial index: more than a diagnostic test?

The ankle-brachial index (ABI) is the relationship between the systolic blood pressure taken at the ankle level and the brachial artery. A pathological ABI (<0.90 or >1.40) indicates the presence of peripheral artery disease (PAD). Many studies indicate the great utility of this test in the diagnosis of PAD due to its ease of use, reproducibility, low cost, and high cost-effectiveness. This evaluation can be directly correlated with cardiovascular morbidity and mortality; however, it has recently been confirmed that a low ABI can be a predictor of major cardiovascular events, as it is related to diabetes mellitus, chronic coronary disease, stroke, and more. The objective of this work was to review the current evidence on the importance of ABI in the diagnosis of PAD and its main role as a predictor of cardiovascular morbidity and mortality.

Vascular calcification progression in patients with end-stage chronic kidney disease

BACKGROUND

Intima media thickness (IMT), vascular calcifications and ankle-brachial pressure index (ABPI) were shown to be independent predictors of mortality in end-stage renal disease (ESRD) patients.

METHODS

Between January 2018 and March 2019, a physician-initiated, nonrandomized, prospective study was conducted. Carotid IMT, vascular calcifications analysis values and measurements of the ABPI, were made at baseline and after 1-year of follow-up.

RESULTS

A total of 284 patients, 152 patients with dialysis (100 hemodialysis (HD) and 52 CAPD (continuous ambulatory peritoneal dialysis)) and 132 patients with stage 4 chronic kidney disease (control group), were included (55% male, 67 [29-88] years). The values of carotid IMT at baseline were higher in the HD group than in the CAPD group (1.10±0.08 mm vs. 0.08±0.04 mm, P=0.004). Adragao and Kauppila scores were higher in the HD group than in the CAPD group (2.56±2.10 vs. 1.08±2.02, P=0.009; and 7.40±6.86 vs. 4.44±5.26, P<0.001; respectively). These differences remained after 1-year of follow-up. Pathological ABPI after 1-year follow-up was more prevalent in the HD group than in the CAPD or control groups (32.0% vs. 19.4% vs. 7.7%, respectively, P=0.042). Multivariate regression analysis revealed that age, gender, dialysis type and LDLc were independent predictors for carotid IMT increase; age, dialysis type and smoking for vascular calcifications increase on Adragao Score; and dialysis type on Kauppila Score. Only the dialysis type was the independent predictor for all vascular calcifications markers.

CONCLUSIONS

Dialysis, particularly HD, is an independent risk factor for cardiovascular calcification increase in ESRD patients.

CHA2DS2-VASc Score as a Predictor of Cardiovascular and All-Cause Mortality in Chronic Kidney Disease Patients

INTRODUCTION

Chronic kidney disease (CKD) is a risk factor for cardiovascular and all-cause mortality. Recognition of high-risk patients is important and could lead to a different approach and better treatment. The CHA2DS2-VASc score was originally used to predict cerebral infarction in patients with atrial fibrillation (AF), but it is also a useful predictor of outcome in other cardiovascular conditions, independent of AF. Therefore, the aim of our research was to assess the role of CHA2DS2-VASc score in predicting cardiovascular and all-cause mortality in CKD patients.

METHODS

Stable nondialysis CKD patients were included. At the time of inclusion, medical history data and standard blood results were collected and CHA2DS2-VASc score was calculated. Patients were followed till the same end date, until kidney transplantation or until their death.

RESULTS

Eighty-seven CKD patients were included (60.3 ± 12.8 years, 66% male). Mean follow-up time was 1,696.5 ± 564.6 days. During the follow-up, 21 patients died and 11 because of cardiovascular reasons. Univariate Cox regression analysis showed that CHA2DS2-VASc score is a significant predictor of cardiovascular and all-cause mortality. In multivariate Cox regression analysis, in which CHA2DS2-VASc score, serum creatinine, urinary albumin/creatinine, hemoglobin, high-sensitivity C-reactive protein, and intact parathyroid hormone were included, CHA2DS2-VASc score was an independent predictor of cardiovascular (HR: 2.04, CI: 1.20-3.45, p = 0.008) and all-cause mortality (HR: 2.06, CI: 1.43-2.97, p = 0.001). The same was true after adding total cholesterol, triglycerides, and smoking status to both the analyses.

CONCLUSION

The CHA2DS2-VASc score is a simple, practical, and quick way to identify the risk for cardiovascular and all-cause mortality in CKD patients.

Predictive value of abnormal ankle-brachial index in patients with diabetes: A meta-analysis

AIMS

This meta-analysis aimed to examine the association of abnormal ankle brachial index (ABI) with adverse prognosis in patients with diabetes.

METHODS

We systematically searched PubMed and Embase databases from inception to October 31, 2020 for observational studies investigating the predictive utility of abnormal ABI in patients with diabetes. The normal ABI is usually defined by 0.9-1.3 or 1.4.

RESULTS

Data were collected from 9 studies involving 9673 patients. When compared with the reference normal ABI, abnormal ABI was associated with a higher risk of cardiovascular mortality (risk ratio [RR] 1.98; 95% confidence intervals [CI] 1.66-2.37), all-cause mortality (RR 2.12; 95% CI 1.81-2.49), and major adverse cardiovascular events ([MACEs] RR 2.37; 95% CI 1.73-3.26). Subgroup analysis indicated that the pooled RR of cardiovascular mortality was similar in individuals with abnormally low ABI (RR 1.98; 95% CI 1.64-2.39) or high ABI (RR 2.00; 95% CI 1.12-3.59).

CONCLUSIONS

Abnormal ABI independently predicts subsequent risk of cardiovascular or all-cause mortality and MACEs in patients with diabetes. However, the predictive role of abnormal ABI is largely dominated by the low ABI rather than the high ABI.

Combination of low ankle-brachial index and high ankle-brachial index difference for mortality prediction

Low ankle-brachial index (ABI) and high ABI difference (ABID) are each associated with poor prognosis. No study has assessed the ability of the combination of low ABI and high ABID to predict survival. We created an ABI score by assigning 1 point for ABI < 0.9 and 1 point for ABID ≥ 0.17 and examine the ability of this ABI score to predict mortality. We included 941 patients scheduled for echocardiographic examination. The ABI was measured using an ABI-form device. ABID was calculated as |right ABI-left ABI|. Among the 941 subjects, the prevalence of ABI < 0.9 and ABID ≥ 0.17 was 6.1% and 6.8%, respectively. Median follow-up to mortality was 93 months. There were 87 cardiovascular and 228 overall deaths. All ABI-related parameters, including ABI, ABID, ABI < 0.9, ABID ≥ 0.17, and ABI score, were significantly associated with overall and cardiovascular mortality in the multivariable analysis (P ≤ 0.009). Further, in the direct comparison of multivariable models, the basic model + ABI score was the best at predicting overall and cardiovascular mortality among the five ABI-related multivariable models (P ≤ 0.049). Hence, the ABI score, a combination of ABI < 0.9 and ABID ≥ 0.17, should be calculated for better mortality prediction.

Usefulness of the ratio of brachial pre-ejection period to brachial ejection time in prediction of cardiovascular and overall mortality in patients with acute myocardial infarction

Left ventricular systolic function is a good indicator of cardiac function and a powerful predictor of adverse cardiovascular (CV) outcomes. High ratio of pre-ejection period (PEP) to ejection time (ET) is associated with reduced left ventricular systolic function. Brachial PEP (bPEP) and brachial ET (bET) can be automatically calculated from an ankle-brachial index (ABI)-form device and bPEP/bET was recently reported to be a new and useful parameter of cardiac performance. However, there were no studies evaluating the utility of bPEP/bET for prediction of CV and overall mortality in patients with acute myocardial infarction (AMI). We included 139 cases of AMI admitted to our cardiac care unit consecutively. ABI, bPEP, and bET were obtained from the ABI-form device within the 24 hours of admission. There were 87 overall and 22 CV mortality and the median follow-up to mortality event was 98 months. After multivariable analysis, high bPEP/bET was not only associated with increased long-term CV mortality (hazard ratio (HR) = 1.046; 95% confidence interval (CI): 1.005–1.088; P = 0.029), but also associated with long-term overall mortality (HR = 1.023; 95% CI: 1.001–1.045; P = 0.042). In addition, age was also a significant predictor for CV and overall mortality after the multivariable analysis. In conclusion, bPEP/bET was shown to be a significant predictor for CV and overall mortality in AMI patients after multivariable analysis. Therefore, by means of this novel parameter, we could easily find out the high-risk AMI patients with increased CV and overall mortality.

Usefulness of Ankle-Brachial Index Calculated Using Diastolic Blood Pressure and Mean Arterial Pressure in Predicting Overall and Cardiovascular Mortality in Hemodialysis Patients

No study has investigated the predictive ability of ankle-brachial index (ABI) calculated using diastolic blood pressure (DBP) (ABIdbp) and mean arterial pressure (MAP) (ABImap) for overall and cardiovascular (CV) mortality in hemodialysis (HD) patients. Our study was aimed to investigate the issue. Two hundred and seven routine HD patients were enrolled. ABI values were measured by ABI-form device. During the follow-up period (122 months), 124 of the 207 patients (59.0%) died, and 59 deaths due to CV cause. Multivariate analysis showed that low ABIsbp, ABIdbp, and ABImap were all significantly associated with increased overall (p ≤ 0.015) and CV mortality (p ≤ 0.015) in whole study patients. A subgroup analysis after excluding 37 patients with ABIsbp < 0.9 or > 1.3 found ABIsbp and ABIsbp < 0.9 were not associated with overall and CV mortality. However, ABImap and ABIdbp < 0.87 were significantly associated with overall mortality (p ≤ 0.042). Furthermore, ABIdbp and ABIdbp < 0.87 were significantly associated with CV mortality (p ≤ 0.030). In conclusion, ABIsbp, ABIdbp, and ABImap were all useful in predicting overall and CV mortality in our HD patients. In the subgroup patients with normal ABIsbp, ABIsbp and ABIsbp < 0.9 were not useful to predict overall and CV mortality. Nevertheless, ABImap and ABIdbp < 0.87 could still predict overall mortality, and ABIdbp and ABIdbp < 0.87 could predict CV mortality. Hence, calculating ABI using DBP and MAP may provide benefit in survival prediction in HD patients, especially in the patients with normal ABIsbp.

Change in ankle-brachial index and mortality among individuals with chronic kidney disease: findings from the Chronic Renal Insufficiency Cohort Study

BACKGROUND

Patients with chronic kidney disease (CKD) have an increased risk of peripheral arterial disease (PAD). The ankle-brachial index (ABI), a noninvasive measure of PAD, is a predictor of adverse events among individuals with CKD. In general populations, changes in ABI have been associated with mortality, but this association is not well understood among patients with CKD.

METHODS

We conducted a prospective study of 2920 participants in the Chronic Renal Insufficiency Cohort Study without lower extremity revascularization or amputation at baseline and with at least one follow-up ABI measurement (taken at annual visits) during the first 4 years of follow-up. The ABI was obtained by the standard protocol.

RESULTS

In Cox proportional hazard regression analyses, we found a U-shaped association of average annual change in ABI with all-cause mortality. After adjusting for baseline ABI and other covariates, compared with participants with an average annual change in ABI of 0-<0.02, individuals with an average annual change in ABI <-0.04 or ≥0.04 had multivariable-adjusted hazard ratios (HRs) of 1.81 [95% confidence interval (CI) 1.34-2.44) and 1.42 (95% CI 1.12-1.82) for all-cause mortality, respectively. Compared with the cumulative average ABI of 1.0-<1.4, multivariable-adjusted HRs for those with a cumulative average ABI of <0.9, 0.9-<1.0 and ≥1.4 were 1.93 (95% CI 1.42-2.61), 1.20 (0.90-1.62) and 1.31 (0.94-1.82), respectively.

CONCLUSIONS

This study indicates both larger decreases and increases in average annual changes in ABI (>0.04/year) were associated with higher mortality risk. Monitoring changes in ABI over time may facilitate risk stratification for mortality among individuals with CKD.

Usefulness of ankle-brachial index calculated using diastolic blood pressure for prediction of mortality in patients with acute myocardial infarction

A low ankle-brachial index (ABI) calculated using systolic blood pressure (SBP) (ABIsbp) is associated with poor cardiovascular outcome in patients with acute myocardial infarction (AMI). ABI is always calculated using SBP clinically. However, there was no study investigating ABI calculated using mean artery pressure (MAP)(ABImap) and diastolic blood pressure (DBP)(ABIdbp) for mortality prediction in AMI patients. Therefore, our study was aimed to investigate the issue. 199 AMI patients were enrolled. Different ABIs were measured by an ABI-form device. The median follow-up to mortality was 64 months. There were 40 cardiovascular and 137 all-cause mortality. The best cutoff values of ABImbp and ABIdbp for mortality prediction were 0.91 and 0.78, respectively. After multivariate analysis, only ABIdbp and ABIdbp < 0.78 could predict cardiovascular mortality (P ≤ .047). However, all of six ABI parameters, including ABIsbp, ABImap, ABIdbp, ABIsbp < 0.90, ABImap < 0.91, and ABIdbp < 0.78, could predict all-cause mortality (P ≤ .048). In a direct comparison of six ABI models for prediction of all-cause mortality, basic model + ABIdbp <0.78 had the highest predictive value (P ≤ .025). In conclusion, only ABIdbp and ABIdbp < 0.78 could predict cardiovascular and all-cause mortality after multivariate analysis in our study. Furthermore, when adding into a basic model, ABIdbp < 0.78 had the highest additively predictive value for all-cause mortality in the six ABI parameters. Hence, calculation of ABI using DBP except SBP might provide an extra benefit in prediction of cardiovascular and all-cause mortality in AMI patients.

Long-Term Cilostazol Treatment and Predictive Factors on Outcomes of Endovascular Intervention in Patients with Diabetes Mellitus and Critical Limb Ischemia

INTRODUCTION

Despite improvements in endovascular interventions and multidisciplinary approaches, improving clinical outcomes and increasing limb salvage have become increasingly challenging. This prospective study investigated the associations of cilostazol treatment with clinical outcomes and predictive factors in patients with diabetes mellitus (DM) and critical limb ischemia (CLI) after endovascular revascularization of the affected angiosome.

METHODS

In this study, 172 consecutive patients with CLI (Fontaine levels III-IV) received cilostazol treatment after successful endovascular intervention according to the angiosome concept, and their primary patency rates and cardiovascular and amputation events during a 24-month follow-up period were assessed.

RESULT

The 24-month primary patency rate, mortality rate, and amputation rate were better in the patients under long-term cilostazol treatment (P < 0.001, P = 0.029, and P = 0.014). Weighted multivariate Cox analyses with a propensity scoring-based method showed that long-term cilostazol treatment [hazard ratio (HR) 0.2, 95% confidence interval (CI) 0.11-0.36, P < 0.001], direct revascularization (DR) (HR 0.46, 95% CI 0.28-0.74, P = 0.002), and supervised exercise (HR 0.4, 95% CI 0.24-0.66, P < 0.001) were independently associated with primary patency. Patients with lower-extremity amputation (LEA) had a higher risk of coronary artery disease (CAD) and mortality. Cellulitis and neuropathy were independently associated with LEA events (cellulitis: HR 2.89, 95% CI 1.66-5.05, P < 0.001; neuropathy: HR 2.2, 95% CI 1.31-3.7, P = 0.003).

CONCLUSION

Our results showed that patients with DM who received cilostazol treatment for more than 3 months had significantly better outcomes and decreased amputation and mortality rates after DR, and cellulitis and neuropathy were highly associated with the risk of limb loss. A large-scale randomized trial should be conducted in the future to confirm these results.

TRIAL REGISTRATION

Taipei Veterans General Hospital (TVGH) IRB no. 2013-08-020B. Registered 30 August 2013.

Comparison of different ankle-brachial indices in the prediction of overall and cardiovascular mortality

BACKGROUND AND AIMS

Low ankle-brachial index (ABI) calculated using systolic blood pressure (SBP) is associated with poor prognosis. However, there is no study assessing ABI calculated using mean artery pressure (MAP) and diastolic blood pressure (DBP) in predicting mortality.

METHODS

Two cohort populations were enrolled. The first population comprised 379 patients (106 patients with angiography-proved peripheral artery disease (PAD) and 273 relative normal patients) to evaluate the best cutoff values of ABImbp and ABIdbp for prediction of PAD. The second population included 941 patients undergoing echocardiographic examinations to assess the ability of different ABIs in predicting mortality. ABIs were measured using an ABI-form device.

RESULTS

The best cutoff values of ABImbp and ABIdbp for prediction of PAD were 0.92 and 0.88. In our second population, median follow-up to mortality was 93 months. There were 87 cardiovascular and 228 overall deaths. Multivariable analysis showed ABIsbp, ABImap, ABIdbp, ABIsbp <0.9, and ABImap <0.92 could predict overall and cardiovascular mortality (all p < 0.001). ABIdbp <0.88 could only predict CV mortality (p = 0.033). In a direct comparison of 6 multivariable models, the basic model consisting of significant variables in the univariable analysis plus ABImap <0.92 had the highest predictive value for overall and cardiovascular mortality (all p < 0.001).

CONCLUSIONS

In a direct comparison of 6 multivariable models, the basic model + ABImap < 0.92 was the best model in predicting overall and cardiovascular mortality. Hence, calculation of ABI using MAP except SBP might provide extra benefit in survival prediction.

Prognostic Value of Abnormal Ankle–Brachial Index in Patients With Coronary Artery Disease: A Meta-Analysis

The prognostic value of the ankle–brachial index (ABI) in patients with coronary artery disease (CAD) remains undefined. This meta-analysis sought to investigate the association of abnormal ABI and adverse outcomes in patients with CAD. PubMed, Embase, China National Knowledge Infrastructure, VIP, and Wanfang databases were comprehensively searched for studies published from inception to September 10, 2019. All observational studies investigating the association of abnormal baseline ABI and risk of major adverse cardiovascular events (MACE) or all-cause mortality were selected. Normal ABI is usually defined as between 0.9 and 1.4. The prognostic values were summarized by pooling risk ratio (RR) with 95% confidence intervals (CIs) for abnormal versus normal ABI category. Nine (9384 patients with CAD) studies were included. Abnormal ABI was independently associated with MACE (RR: 2.46; 95% CI: 2.02-2.99) and all-cause mortality (RR: 1.74; 95% CI: 1.32-2.30). Subgroup analysis showed that the pooled RR for MACE was 2.34 (95% CI: 1.73-3.16) for an abnormal low ABI. Abnormal ABI predicts MACE and all-cause mortality in patients with CAD, even after adjusting conventional confounding factors. However, the prognostic value of abnormal ABI is mainly dominated by a low ABI rather than a high ABI.

Usefulness of four-limb blood pressure measurement in prediction of overall and cardiovascular mortality in acute myocardial infarction

Four-limb blood pressure measurement could improve mortality prediction in the elderly. However, there was no study to evaluate whether such measurement was still useful in predicting overall and cardiovascular (CV) mortality in acute myocardial infarction (AMI). Two hundred AMI patients admitted to cardiac care unit were enrolled. The 4-limb blood pressures, inter-limb blood pressure differences, and ankle brachial index (ABI) were measured using an ABI-form device. The median follow-up to mortality was 64 months (25th-75th percentile: 5-174 months). There were 40 and 138 patients documented as CV and overall mortality, respectively. After multivariable adjustment, the ankle diastolic blood pressure (DBP) on the lower side, ABI value, ABI < 0.9, interarm DBP difference, interankle systolic blood pressure (SBP) and DBP differences, interankle SBP difference ≥ 15 mmHg, and interankle DBP difference ≥ 10 mmHg could predict overall mortality (P ≤ 0.025). The ankle DBP on the lower side, interankle DBP difference, and interankle DBP difference ≥ 10 mmHg could predict CV mortality (P ≤ 0.031). In addition, in the Nested Cox model, the model including the ankle DBP on the lower side and the model including interankle DBP difference had the best value for overall and CV mortality prediction, respectively (P ≤ 0.031). In AMI patients, 4-limb blood pressure measurement could generate several useful parameters in predicting overall and CV mortality. Furthermore, ankle DBP on the lower side and interankle DBP difference were the most powerful parameters in prediction of overall and CV mortality, respectively.

Relation between high Ankle-Brachial Index and cardiovascular outcomes in the general population and cardiovascular disease: a meta-analysis

INTRODUCTION

Conflicting findings have been reported on the association between high Ankle-Brachial Index (ABI) and cardiovascular outcomes. This meta-analysis aimed to assess the association of abnormally high ABI and cardiovascular outcomes in the general population and suspected or established cardiovascular disease (CVD) patients.

EVIDENCE ACQUISITION

A comprehensive literature search was conducted in PubMed and Embase databases through November 10th, 2018. All observational studies evaluating the association of high ABI with cardiovascular events including stroke, coronary heart disease (CHD), congestive heart failure, and composite of CVD/all-cause mortality in the general population and suspected or established CVD patients were included. We pooled risk ratios (RR) with 95% confidence intervals (CI) for the abnormally high ABI (> 1.3 or >1.4) versus the reference normal ABI category.

EVIDENCE SYNTHESIS

We identified 10 cohort studies enrolling 39,421 participants. A random effect model meta-analysis indicated that the pooled RR of composite of CVD/all-cause mortality was 1.07 (95% CI 0.83-1.38) in the general population and 1.26 (95% CI 1.03-1.55) in suspected or established CVD patients. Moreover, participants with abnormally high ABI did not increase the risk of stroke (RR 1.60; 95% CI 0.83-3.06) and CHD (RR 1.40; 95% CI 0.87-2.24) in the general population.

CONCLUSIONS

Abnormally high ABI appears to be associated with an increased risk of a composite of CVD/all-cause mortality in suspected or established CVD patients but not in the general population. However, additional well-designed studies are required to support the current findings.

Impact of peripheral artery disease on the quality of life of patients with diabetes mellitus

BACKGROUND

Diabetes Mellitus (DM) has become one of the main problems of health, which might lead to a series of complications, such as peripheral vasculopathy.

PURPOSE

The objectives of this study were to determine whether peripheral artery disease affects the quality of life and pain level and functionality of the foot in patients with DM.

METHODS

The sample consisted of 150 participants: with peripheral vasculopathy and DM, with DM, without peripheral vasculopathy, with neither DM nor peripheral vasculopathy. Questionnaires SF-12, EuroQol 5D, FFI, and the Manchester Foot Pain and Disability Index were used.

RESULTS

There were significant differences in the physical component of SF-12, in the visual health scale of EuroQol 5D and the functional component of the Manchester Foot Pain and Disability Index the best score was obtained by group C.

CONCLUSION

Peripheral vasculopathy influences the quality of life of patients with DM and causes functional limitations.

Cardiovascular changes in patients with mild-to-moderate chronic kidney disease compared with healthy subjects: a 5-year follow-up study

BACKGROUND

There is limited knowledge about how cardiovascular parameters change over time in patients with mild-to-moderate chronic kidney disease (CKD). We studied several cardiovascular biomarkers over a 5-year period in patients with mild-to-moderate CKD and in healthy controls.

METHODS

Fifty-four patients with CKD stages 2-3 and 54 controls were included. The CKD patients were closely monitored and well controlled for hypertension and other cardiovascular risk factors. Ambulatory blood pressure (BP) monitoring, ankle-brachial index (ABI), carotid and cardiac ultrasound (including measurement of the left ventricular mass index (LVMI)), and biochemical analyses were evaluated.

RESULTS

Renal function decreased in both groups, with no significant difference in the change over time. In the CKD patients, none of the BP variables increased over time, but in the controls, average 24-h and daytime systolic BP increased significantly. ABI increased slightly in the CKD patients (P<0·001), but not in the controls (P = 0·963), and phosphate had a significant positive effect on ABI. Although in the CKD patients, there was no significant increase over time in common carotid artery diameter (P = 0·274), there was a small but significant increase in the controls (P = 0·001). LVMI increased significantly over time in both groups.

CONCLUSIONS

In our study of patients with mild-to-moderate CKD, the progression of cardiovascular changes over time was relatively slow. Good BP control and treatment of other risk factors may have contributed to slow the progress of cardiovascular involvement, which emphasizes the importance of dedicated care in this population.

Atherosclerosis in Chronic Kidney Disease: More, Less, or Just Different?

Patients with chronic kidney disease (CKD) are at an increased risk of premature mortality, mainly from cardiovascular causes. The association between CKD on hemodialysis and accelerated atherosclerosis was described >40 years ago. However, more recently, it has been suggested that the increase in atherosclerosis risk is actually observed in early CKD stages, remaining stable thereafter. In this regard, interventions targeting the pathogenesis of atherosclerosis, such as statins, successful in the general population, have failed to benefit patients with very advanced CKD. This raises the issue of the relative contribution of atherosclerosis versus other forms of cardiovascular injury such as arteriosclerosis or myocardial injury to the increased cardiovascular risk in CKD. In this review, the pathophysiogical contributors to atherosclerosis in CKD that are shared with the general population, or specific to CKD, are discussed. The NEFRONA study (Observatorio Nacional de Atherosclerosis en NEFrologia) prospectively assessed the prevalence and progression of subclinical atherosclerosis (plaque in vascular ultrasound), confirming an increased prevalence of atherosclerosis in patients with moderate CKD. However, the adjusted odds ratio for subclinical atherosclerosis increased with CKD stage, suggesting a contribution of CKD itself to subclinical atherosclerosis. Progression of atherosclerosis was closely related to CKD progression as well as to the baseline presence of atheroma plaque, and to higher phosphate, uric acid, and ferritin and lower 25(OH) vitamin D levels. These insights may help design future clinical trials of stratified personalized medicine targeting atherosclerosis in patients with CKD. Future primary prevention trials should enroll patients with evidence of subclinical atherosclerosis and should provide a comprehensive control of all known risk factors in addition to testing any additional intervention or placebo.

Ankle-brachial index, arterial stiffness, and biomarkers in the prediction of mortality and outcomes in patients with end-stage kidney disease

BACKGROUND

Although ankle-brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) are significant predictors of major adverse cardiovascular event (MACE), their prognostic value in association with biomarkers has not been fully evaluated in patients with end-stage kidney disease (ESKD).

HYPOTHESIS

We hypothesized that ABI/baPWV would provide better prognostic value independent of biomarkers in ESKD patients.

METHODS

This study included 104 ESKD patients treated with maintenance hemodialysis who underwent ABI and baPWV examinations and laboratory tests, including brain-natriuretic peptide, high-sensitive cardiac troponin T (hs-cTnT), and high-sensitive C-reactive protein (hs-CRP). MACE was defined as a composite event of all-cause death, acute coronary syndrome, and stroke.

RESULTS

During a mean follow-up of 3.6 ± 1.7 years, a total of 51 MACE were observed. The independent factors associated with MACE were age >75 years (adjusted hazard ratio [HR], 2.15; P < .05), abnormal ABI (adjusted HR, 2.01; P < .05), left ventricular ejection fraction (LVEF) <50% (adjusted HR, 3.33; P < .001), the upper tertile of hs-cTnT (adjusted HR, 2.77; P < .05), and hs-CRP (HR, 1.96; P < .05). However, baPWV did not remain as an independent predictor of MACE in the entire cohort and also in patients without abnormal ABI. The combination of predictors improves the predictive value of MACE, providing increased HR with 4.00 for abnormal ABI + hs-CRP, 4.42 for abnormal ABI + hs-cTnT, and 7.04 for abnormal ABI + LVEF <50% (all P < .001).

CONCLUSION

Abnormal ABI is a robust predictor of MACE independent of biomarkers and their combination provides better risk stratification compared with a single predictor in ESKD patients.

Value of the arterial stiffness index and ankle brachial index in subclinical atherosclerosis screening in healthy community-dwelling individuals

BACKGROUND

Carotid intima media thickness (cIMT) and the carotid plaque score (cPS) are valid markers for detecting subclinical atherosclerosis. Evaluation of ASI and ABI for detection of atherosclerosis is assessed in this study. Finding a model to see which individual has a risk of having atherosclerosis, so those people can be further assessed by invasive but more accurate atherosclerosis detection methods like angiography is another objective of this study.

METHODS

Data of 212 healthy community-dwelling subjects, consisting of carotid duplex records, ASI and ABI measurements, certain laboratory tests, and related cardiovascular disease (CVD) risks were analyzed for correlations.

RESULTS

The ABI was independently associated with high cPS. Age, hypertension and Waist circumference are determinants of subclinical atherosclerosis as in high cIMT and high cPS.

CONCLUSIONS

The use of the ASI cannot replace carotid ultrasound in detecting subclinical atherosclerosis because it is not independently associated with high cIMT and cPS while ABI can be used in detection of high cPS in healthy community-dwelling individuals. Public health policies to encourage weight reduction and treating hypertension can help prevention of subclinical atherosclerosis in healthy community-dwelling individuals. Models consist of age, body compositions like waist circumference and hypertension history can be used in further assessment of atherosclerosis.