Prognostic value of functional performance for mortality in patients with peripheral artery disease

The calf muscle strength correlation with the severity of ischemia and outcomes in patients with chronic lower limb ischemia

OBJECTIVE

The association between peripheral arterial disease (PAD) as one of the chronic vascular diseases with decreased muscle endurance of the lower limbs has been reported in many studies. This study evaluated the correlation between calf strength measures with disease severity and its outcomes in patients with chronic limb ischemia.

PARTICIPANTS

This study was conducted on 53 patients with chronic limb ischemia referred to the Department of Vascular Surgery Taleghani Hospital, affiliated to Shahid Beheshti University of Medical Sciences between October 2020 and November 2021.

DESIGN

The strength measurements included the dorsiflexion strength (DFS) and plantar flexion strength (PFS) of the affected limbs, which were measured using a newly developed dynamometer. Disease severity evaluated with angiography and outcomes were evaluated in all patients for three months.

RESULTS

The mean age was 64.51 ± 9.3 years. The mean DFS and PFS were 13.55 ± 4.24 kg and 20.1 ± 8.29 kg, respectively. The need for invasive intervention was required in 42 (79.2%) patients. Amputation was performed in 21(39.6%). The multivariate analysis showed chronic limb ischemia severity (B: 7.11, 95% CI: 11.74, -2.46, P: 0.001), involvement level (B: 2.53, 95% CI: 4.03, -1.02, P: 0.042) and outcome type (B: 2.66, 95%CI: 4.22, -1.08, P: 0.039) were significantly related to DFS. The chronic limb ischemia severity (B: 3.89, 95%CI: 6.14, -1.64, P: 0.002) and level of involvement (B: 2.11, 95%CI: 3, -1.01, P:0.047) were significantly associated with PFS.

CONCLUSION

Our study showed that PFS and DFS were lower in patients with severe forms of chronic limb ischemia and those with simultaneous involvement of both above and below knee. DFS in patients requiring amputation was significantly lower than patients who did not require amputation during three months follow-up.

Cutting-edge European guidelines for managing lower extremity peripheral arterial disease - Featuring selected insights on PAD management

The new guidelines for the management of peripheral arterial and aortic diseases (PAAD) from the European Society of Cardiology and endorsed by the European Society of Vascular Medicine (ESVM), emphasize on a comprehensive and multidisciplinary approach focusing on prevention, diagnosis, treatment, and follow-up of patients with a wide range of PAAD, including lower extremity peripheral arterial disease (PAD). The aim of this summary, focusing on PAD and coordinated by the Young Academy of ESVM, is to provide young angiologists with the fundamental principles of these guidelines and to assist them in navigating their everyday clinical practice. PAD diagnosis relies on objective evaluation of flow/oxygen reduction at rest, with arterial ultrasound as the first imaging modality to confirm the presence of arterial lesions. The main goals of PAD management are not only to improve functioning and prevent the occurrence of adverse events at the lower limb level, but also to reduce the overall atherosclerotic burden and achieve the general well-being of patients. To this end, traditional and nontraditional cardiovascular risk factors need to be properly addressed through lifestyle changes and tailored drug therapies. For patients with exertional limb symptoms, supervised exercise training is recommended. Interventional treatment is indicated for limb salvage in patients with chronic limb threatening ischemia and may also be discussed in a multidisciplinary setting in less severe patients with persisting symptoms and reduced quality of life after a minimum period of optimal medical treatment including exercise therapy. For trainees or young specialists in Angiology/Vascular Medicine, these guidelines provide essential elements to improve patient management, encourage interdisciplinary collaboration, and ensure an integrated approach to vascular diseases.

A Randomized Control Trial Investigating the Effect of Different Treatment Strategies on Mitochondrial Function in Peripheral Arterial Disease: A Study Protocol

Peripheral arterial disease encompasses different clinical symptoms, depending on the severity of the disease. In early stages, a walking-induced pain, known as intermittent claudication, is the leading clinical symptom. Repeating cycles of ischemia and reperfusion induce a typical myopathy, with mitochondria playing the key role within this pathophysiological condition. The aim of this study is to further evaluate the effects of different treatment strategies on mitochondrial function and overall cardiovascular outcomes within a randomized controlled trial. After inclusion, patients will be randomized into different study groups. Study group 1 will receive conservative treatment, while study group 2 will receive revascularization of underlying atherosclerotic lesions. Additionally, a healthy control group will be included. Muscle biopsies will be obtained from ischemic and nonischemic muscle regions, being defined by the anatomic localization of the atherosclerotic lesion, before initiation of treatment as well as after a time interval of 12 wk. Mitochondrial function and content will be evaluated using high-resolution respirometry and citrate synthase activity measurements. Cardiovascular outcomes will be determined by established protocols. This study is registered on ClinicalTrials.gov-NCT05644158. This study aims to gain further insights into the exact pathophysiological mechanism underlying mitochondrial dysfunction in peripheral arterial disease. The potential effects of mitochondrial regeneration within ischemic muscle regions following a conservative treatment approach will be compared to those reported after revascularization procedures. Additionally, correlation with cardiovascular outcome parameters and in vivo methods will provide a comprehensive approach to this research question.

Development and feasibility testing of a new device for home-based leg heat therapy in patients with lower extremity peripheral artery disease

People with symptomatic lower extremity peripheral artery disease (PAD) suffer from severe leg pain, walking impairment, and reduced quality of life, but few effective treatments are available. Emerging evidence suggests that regular heat therapy (HT) may improve cardiovascular and physical function in patients with PAD. However, the lack of accessible, practical modalities for unsupervised HT, especially for elderly individuals, has hindered clinical implementation. The goals of this study were to design and assess the feasibility of a portable leg HT system for elderly patients with PAD. Building on a cryotherapy water-circulating device used in sports recovery, we developed a new prototype system consisting of a single-touch controller unit integrating a heater, water pump, and air pump, and leg sleeves with inner-layer water-circulating pads and an outer layer of inflatable bladders. The system was designed to ensure efficient heat transfer through gentle pneumatic inflation, adapting to varying limb dimensions. Safety features included temperature sensors with auto shut-off and a built-in timer. The prototype's feasibility and safety were evaluated in a single-arm pilot trial with six symptomatic patients with PAD, who were asked to apply the therapy daily for 90 minutes for 12 weeks. Primary outcomes included completion rates, safety, and device usability. Secondary outcomes were changes in blood pressure, 6-minute walk distance, calf strength, sit-to-stand performance, and quality of life. Participants underwent a 90-minute supervised treatment session with the prototype HT units to assess the acute physiological responses before starting the 12-week intervention. Leg HT gradually increased leg skin temperature from 33.8 ± 0.8°C to 38.7 ± 0.7°C at 90 minutes and reduced arterial blood pressure, with mean reductions of 13 mm Hg in systolic and 12 mm Hg in diastolic blood pressure after treatment. All participants completed the 12-week program without serious adverse events, indicating that leg HT is safe and well-tolerated. The 6-minute walk distance improved by an average of 32 m, coupled with increased calf muscle strength and reduced time for the sit-to-stand test. Improvements were also observed in self-reported walking speed and quality of life. This study represents the first step in developing a portable leg heating system for elderly patients with PAD, demonstrating that home-based leg HT is feasible and safe. However, further engineering refinements are needed to enhance portability, simplify application, and encourage long-term adherence. Developing methods to track compliance with the treatment regimen will be crucial for the success of this unsupervised, home-based therapy.

Single-centre, double-blinded, randomised placebo-controlled trial to determine the effect of a 12-week home-based programme of footplate neuromuscular electrical stimulation on walking capacity in people with peripheral artery disease: a protocol for the Foot-PAD trial

INTRODUCTION

Patients with peripheral artery disease (PAD) can experience intermittent claudication, which limits walking capacity and the ability to undertake daily activities. While exercise therapy is an established way to improve walking capacity in people with PAD, it is not feasible in all patients. Neuromuscular electrical stimulation (NMES) provides a way to passively induce repeated muscle contractions and has been widely used as a therapy for chronic conditions that limit functional capacity. Preliminary trials in patients with PAD demonstrate that stimulation of the leg muscles using a footplate-NMES device can be performed without pain and may lead to significant gains in walking capacity. Studies, to date, have been small and have not been adequately controlled to account for any potential placebo effect. Therefore, the current trial will compare the effect of a 12-week programme of footplate-NMES with a placebo-control on walking capacity (6 min walking distance) and other secondary outcomes in patients with PAD.

METHODS AND ANALYSIS

The Foot-PAD trial is a double-blinded, randomised placebo-controlled trial to determine the effect of a 12-week home-based programme of footplate NMES on walking capacity in people with PAD. This is a single-centre trial with numerous recruitment locations. A total of 180 participants with stable PAD and intermittent claudication will be randomly assigned (1:1 ratio) to receive either footplate-NMES (intervention condition) or footplate-placebo (control condition) for two 30 min periods each day for 12 weeks. The footplate-NMES device will deliver stimulation sufficient to induce contraction of the leg muscles and repeated plantar and dorsiflexion at the ankles. The footplate-placebo device will deliver a momentary low-intensity transient stimulation that is insufficient to induce contraction of the leg muscles. Outcomes will be assessed at baseline (week 0), mid-intervention (week 6), postintervention (week 12) and 6 weeks after the completion of the intervention (week 18). The primary outcome is walking capacity at week 12, measured as maximum walking distance during the 6 min walk test. Secondary outcomes will include pain-free walking distance during the 6 min walk test; pain-free and maximum walking time during a graded treadmill walking test; disease-specific quality of life (Intermittent Claudication Questionnaire), self-reported walking impairment (Walking Impairment Questionnaire) and accelerometer-derived physical activity levels. Exploratory outcomes will include the Ankle-Brachial Index; leg vascular function; perception of device-use experience and symptom monitoring throughout the trial using the Claudication Symptom Instrument and a pain Visual Analogue Scale.

ETHICS AND DISSEMINATION

The Foot-PAD trial has received ethics approval from the Human Research Ethics Committees of Queensland Health Metro North Hospital and Health Service (78962) and the University of the Sunshine Coast (A21659). Regardless of the study outcomes, the study findings will be published in peer-reviewed scientific journals and presented at scientific meetings.

TRIAL REGISTRATION NUMBER

ACTRN12621001383853.

Saving Legs & Lives: the efficacy of a community-based cardiovascular rehabilitation programme versus usual care on exercise capacity and quality of life in patients who have undergone lower limb revascularisation for peripheral arterial disease-protocol for a single-centre randomised-controlled trial

INTRODUCTION

Peripheral artery disease (PAD) is an atherosclerotic condition characterised by stenosis or occlusion of the arteries in the lower limbs. Patients with PAD commonly report intermittent claudication (leg pain/discomfort) during physical activities, which significantly limits the ability to walk and perform activities of daily living. Supervised exercise training is an effective therapy that can improve walking capacity in people with PAD. Emerging evidence also suggests that supervised exercise therapy following lower limb revascularisation can further enhance walking capacity when compared with revascularisation alone. However, access to dedicated exercise programmes for patients with PAD is limited in most countries, and there is a need to test the efficacy of alternative rehabilitation strategies and referral pathways. This randomised-controlled study aims to assess the efficacy of a cardiovascular rehabilitation (CR) programme versus usual care on walking capacity and quality of life in patients who have undergone lower limb revascularisation for PAD.

METHODS AND ANALYSIS

This will be a single-centre, prospective, parallel group, randomised-controlled trial. Sixty-six participants who have undergone a lower limb revascularisation procedure for PAD, in the previous 12 months, will be randomly allocated to a CR programme or a usual care (control) group. The CR programme will include two supervised exercise sessions per week for 6 weeks primarily consisting of intermittent treadmill walking at a moderate exercise intensity and home-based walking advice. During the 6-week programme, participants will also attend one education seminar (5.5 hours) which will cover topics such as diet, medications, exercise training and lifestyle modifications for the management of cardiovascular diseases. The control group will receive usual care and medical advice from their local doctor and vascular surgeon. The primary outcome will be 6-min walk distance. Secondary outcomes include pain-free walking distance during the six-minute walk test, maximal and pain-free walking time during a graded treadmill walking test, cardiorespiratory fitness, self-reported walking capacity, disease-specific quality of life, and self-reported and objectively measured physical activity levels. Exploratory outcomes include brachial artery flow-mediated dilation, arterial stiffness, ankle-brachial blood pressure index and biomarkers of cardiovascular disease risk. Outcomes will be assessed at baseline (week 1), following the CR/usual care period (week 8) and again at 6-month follow-up (week 34).

ETHICS AND DISSEMINATION

This study has received ethics approval from the Human Research Ethics Committees of Queensland Health Metro North Hospital and Health Service (94155) and the University of the Sunshine Coast (S231914). Findings from this study will be disseminated in peer-reviewed journals and through national and international conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12623000190606.

Association between grip strength, walking pace and incident peripheral artery disease: A prospective study of 430,886 UK biobank participants

Background and aims

Patients with peripheral artery disease (PAD) presented overall muscle weakness and reduced physical performance. Previous study focused on the impact of muscle weakness on outcomes of established PAD, however the relationship between compromised muscle function and incident PAD remained unclear.

Methods

A prospective study involving 430,886 participants aged 40-69 y from UK biobank was conducted. The main outcome was incident PAD. Grip strength and walking pace were used as indicators for muscle function. Grip strength was measured using a Jamar J00105 hydraulic hand dynamometer, while walking pace was self-reported by the participants. Cox proportional hazard models were employed to investigate the relationship between grip strength, walking pace, and incident PAD.

Results

A total of 430,886 individuals were included in the final analysis. The mean age of the participants were 56.44 years, and 55.3 % were female. Over a median follow-up period of 13.81 years, 5,661 participants developed PAD. Higher grip strength, whether absolute or relative, exhibited a dose-dependent inverse association with incident PAD. Each 1 kg increment in absolute grip strength and each 0.01 kg/kg increase in relative grip strength were associated with reduced PAD risk by 2 % (HR: 0.98; 95 % CI [0.97-0.98]) and 83 % (HR: 0.17; 95 % CI [0.13-0.23]), respectively. Slow walking pace significantly correlated with increased PAD risk, while brisk walking pace was associated with decreased PAD risk.

Conclusion

Absolute grip strength, relative grip strength and walking pace were inversely associated with the risk of incident PAD.

Lifestyle factors as determinants of atherosclerotic cardiovascular health

A sedentary lifestyle, low levels of physical activity and fitness, poor dietary patterns, and psychosocial stress are strongly associated with increased morbidity and mortality from atherosclerotic cardiovascular disease (ASCVD). Conversely, engaging in regular physical activity, maintaining optimal fitness levels, adhering to a heart-healthy dietary pattern, effectively managing body weight, ensuring adequate sleep, implementing stress-reduction strategies, and addressing psychosocial risk factors are associated with a reduced risk of ASCVD. This comprehensive review synthesizes current evidence from large observational studies and randomized controlled trials on lifestyle factors as determinants of ASCVD health. It also briefly reviews mechanistic insights into how factors such as low shear stress, increased reactive oxygen species production, chronic inflammation, platelets and coagulation activation, endothelial dysfunction, and sympathetic hyperactivity contribute to the initiation and exacerbation of ASCVD risk factors. These include obesity, hyperglycemia, type 2 diabetes, hypertension, and dyslipidemia, subsequently leading to the development and progression of atherosclerosis, ultimately resulting in chronic ASCVD or acute cardiovascular events. To bridge the translational gap between epidemiologic and trial-based evidence and clinical practice, practical recommendations are summarized to facilitate the translation of scientific knowledge into actionable interventions to promote ASCVD health. Acknowledged is the gap between the evidence-based knowledge and adoption within healthcare systems, which remains a crucial objective in advancing cardiovascular health at the population level.

Systematic review and meta-analysis comparing the autogenous vein bypass versus a prosthetic graft for above-the-knee femoropopliteal bypass surgery in patients with intermittent claudication

OBJECTIVES

According to guidelines, the autogenous saphenous vein (ASV) is the preferred conduit for femoropopliteal bypass surgery in all patients with peripheral artery disease. However, in contrast to patients with critical limb ischemia (CLI), patients with intermittent claudication (IC) only, tend to have milder disease, and thus a prosthetic graft may be as good as a vein conduit. The objective of this study was to compare patency rates of the ASV and a prosthetic graft in femoropopliteal bypass surgery in patients with IC.

METHODS

A systematic literature search was performed in the PubMed, Embase, and Cochrane databases to identify randomized controlled trials comparing prosthetic graft versus ASV in patients with IC. Articles with a mixed IC and CLI study population were included if more than 50% of the study cohort was treated for IC. Primary analysis was performed on IC patients only. Secondary analysis was performed on the mixed group. The primary endpoint was short- and long-term patency and secondary endpoints were complications, limb salvage, and mortality.

RESULTS

In total, six studies with 524 patients were included. Only two studies reported solely on patients with IC. All these patients underwent above-the-knee bypasses and average patency rates at one and 5 years were 88% and 76% vs 81% and 68% in the ASV and the PTFE groups, respectively. One and five-year patency was not statistically different between the groups (OR 5.21; 95% CI 0.60-45.36 and OR 2.10; 95% CI 0.88-5.01). In a mixed population of patients with IC and CLI (84% IC patients), 1 year patency was comparable (OR 1.40; 95% CI 0.87-2.25). However, after a follow-up of over 3 years, this mixed group had significantly higher patency rates in favour of the ASV (OR 2.06; 95 % CI 1.30-3.26). Complication and amputation rates were comparable in both groups.

CONCLUSIONS

Limited data are available for patients receiving above-the-knee femoropopliteal bypass for intermittent claudication. The ASV remains the conduit of choice for femoropopliteal bypass surgery. However, the prosthetic conduit seems a feasible alternative for patients with intermittent claudication in whom the ASV is not present or unsuitable.

Blood Oxygen Level-Dependent MR Imaging of Lower Extremities in Peripheral Artery Disease and Its Correlation With Walking Performance

BACKGROUND

A noninvasive and reliable approach to quantitatively measure muscle perfusion of lower extremity is needed to aid the diagnosis and treatment of peripheral artery disease (PAD).

PURPOSE

To verify the reproductivity of using blood oxygen level-dependent (BOLD) imaging to evaluate perfusion in lower extremities, and explore its correlation with walking performance in patients with PAD.

STUDY TYPE

Prospective observational study.

SUBJECTS

Seventeen patients with lower extremity PAD (mean age: 67 ± 6 years, 15 males) and eight older adults (controls).

FIELD STRENGTH/SEQUENCE

Dynamic multi-echo gradient echo T2* weighted imaging at 3T.

ASSESSMENT

Perfusion was analyzed in regions of interest according to muscle groups. Perfusion parameters were measured, such as minimum ischemia value (MIV), time to peak (TTP), and gradient during reactive hyperemia (Grad) by two independent users. Walking performance experiments including short physical performance battery (SPPB) and 6-minute walk were tested in patients.

STATISTICAL TESTS

BOLD parameters were compared using Mann-Whitney U test and Kruskal-Wallis test. Relations between parameters and walking performance were assessed by Mann-Whitney U test and Spearman's correlation coefficient.

RESULTS

Good to perfect agreement was demonstrated for all perfusion parameters of interuser reproducibility, and the interscan reproducibility of MIV, TTP, and Grad was good. The TTP of the patients was longer than that of the controls (87.85 ± 38.85 s vs. 36.54 ± 7.27 s), while the Grad of patients was smaller (0.16 ± 0.12 msec/s vs. 0.24 ± 0.11 msec/s). Among PAD patients, the MIV was significantly lower in the low SPPB subgroup (score 6-8) than in the high SPPB group (score 9-12), and the TTP was negatively correlated with 6-minute walk distance (ρ = -0.549).

DATA CONCLUSION

BOLD imaging method had overall good reproducibility for the perfusion assessment of calf muscles. The perfusion parameters were different between PAD patients and controls, and were correlated with lower extremity function.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 2.

Exercise Therapy in the Management of Peripheral Arterial Disease

The incidence and prevalence of peripheral artery disease (PAD) are increasing globally and have a marked economic burden in the United States. The American Heart Association/American College of Cardiology guidelines recommend exercise therapy as a Class 1A, but its utilization remains suboptimal. This state-of-the-art review aims to provide a comprehensive review of the most updated information available on PAD, along with its risk factors, management options, outcomes, economic burden, and the role of exercise therapy in managing PAD.

Time-course evolution of functional performance during a 3-month supervised exercise training program in patients with symptomatic peripheral artery disease

INTRODUCTION

Functional performance is impaired in patients with peripheral artery disease (PAD). The effects of a supervised exercise training (SET) program on functional performance have yet to be clearly determined. The aim was to investigate the time-course evolution of functional performance during a 3-month SET program.

METHODS

Patients with chronic symptomatic PAD participating in a 3-month SET program were investigated. Six-minute walking distance (6MWD), the stair climbing test (SCT), and the Short Physical Performance Battery (SPPB) were assessed before SET, after the first and second months of SET, and following the SET program. The ankle- and toe-brachial indices were measured before and after the SET program.

RESULTS

Ninety patients with PAD (age 65.4 ± 10.2 years) were analyzed. The 6MWD significantly improved after the first (+7%, p ⩽ 0.001) and second months (+13%, p ⩽ 0.001) and following SET (+14%, p ⩽ 0.001) compared to before the SET program. The 6MWD significantly improved after the 2nd month (+6%, p ⩽ 0.001) and following SET (+7%, p ⩽ 0.001) compared to after the first month of the SET program. The SPPB score and SCT performance significantly improved after the first (SPPB score: +9%, p ⩽ 0.001; SCT: +17%, p ⩽ 0.001) and second months (SPPB score: +11%, p ⩽ 0.001; SCT: +24%, p ⩽ 0.001) and following SET (SPPB score: +12%, p ⩽ 0.001; SCT: +25%, p ⩽ 0.001) compared to before the SET program. No significant differences were observed following SET compared to the second month of the SET program. Vascular parameters did not change significantly.

CONCLUSIONS

A 3-month SET program improves several components of functional performance, and adaptations mainly occur during the 1st and 2nd months of the SET program.

Objective assessment of functional capacity in patients with peripheral artery disease: a narrative review

INTRODUCTION

Peripheral artery disease (PAD) patients with claudication symptoms exhibit impaired functional capacity, which has been associated with disease severity, worse quality of life and higher risk of cardiovascular events. Different tests have been used to assess functional capacity in PAD patients. Therefore, understanding the characteristics, strengths and limitations of these tests are important to support the choice of tests to be used in clinical practice.

AREAS COVERED

This review summarizes the main methods to assess functional capacity in PAD patients, discussing their psychometric properties, applications, and limitations.

EXPERT OPINION

Robust evidence supports the use of treadmill and six-minute walk tests in PAD patients, as their results are associated with clinically meaningful outcomes, adequate psychometric properties and are sensitive to effects of interventions. On the other hand, other functional tests (Shuttle-walk test, outdoor walking capacity test, timed-up and go, four-meter walk test, heel-rise test, short physical performance battery and modified physical performance battery) are related to activities of daily living and do not require sophisticated equipment and can be easily used in clinical practice. However, these other tests still need evidence regarding their clinical relevance, reliability, and ability to detect long-term intervention changes, providing further investigation directions.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Association between home-based exercise using a pedometer and clinical prognosis after endovascular treatment in patients with peripheral artery disease

BACKGROUND

Exercise therapy following endovascular treatment (EVT) is important for patients with peripheral artery disease (PAD); however, continuous exercise therapy is difficult to be performed in clinical practice. This study aimed to investigate the association between the implementation of home-based exercise using pedometers after EVT and 1-year clinical outcomes.

METHODS

This multicenter observational prospective cohort registry included patients with PAD complaining of intermittent claudication who underwent EVT for aortoiliac and/or femoropopliteal artery lesions between January 2016 and March 2019. Patients were instructed to perform home-based exercises using a specific pedometer after EVT. The study population was divided into good and poor recording groups according to the frequency of the pedometer measurements. The good recording group was defined as those who completed ≥50 % of the prescribed daily pedometer recording during the follow-up period. The poor recording group was defined as those with an inability to use a pedometer and/or who completed <50 % of the prescribed daily pedometer recordings. The primary outcome was 1-year major adverse events (MAE), defined as a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, target vessel revascularization, and major amputation of the target limb.

RESULTS

The mean age was 74.4 years; 78 % were male. A total of 623 lesions were analyzed (58.7 % aortoiliac, 41.3 % femoropopliteal). At 1 year, a lower cumulative incidence of MAE was observed in the good recording group compared to that in the poor recording group [10/233 (4.3 %) vs. 35/267 (13.7 %) patients, respectively; p < 0.001]. Multivariate Cox regression analysis showed that patients in the good recording group had a lower hazard ratio for 1-year MAE (0.33; 95 % confidence interval, 0.16-0.68; p = 0.004) than that in the poor recording group.

CONCLUSIONS

Good self-recording of pedometer measurements was associated with favorable prognosis in patients with PAD following EVT.

Frailty score and outcomes of patients undergoing vascular surgery and amputation: A systematic review and meta-analysis

INTRODUCTION

Frailty is associated with adverse postoperative health outcomes, including increased mortality, longer length of stay, higher rehospitalization, and other complications. There are many frailty assessment tools are to assess the level of frailty in vascular surgery patients. The aim of this study was to perform a systematic review and meta-analysis to assess the association between the frailty levels described by different frailty scores and adverse postoperative health outcomes among hospitalized vascular surgery patients and patients undergoing amputation.

METHODS

Studies utilizing frailty scores and similar frailty assessment tools to describe frailty and investigate the association between frailty and health outcomes were searched. The primary outcomes of this study were in-hospital mortality, postdischarge mortality, length of hospital stay, rehospitalization, and discharge location. Additional outcomes included postoperative myocardial infarction, postoperative renal failure, cerebrovascular accident and stroke, comorbidities, and estimated glomerular filtration rate (eGFR) levels. Joanna Briggs Institute (JBI) Critical Appraisal Tools were used for quality assessment.

RESULTS

In total, 24 studies with 1,886,611 participants were included in the final analysis. The overall results found that higher in-hospital mortality and postdischarge mortality were significantly associated with frailty. Frailty was also found to be significantly associated with a longer length of hospital stay, higher rehospitalization, and higher likelihood of non-home discharge. In addition, the results also showed that frailty was significantly associated with all kinds of comorbidities investigated, except chronic kidney disease. However, lower eGFR levels were significantly associated with frailty.

CONCLUSION

Among patients who underwent all types of vascular surgery and those who underwent amputations, assessment of frailty was significantly associated with adverse postoperative outcomes and multiple comorbidities.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=336374, identifier CRD42022336374.

Physical activity, cardiorespiratory fitness, and cardiovascular health: A clinical practice statement of the American Society for Preventive Cardiology Part II: Physical activity, cardiorespiratory fitness, minimum and goal intensities for exercise training, prescriptive methods, and special patient populations

The prescription of exercise for individuals with and without cardiovascular disease (CVD) should be scientifically-based yet adapted to the patient. This scientific statement reviews the clinical and physiologic basis for the prescription of exercise, with specific reference to the volume of physical activity (PA) and level of cardiorespiratory fitness (CRF) that confer significant and optimal cardioprotective benefits. Recommendations are provided regarding the appropriate intensity, frequency, and duration of training; the concept of MET-minutes per week; critical components of the exercise session (warm-up, conditioning phase, cool-down); methodologies for establishing the training intensity, including oxygen uptake reserve (V̇O2R), target heart rate derivation and rating perceived exertion; minimum and goal intensities for exercise training; and, types of training activities, including resistance training, adjunctive lifestyle PA, marathon/triathlon training, and high-intensity interval training. In addition, we discuss the rationale for and value of exercise training programs for patients with peripheral artery disease, diabetes mellitus, and heart failure.

Supervised exercise training in patients with lower extremity peripheral artery disease

Summary: The optimal first line management of patients with symptomatic chronic lower extremity peripheral artery disease (PAD) includes secondary prevention of cardiovascular risk factors, pharmacological treatment, and supervised exercise therapy (SET). SET programs have shown to be effective in improving walking performance, functional performance, and quality of life. However, despite a large body of evidence, and despite national and international guidelines recommending SET as first line therapy, SET remains largely underused in patients with chronic PAD. This position paper aims to describe how SET is perceived, its accessibility and structure through Europe. An anonymous web-based survey was used. It comprised 21 questions developed in conjunction with an angiologist and a clinical exercise physiologist specialist in vascular rehabilitation. We had 131 responders from 17 countries. For patients with PAD, SET programs exist only in 59% of European countries. SET reimbursement is available in 41% of countries. SET programs showed to be heterogeneous across countries. Thirty-four percent of the SET programs are PAD-dedicated, while 23% are part of a cardiac rehabilitation program. In addition, among existing SET programs, 65% are dedicated to symptomatic patients with PAD only, 9% to both asymptomatic and symptomatic, 8% to post-revascularized patients only, and 1% to asymptomatic patients with PAD only. Finally, 17% reported not knowing which patients are eligible for enrolment in a SET program. Duration, frequency, and modality of SET also varied from country to country. Overall, these data indicate that a large variability of SET availability and characteristics exists across Europe. Therefore, there is an urgent need to provide detailed guidance to deliver optimal exercise therapeutic care in patients with PAD.

Effects of Walking Exercise at a Pace With Versus Without Ischemic Leg Symptoms on Functional Performance Measures in People With Lower Extremity Peripheral Artery Disease: The LITE Randomized Clinical Trial

Background In people with peripheral artery disease, post hoc analyses of the LITE (Low Intensity Exercise Intervention in Peripheral Artery Disease) randomized trial were conducted to evaluate the effects of walking exercise at a pace inducing ischemic leg symptoms on walking velocity and the Short Physical Performance Battery, compared with walking exercise without ischemic leg symptoms and compared with a nonexercising control group. Methods and Results Participants with peripheral artery disease were randomized to: home-based walking exercise that induced ischemic leg symptoms; home-based walking exercise conducted without ischemic leg symptoms; or a nonexercising control group for 12 months. Outcomes were change of walking velocity over 4 m and change of the Short Physical Performance Battery (0-12, with 12=best) at 6- and 12-month follow-up. A total of 264 participants (48% women, 61% Black race) were included. Compared with walking exercise without ischemic symptoms, walking exercise that induced ischemic symptoms improved change in usual-paced walking velocity over 4 m at 6-month (0.056 m/s [95% CI, 0.019-0.094 m/s]; P<0.01) and 12-month follow-up (0.084 m/s [95% CI, 0.049-0.120 m/s]; P<0.01), change in fast-paced of walking velocity over 4 m at 6-month follow-up (P=0.03), and change in the Short Physical Performance Battery at 12-month follow-up (0.821 [95% CI, 0.309-1.334]; P<0.01). Compared with control, walking exercise at a pace inducing ischemic symptoms improved change in usual-paced walking velocity over 4 m at 6-month follow-up (0.066 m/s [95% CI, 0.021-0.111 m/s]; P<0.01). Conclusions In people with peripheral artery disease, those who walked for exercise at a comfortable pace without ischemic leg symptoms slowed their walking speed during daily life and worsened the Short Physical Performance Battery score, a potentially harmful effect, compared with people who walked for exercise at a pace inducing ischemic leg symptoms. Compared with a control group who did not exercise, home-based walking exercise at a pace inducing ischemic leg symptoms significantly improved change of walking velocity over 4 m at 6-month follow-up, but this benefit did not persist at 12-month follow-up. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02538900.

Peripheral artery disease and physical function in women with and without HIV

OBJECTIVES

Peripheral artery disease (PAD) is associated with decreased physical function and increased mortality in the general population. We previously found that PAD is common in middle-aged women with and without HIV infection, but its association with functional decline is unclear. We examine the contribution of PAD to functional decline in the Women's Interagency HIV Study, controlling for traditional cardiovascular risk factors and HIV-related factors.

METHODS

Analysis included 1839 participants (72% with HIV) with measured ankle-brachial index (ABI) and 4 m gait speed. ABI values categorized PAD severity. Linear models with repeated measures estimated the association of PAD severity with log-transformed gait speed after controlling for demographic, behavioral, and metabolic risk factors, and HIV/hepatitis C virus status.

RESULTS

Median age was 50 years and more than 70% were Black. Compared with normal ABI, there was a dose-response relationship between increasing PAD severity and slower gait speed in univariable analyses: 6% slower gait speed for low-normal ABI [95% confidence interval (CI): 4-9%], 10% for borderline PAD (95% CI: 6-13%), 14% for mild PAD (95% CI: 9-18%), and 16% for moderate-severe PAD (95% CI: 5-25%). PAD severity remained associated with slower gait speed in multivariable analyses. HIV/hepatitis C virus co-infection was independently associated with 9% (95% CI: 4-14%) slower gait speed compared with those with neither infection. Among women with HIV, neither CD4+ cell count nor HIV-RNA level was associated with gait speed.

CONCLUSION

In middle-aged women with and without HIV infection, greater PAD severity is associated with progressively slower gait speed. Early detection of subclinical PAD may decrease the risk of lower extremity functional impairment and its long-term health consequences.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

One-Year Change in Walking Performance and Subsequent Mobility Loss and Mortality Rates in Peripheral Artery Disease: Longitudinal Data From the WALCS

Background Associations of 1-year change in functional performance measures with subsequent mobility loss and mortality in people with lower extremity peripheral artery disease are unknown. Methods and Results Six-minute walk and 4-meter walking velocity (usual and fastest pace) were measured at baseline and 1 year later in 612 people with peripheral artery disease (mean age 71±9 years, 37% women). Participants were categorized into tertiles, based on 1-year changes in walking measures. Cox proportional hazards models were used to examine associations between 1-year change in each walking measure and subsequent mobility loss and mortality, respectively, adjusting for potential confounders. Compared with the best tertile, the worst tertile (ie, greatest decline) in 1-year change in each performance measure was associated with higher rates of mobility loss: 6-minute walk (Tertile 1 [T1] cumulative incidence rate [IR], 72/160; Tertile 3 [T3] IR, 47/160; hazard ratio [HR], 2.35; 95% CI, 1.47-3.74), usual-paced 4-meter walking velocity (T1 IR, 54/162; T3 IR, 57/162; HR, 2.21; 95% CI, 1.41-3.47), and fast-paced 4-meter walking velocity (T1 IR, 61/162; T3 IR, 58/162; HR, 1.81; 95% CI, 1.16-2.84). Compared with the best tertile, the worst tertiles in 1-year change in 6-minute walk (T1 IR, 66/163; T3 IR, 54/163; HR, 1.61; 95% CI, 1.07-2.43) and fast-paced 4-meter walking velocity (T1 IR, 63/166; T3 IR, 44/166; HR, 1.75; 95% CI, 1.16, 2.64) were associated with higher mortality. Conclusions In people with peripheral artery disease, greater 1-year decline in 6-minute walk or 4-meter walking velocity may help identify people with peripheral artery disease at highest risk for mobility loss and mortality.

Sustained physical activity in peripheral artery disease: Associations with disease severity, functional performance, health-related quality of life, and subsequent serious adverse events in the LITE randomized clinical trial

This study investigated cross-sectional associations of peripheral artery disease (PAD) severity (defined by the ankle-brachial index (ABI)) and amounts of daily sustained physical activity (PA) (defined as > 100 activity counts per minute lasting 5 consecutive minutes or more). This study also investigated associations of amounts of daily sustained PA with 6-minute walk (6MW) distance and the Short Form-36 physical functioning domain (SF-36 PF) score in cross-sectional analyses and with serious adverse events (SAEs) in longitudinal analyses of people with PAD. PA was measured continuously for 10 days using a tri-axial accelerometer at baseline in 277 participants with PAD randomized to the LITE clinical trial. In regression analyses, each 0.15 lower ABI value was associated with a 5.67% decrease in the number of daily bouts of sustained PA (95% CI: 3.85-6.54; p < 0.001). Every additional bout of sustained PA per day was associated with a 4.56-meter greater 6MW distance (95% CI: 2.67-6.46; p < 0.0001), and a 0.81-point improvement in SF-36 PF score (95% CI: 0.34-1.28; p < 0.001). Participants with values of daily bouts of sustained PA below the median had higher rates of SAEs during follow-up, compared to participants above the median (41% vs 24%; p = 0.002). In conclusion, among participants with PAD, lower ABI values were associated with fewer bouts of daily sustained PA. A greater number of bouts of daily sustained PA were associated with better 6MW performance and SF-36 PF score, and, in longitudinal analyses, lower rates of SAEs. Clinicaltrials.gov ID: NCT02538900.

Effect of frailty on physical activity levels and walking capacity in patients with peripheral artery disease: A cross-sectional study

BACKGROUND

This study aimed to analyze the effect of frailty on walking capacity and physical activity levels of patients with peripheral artery disease (PAD).

METHODS

A cross-sectional study including 216 symptomatic PAD patients (e.g. claudication) was conducted. Moreover, the frailty profile was established, for which six-minute walk test, Walking Impairment Questionnaire (WIQ), and physical activity level were evaluated.

RESULTS

Frailty was prevalent in 13.4%, 72.2%, and 14.4% of frail, pre-frail, and not-frail patients, respectively. Walking capacity was lower in frail patients than in not-frail patients (p < 0.024). The domains of distance and speed of WIQ were lower in frail patients than in not-frail patients, and these domains were also lower in pre-frail than in not-frail patients (p < 0.050 for all). The domain of stairs was lower in frail patients than in not-frail and pre-frail patients (p = 0.016). Physical activity levels were similar among groups (p > 0.050).

CONCLUSION

Frailty is associated with further walking impairment in patients with PAD.

Determinants of gait speed in patients with heart failure with reduced ejection fraction

OBJECTIVE

Given the prognostic significance of gait speed, there is insufficient evidence about possible functional determinants of gait speed in patients with heart failure with reduced ejection fraction (HFrEF). Therefore, the objective of this study was to investigate the functional determinants of gait speed in patients with HFrEF.

METHODS

Fifty-nine patients with HFrEF participated in this cross-sectional study. Demographic and clinical characteristics were recorded. The gait speed was determined with a 4-meter walking test. Dyspnea perception was assessed with the modified medical research council (mMRC) scale. Functional capacity was evaluated with a 6-minute walk test (6MWT). The five times sit-to-stand (5-STS) test and the Berg Balance Scale (BBS) were used to measure functional mobility and balance. Physical activity was evaluated with the International Physical Activity Questionnaire (IPAQ) Short-Form.

RESULTS

Gait speed was correlated with age (r=-0.368, p=0.004), NYHA functional class (r=-0.438, p=0.001), mMRC score (r=-0.422, p=0.001), 6MWT (r=0.650, p<0.001), 5STS (r=-0.506, p<0.001), BBS (r=0.586, p<0.001), IPAQ (r=0.305, p=0.019) and IPAQ-Sitting time (r=-0.327, p=0.011). On multiple linear regression analysis, the 6MWT distance and BBS were independent determinants of the usual gait speed in patients with HFrEF, accounting for 44.4% of the variance.

CONCLUSION

This study indicates that functional capacity and balance are independent functional determinants of gait speed in patients with HFrEF.

Validity and reliability of 2-min step test in patients with symptomatic peripheral artery disease

BACKGROUND

Although 2-min step test (2MST) has been useful in general population, no study has investigated its validity in patients with peripheral artery disease (PAD).

OBJECTIVE

To analyze the validity and reliability of the 2MST in patients with PAD and claudication symptoms.

METHODS

Twenty-four patients with PAD and claudication symptoms were recruited and performed the 2MST comparing it to the six-minute walk test (6MWT). Test performance, step indicators, and heart rate were measured during the test. Validity was verified using Pearson correlation between the performance of 2MST (number of steps) and 6MWT (distance and number of steps). The reliability was analyzed by the intraclass correlation coefficient and by the limits of agreement of Bland and Altman.

RESULTS

A similar performance was observed between the two 2MST (65 ± 10 steps vs. 66 ± 10 steps, p = 0.43) with a significant intraclass coefficient correlation of 0.945. The bias between tests was of 0.79 steps with the limits of agreement between -9.6 and 11.2 steps. The 90% minimum detectable difference was 3.2 steps. The number of steps in 2MST was significantly correlated with the number of steps in 6MWT (r = 0.55, p<0.01). However, the number of steps in 2MST did not correlate with distance in the 6MWT (r = 0.26, p = 0.23). The peak heart rate was lower in 2MST compared to 6MWT (p<0.05).

CONCLUSION

The 2MST present adequate reliability and validity in patients with symptomatic PAD.

Effects of supervised exercise therapy on blood pressure and heart rate during exercise, and associations with improved walking performance in peripheral artery disease: Results of a randomized clinical trial

OBJECTIVE

Supervised exercise therapy (SET) improves walking ability in people with peripheral artery disease (PAD). However, the effects of SET on cardiovascular health in PAD remain unclear. Using data from a randomized clinical trial, this post hoc analyses investigated the effects of a 6-month SET intervention, compared with a control group, on changes in blood pressure (BP) and heart rate (HR) during a graded treadmill exercise test in people with PAD.

METHODS

We randomized 210 participants with PAD to either SET (3× weekly) or control (1× weekly health lectures) for 6 months. A graded treadmill exercise test, 6-minute walk test, and Walking Impairment Questionnaire were completed at baseline and the 6-month follow-up. BP and HR were measured at the end of each 2-minute stage of the graded treadmill exercise test. Mixed effects regression models compared the overall mean 6-month change in systolic BP, diastolic BP, pulse pressure (PP), and HR during the first 5 stages of the graded treadmill exercise test between groups.

RESULTS

Of the 210 randomized participants with PAD, 176 (67 ± 9 years; 72 [41%] female, 115 [65%] Black) completed the graded treadmill exercise test at baseline and the 6-month follow-up. Compared with the control group at the 6-month follow-up, SET significantly decreased overall mean systolic BP (-12 mm Hg; P < .001), PP (-9 mm Hg; P < .001), and HR (-7 b/min; P < .01) during a graded treadmill exercise test but not diastolic BP. Among participants randomized to SET, a greater decrease in systolic BP, PP, and HR during a graded treadmill exercise test was significantly associated with a greater improvement in 6-minute walk distance (systolic BP, r = -0.19 [P = .03] and PP, r = -0.23 [P < .01]; and HR, r = -0.21 [P < .01]) and with maximal treadmill walking distance (systolic BP, r = -0.21 [P < .01] and PP, r = -0.17 [P = .03]) at the 6-month follow-up. A greater decrease in the HR during a graded treadmill exercise test was significantly associated with a better WIQ distance score (r = -0.27; P = .03) at the 6-month follow-up.

CONCLUSIONS

In people with PAD, compared with a control group, SET improved cardiovascular health, measured by changes in BP and HR during exercise. The degree of improvement in cardiovascular health correlated with the degree of improvement in walking performance in people with PAD. NCT: 01408901.

Importance of physical detraining in functional capacity of individuals with chronic peripheral arterial occlusive disease: a cross-sectional pilot study

BACKGROUND

Physical training is a well-established strategy for rehabilitation of the functional capacity of individuals with chronic peripheral arterial occlusive disease (PAOD). However, some individuals quit training after participating in a physical training program, undergoing detraining. There is scant literature on the effects of physical detraining in individuals with PAOD and it is therefore important to investigate the effects of this phenomenon.

OBJECTIVES

The objective of this article was to evaluate the effects of physical detraining on functional capacity in individuals with PAOD.

METHODS

Cross-sectional study with 22 individuals. Participants were divided into two groups: a detraining group (DG) and a control group (CG). The distance covered in the 6-minute walk test (6MWTD) and the pain-free walking distance (PFWD) were evaluated. The PFWD is the distance covered until claudication begins, i.e., the distance covered without pain.

RESULTS

Mean age was 66 ± 8 in the DG and 67 ± 7 in the CG. There were no differences between the groups in either the 6MWTD or the PFWD (p = 0.428; p = 0.537, respectively).

CONCLUSIONS

The present pilot study allows us to conclude that the functional capacity of individuals with PAOD who participated in a physical training program and subsequently underwent detraining was not superior in relation to individuals who did not participate in a physical training program. The results of the present study serve to encourage maintenance of physical exercise, since physical training is no longer effective if detraining occurs.

Functional Status and Out-of-Hospital Outcomes in Different Types of Vascular Surgery Patients

BACKGROUND

We aimed to determine the correlation between the functional status at discharge in non-cardiac vascular surgery patients and the out-of-hospital mortality.

METHODS

We performed a retrospective cohort study including adult non-cardiac vascular surgery patients (open, endovascular and venous procedures) surviving hospitalization in Boston, Massachusetts, USA. The exposure of interest was functional status determined by a licensed physical therapist at hospital discharge and rated based on qualitative categories adapted from the Functional Independence Measure. The primary outcome was all cause 90-day mortality after hospital discharge. The secondary outcome was readmission within 30days. Adjusted odds ratios were estimated by multivariable logistic regression models.

RESULTS

This cohort included 2318 patients (male 51%; mean age 61 ± 17.7). After evaluation by a physiotherapist, 425 patients scored the lowest functional status, 631 scored moderately low, 681 moderately high and 581 scored the highest functional status. The lowest functional status was associated with a 3.41-fold increased adjusted odds for 90-day mortality (95%CI, 1.70-6.84) compared to patients with the highest functional status. When excluding venous intervention patients, the adjusted odds ratio was 6.76 (95%CI, 2.53-18.12) for the 90-day mortality post-discharge. The adjusted odds for readmission within 30-days was 1.5-fold increase in patients with the lowest functional status (95%CI, 1.04-2.20).

CONCLUSIONS

In vascular surgery patients surviving hospitalization, functional status is strongly associated with out-of-hospital mortality and readmission rate. Future trials could provide evidence if improvement of functional status could prevent adverse outcomes in the postoperative setting.

Satisfaction and Acceptability of Telemonitored Home-Based Exercise in Patients With Intermittent Claudication: Pragmatic Observational Pilot Study

BACKGROUND

Current guidelines recommend supervised exercise training (SET) as a first-line treatment in patients with intermittent claudication (IC). SET has been shown to be more effective than home-based exercise therapy (HBET). However, the lack of available SET programs hampers broad SET implementation in clinical practice.

OBJECTIVE

The aim of this study is to assess patient satisfaction and acceptability of a structured HBET program using wearable technology and elastic band resistance exercises.

METHODS

A total of 20 patients with IC (Rutherford 1-3) with internet access and currently not engaged in structured exercise training were recruited in a pragmatic observational pilot study. Participants were instructed to complete 3 walking sessions and 2 elastic band resistance exercise sessions per week in their home environment during a 4-week period. Patient satisfaction and acceptability were assessed using a 5-point Likert scale questionnaire (1-2=very unsatisfied, 3=neutral, and 4-5=very satisfied) evaluating the materials and intervention content. Secondary outcomes were evaluated at baseline and at completion of the 4-week intervention and included maximal walking distance (MWD) and pain-free walking distance (PFWD), physical fitness, and patient-reported outcomes on quality of life, walking capacity, levels of kinesiophobia, and self-efficacy. Statistically significant changes were tested using paired t tests or Wilcoxon signed-rank tests.

RESULTS

All patients (15 men, 5 women; mean age 64.6, SD 10.6 years; range 41-81 years) completed the 4-week intervention and were highly satisfied with the program (mean overall score 4.5, SD 0.5). Patients' questionnaire responses documented willingness to recommend the exercise program to other patients (mean 4.5, SD 0.5; median 4.5) and preference for continuing the intervention (mean 4.3, SD 0.5; median 4). Furthermore, participants endorsed the use of the sports watches to track walking sessions (mean 4.25, SD 0.6; median 4), felt safe (mean 4.4, SD 0.6; median 4), and appreciated personal feedback (mean 4.55, SD 0.5; median 5) and flexibility of training (mean 4.1, SD 0.7; median 4). Resistance training was not preferred over walking training (mean 2.65, SD 0.8; median 3). In addition, PFWD (+89 m; P=.001), MWD (+58 m; P=.03), Walking Impairment Questionnaire distance score (+0.18; P=.01), activity-related scores (+0.54; P<.001), and total quality of life (+0.36; P=.009) improved following the intervention. Other patient-related outcomes, physical fitness, and physical activity remained to be statistically unaltered.

CONCLUSIONS

Patients with IC were satisfied and accepted technology to monitor and guide HBET, with observed short-term effectiveness regarding walking capacity and quality of life. However, elastic band resistance exercises as a part of HBET were not preferred over progressive walking.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04043546; https://clinicaltrials.gov/ct2/show/NCT04043546.

Reallocating Time From Sedentary Behavior to Physical Activity in Patients With Peripheral Artery Disease: Analyzing the Effects on Walking Capacity Using Compositional Data Analysis

BACKGROUND

To examine the associations between physical activity (PA) and sedentary behavior (SB) with walking capacity and the effects of reallocating time from SB to PA in patients with symptomatic peripheral artery disease (PAD) using compositional data analysis.

METHODS

This cross-sectional study included 178 patients (34% females, mean age = 66 [9] y, body mass index = 27.8 [5.0] kg/m2, and ankle-brachial index = 0.60 [0.18]). Walking capacity was assessed as the total walking distance (TWD) achieved in a 6-minute walk test, while SB, light-intensity PA, and moderate to vigorous-intensity PA (MVPA) were measured by a triaxial accelerometer and conceptualized as a time-use composition. Associations between time reallocation among wake-time behaviors and TWD were determined using compositional isotemporal substitution models.

RESULTS

A positive association of MVPA with TWD (relative to remaining behaviors) was found in men (βilr = 66.9, SE = 21.4, P = .003) and women (βilr = 56.5, SE = 19.8; P = .005). Reallocating 30 minutes per week from SB to MVPA was associated with higher TWD in men (6.7 m; 95% confidence interval, 2.6-10.9 m) and women (4.5 m; 95% confidence interval, 1.5-7.5 m).

CONCLUSIONS

The findings highlight, using a compositional approach, the beneficial and independent association of MVPA with walking capacity in patients with symptomatic PAD, whereas SB and light-intensity PA were not associated.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Clinical characteristics and response to supervised exercise therapy of people with lower extremity peripheral artery disease

BACKGROUND

Among people with lower extremity peripheral artery disease (PAD), little is known about variation in response to supervised exercise therapy (SET). Clinical characteristics associated with greater responsiveness to SET have not been identified.

METHODS

Data from participants with PAD in two randomized clinical trials comparing SET vs nonexercising control were combined. The exercise intervention consisted of three times weekly supervised treadmill exercise. The control groups received lectures on health-related topics.

RESULTS

Of 309 unique participants randomized (mean age, 67.9 years [standard deviation, 9.3 years]; 132 [42.7%] women; 185 [59.9%] black), 285 (92%) completed 6-month follow-up. Compared with control, those randomized to SET improved 6-minute walk distance by 35.6 meters (95% confidence interval, 21.4-49.8; P < .001). In the 95 (62.1%) participants who attended at least 70% of SET sessions, change in 6-minute walk distance varied from -149.4 to +356.0 meters. Thirty-four (35.8%) had no 6-minute walk distance improvement. Among all participants, age, sex, race, body mass index, prior lower extremity revascularization, and other clinical characteristics did not affect the degree of improvement in 6-minute walk distance after SET relative to the control group. Participants with 6-minute walk distance less than the median of 334 meters at baseline had greater percentage improvement in 6-minute walk distance compared with those with baseline 6-minute walk distance above the median (+20.5% vs +5.3%; P for interaction = .0107).

CONCLUSIONS

Among people with PAD, substantial variability exists in walking improvement after SET. Shorter 6-minute walk distance at baseline was associated with greater improvement after SET, but other clinical characteristics, including age, sex, prior lower extremity revascularization, and disease severity, did not affect responsiveness to exercise therapy.

Expanding the Use of Six-Minute Walking Test in Patients with Intermittent Claudication

BACKGROUND

Six-min walking test (6MWT) has been widely in patients with symptomatic peripheral artery disease (PAD) to quantify the walking impairment and the efficacy of different therapeutic interventions. Despite the aforementioned usefulness of 6MWT for PAD, the information provided by this test goes beyond the meters walked. The aim of this study was to describe the relative values of 6MWT and body weight-walking distance product (DW) in patients with symptomatic PAD.

METHODS

Two hundred twenty-seven patients with symptomatic PAD participated in the study. The 6MWT was performed and absolute and claudication distances were obtained. The results of 6MWT were then relativized and expressed as a percentage of a healthy subject. DW was obtained by the product of 6MWT distance by weight. In both sexes, the relative 6MWT ranged from 57% to 64%.

RESULTS

Absolute 6MWT total distance (P < 0.001) was lower in women than in men, whereas the relative 6MWT total distance was similar between sexes (P = 0.398). The absolute and relative 6MWT total distance were similar among age categories (P > 0.072). The DW was higher in men than in women (P < 0.05). In addition, in women, DW was higher in younger group than in other age groups (P < 0.05).

CONCLUSIONS

Patients with symptomatic PAD achieve less than 70% of the distance achieved by an age-matched healthy subject. In patients with symptomatic PAD, the relative values of 6MWT total distance are similar between sexes and among different age groups, whereas DW are influenced by age and sex.

Association of six-minute walk distance with subsequent lower extremity events in peripheral artery disease

The prognostic significance of the six-minute walk distance for lower extremity events in people with peripheral artery disease (PAD) is unknown. This longitudinal study assessed whether a poorer six-minute walk distance at baseline was associated with higher rates of subsequent lower extremity atherosclerotic disease events in PAD. A total of 369 patients (mean age 69.4 ± 10.0 years; mean ankle-brachial index (ABI) 0.67 ± 0.17; 31% women; 30% black individuals) from Chicago-area medical centers with PAD were enrolled. Participants underwent baseline six-minute walk testing and returned for annual study visits. Lower extremity events consisted of one or more of the following: ABI decline greater than 15% or medical record adjudicated lower extremity revascularization, critical limb ischemia, or amputation. At a mean follow-up of 33.3 months, lower extremity events occurred in 66/123 (53.7%) people in the first (worst) tertile of six-minute walk performance, 55/124 (44.4%) in the second tertile, and 56/122 (45.9%) in the third (best) tertile. After adjusting for age, sex, race, ABI, comorbidities, and other confounders, participants in the first (worst) tertile of six-minute walk distance at baseline had higher rates of lower extremity events during follow-up, compared to those in the best tertile at baseline (HR = 1.74, 95% CI 1.17-2.60, p = 0.0067). Among people with PAD, a poorer six-minute walk distance was associated with higher rates of subsequent lower extremity PAD-related events after adjusting for confounders. Further study is needed to determine whether interventions that improve six-minute walk distance can reduce lower extremity adverse events in people with PAD.

Polonsky T, Leeuwenburgh C, Ferrucci L, Peterson CA. Correlations of Calf Muscle Macrophage Content With Muscle Properties and Walking Performance in Peripheral Artery Disease

Background Peripheral artery disease (PAD) is a manifestation of atherosclerosis characterized by reduced blood flow to the lower extremities and mobility loss. Preliminary evidence suggests PAD damages skeletal muscle, resulting in muscle impairments that contribute to functional decline. We sought to determine whether PAD is associated with an altered macrophage profile in gastrocnemius muscles and whether muscle macrophage populations are associated with impaired muscle phenotype and walking performance in patients with PAD. Methods and Results Macrophages, satellite cells, and extracellular matrix in gastrocnemius muscles from 25 patients with PAD and 7 patients without PAD were quantified using immunohistochemistry. Among patients with PAD, both the absolute number and percentage of cluster of differentiation (CD) 11b+CD206+ M2-like macrophages positively correlated to satellite cell number (r=0.461 [P=0.023] and r=0.416 [P=0.042], respectively) but not capillary density or extracellular matrix. The number of CD11b+CD206- macrophages negatively correlated to 4-meter walk tests at normal (r=-0.447, P=0.036) and fast pace (r=-0.510, P=0.014). Extracellular matrix occupied more muscle area in PAD compared with non-PAD (8.72±2.19% versus 5.30±1.03%, P<0.001) and positively correlated with capillary density (r=0.656, P<0.001). Conclusions Among people with PAD, higher CD206+ M2-like macrophage abundance was associated with greater satellite cell numbers and muscle fiber size. Lower CD206- macrophage abundance was associated with better walking performance. Further study is needed to determine whether CD206+ macrophages are associated with ongoing reparative processes enabling skeletal muscle adaptation to damage with PAD. Registration URL: https://www.clini​caltr​ials.gov; Unique identifiers: NCT00693940, NCT01408901, NCT0224660.

Associations of Peripheral Artery Disease With Calf Skeletal Muscle Mitochondrial DNA Heteroplasmy

Background Patients with peripheral artery disease (PAD) undergo frequent episodes of ischemia-reperfusion in lower extremity muscles that may negatively affect mitochondrial health and are associated with impaired mobility. We hypothesized that skeletal muscle from PAD patients will show high mitochondrial DNA heteroplasmy, especially in regions more susceptible to oxidative damage, such as the displacement loop, and that the degree of heteroplasmy will be correlated with the severity of ischemia and mobility impairment. Methods and Results Mitochondrial mutations and deletions and their relative abundance were identified by targeted mitochondrial DNA sequencing in biopsy specimens of gastrocnemius muscle from 33 PAD (ankle brachial index <0.9) and 9 non-PAD (ankle brachial index >0.9) subjects aged ≥60 years. The probability of heteroplasmy per DNA base was significantly higher for PAD subjects than non-PAD within each region. In adjusted models, PAD was associated with higher heteroplasmy than non-PAD (P=0.003), but the association was limited to microheteroplasmy, that is heteroplasmy found in 1% to 5% of all mitochondrial genomes (P=0.004). Heteroplasmy in the displacement loop and coding regions were significantly higher for PAD than non-PAD subjects after adjustment for age, sex, race, and diabetes mellitus (P=0.037 and 0.004, respectively). Low mitochondrial damage, defined by both low mitochondrial DNA copy number and low microheteroplasmy, was associated with better walking performance. Conclusions People with PAD have higher "low frequency" heteroplasmy in gastrocnemius muscle compared with people without PAD. Among people with PAD, those who had evidence of least mitochondrial damage, had better walking performance than those with more mitochondrial damage. Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02246660.

Changes in exercise capacity and risk of all-cause mortality in patients with peripheral artery disease: a 10-year retrospective cohort study

We retrospectively studied the association between changes in exercise capacity at discharge from a home-based exercise program and the risk of all-cause mortality among patients with peripheral artery disease (PAD) and claudication. The records of 1076 consecutive PAD patients were assessed between 2003 and 2013. The exercise program was prescribed during a few visits and executed at home at symptom-free walking speed. Ankle-Brachial Index (ABI) and maximal speed (S_max) on an incremental treadmill test were recorded at baseline and discharge. The number and date of deaths and hospitalizations for a 10-year period were collected from the regional registry. A total of 865 PAD patients completed the program (completers), while 221 left the program for health reasons (n = 128, diseased) or for nonhealth reasons (n = 83, quitters). Among the completers, the mortality rate (27%) was significantly lower (p < 0.001) than that of both the diseased (49 deaths, 38%) and the quitters (45 deaths, 54%). The completers (71 ± 9 years; 88% exercise sessions completed) showed significant improvements in the lowest ABI (from 0.62 ± 0.18 to 0.67 ± 0.19) and S_max (from 3.3 ± 1.1 to 3.8 ± 1.1 km h^-1) at discharge. The completers who reached the clinically important difference of S_max ≥ 0.4 km h^-1 at follow-up showed a significantly lower mortality risk (25% vs. 30%; HR 0.72; 95% CI 0.55-0.93) as well a lower rate of hospitalizations (p < 0.001). In conclusion, in PAD patients, active participation in a home-based exercise program was associated with a lower rate of death and better long-term clinical outcomes, particularly for those who attained a moderate increase in exercise capacity.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Durability of Benefits From Supervised Treadmill Exercise in People With Peripheral Artery Disease

Background It is currently unknown whether 6 months of supervised treadmill exercise has a durable benefit on 6-minute walk performance, even after exercise is completed, in people with peripheral artery disease. Methods and Results A total of 156 participants with peripheral artery disease were randomized to 1 of 3 groups: supervised treadmill exercise, supervised resistance training, or attention control. Participants received supervised sessions during months 1 to 6 and telephone contact during months 6 to 12. Primary outcomes were change in 6-minute walk distance and short physical performance battery at 6-month follow-up and have been reported previously. Secondary outcomes were change in 6-minute walk and short physical performance battery at 12-month follow-up and are reported here. A group of 134 participants (86%) completed the 12-month follow-up. At 6-month follow-up, compared with control, 6-minute walk distance improved in the treadmill exercise group (+36.1 m, 95% CI =13.9-58.3, P=0.001). Between 6- and 12-month follow-up, 6-minute walk distance significantly declined (-28.6 m, 95% CI=-52.6 to -4.5, P=0.020) and physical activity declined -272 activity units (95% CI =-546 to +2, P=0.052) in the treadmill exercise group compared with controls. At 12-month follow-up, 6 months after completing supervised treadmill exercise, change in 6-minute walk distance was not different between the treadmill exercise and control groups (+7.5, 95% CI =-17.5 to +32.6, P=0.56). There were no differences in short physical performance battery change between either exercise group and control at 6-month or 12-month follow-up. Conclusions A 6-month supervised treadmill exercise intervention that improved 6-minute walk distance at 6-month follow-up did not have persistent benefit at 12-month follow-up. These results do not support a durable benefit of supervised treadmill exercise in peripheral artery disease. Clinical Trial Registration URL : https://www.clinicaltrials.gov . Identifier: NCT 00106327.

Impact of Low Activity of Daily Living on the Prognosis of Patients with Critical Limb Ischemia and Sarcopenia

BACKGROUND

We aimed to investigate the impact of low activity of daily living (ADL) on the long-term outcomes after infrainguinal bypass surgery in patients with critical limb ischemia (CLI) and sarcopenia.

METHODS

In this multicenter retrospective cohort study, 110 patients with CLI who underwent infrainguinal bypass between April 2011 and September 2016 were divided into 4 groups according to the presence or absence of sarcopenia before surgery and ADL at discharge (Normal group: absence of sarcopenia and normal ADL [Barthel Index ≥60]; Low ADL alone group: absence of sarcopenia and abnormal ADL [Barthel Index <60]; Sarcopenia alone group: presence of sarcopenia and normal ADL; Sarcopenia and low ADL group: presence of sarcopenia and abnormal ADL). Three-year overall survival (OS) and amputation-free survival (AFS) were compared among the 4 groups using the Kaplan-Meier method, and Cox proportional hazards models were used to assess the unadjusted and adjusted associations between patient characteristics and 3-year OS and AFS.

RESULTS

The Sarcopenia and low ADL group was significantly inferior to the other 3 groups in 3-year OS (versus Normal group, P < 0.001; versus Low ADL alone group, P = 0.005; versus Sarcopenia alone group, P = 0.022) and was significantly inferior to the Normal group and Sarcopenia alone group in 3-year AFS (P < 0.001 and P = 0.027, respectively). In the multivariable analysis, after adjustment for age, sex, ischemic heart disease, and hemodialysis, the presence of both sarcopenia and low ADL was a significant predictor of 3-year OS (hazard ratio [HR] 5.99, 95% confidence interval [CI] 1.92-18.69, P = 0.002) and AFS (HR 3.63, 95% CI 1.27-10.39, P = 0.016).

CONCLUSIONS

Low ADL at discharge was a significant predictor of 3-year OS and AFS in patients with CLI and sarcopenia, while either sarcopenia alone or low ADL alone did not significantly affect outcomes.

Identification of new factors associated to walking impairment in patients with vascular-type claudication

OBJECTIVES

Mechanisms of walking limitation in arterial claudication are incompletely elucidated. We aimed to identify new variables associated to walking limitation in patients with claudication.

METHODS

We retrospectively analyzed data of 1120 patients referred for transcutaneous exercise oxygen pressure recordings (TcpO₂). The outcome measurement was the absolute walking time on treadmill (3.2 km/h, 10% slope). We used both: linear regression analysis and a non-linear analysis, combining support vector machines and genetic explanatory in 800 patients with the following resting variables: age, gender, body mass index, the presence of diabetes, minimal ankle to brachial index at rest, usual walking speed over 10 m (usual-pace), number of comorbid conditions, active smoking, resting heart rate, pre-test glycaemia and hemoglobin, beta-blocker use, and exercise-derived variables: minimal value of pulse oximetry, resting chest-TcpO₂, decrease in chest TcpO₂ during exercise, presence of buttock ischemia defined as a decrease from rest of oxygen pressure index ≤15 mmHg. We tested the models over 320 other patients.

RESULTS

Independent variables associated to walking time, by decreasing importance in the models, were: age, ankle to brachial index, usual-pace; resting TcpO₂, body mass index, smoking, buttock ischemia, heart rate and beta-blockers for the linear regression analysis, and were ankle to brachial index, age, body mass index, usual-pace, decrease in chest TcpO₂, smoking, buttock ischemia, glycaemia, heart rate for the non-linear analysis. Testing of models over 320 new patients gave r = 0.509 for linear and 0.575 for non-linear analysis (both p < 0.05).

CONCLUSION

Buttock ischemia, heart rate and usual-pace are new variables associated to walking time.