Peripheral arterial disease in women

Risk of critical limb ischemia in long-term uterine cancer survivors: A population-based study

BACKGROUND

The risk of critical limb ischemia (CLI) which causes ischemic pain or ischemic loss in the arteries of the lower extremities in long-term uterine cancer (UC) survivors remains unclear, especially in Asian patients, who are younger at the diagnosis of UC than their Western counterparts.

AIM

To conduct a nationwide population-based study to assess the risk of CLI in UC long-term survivors.

METHODS

UC survivors, defined as those who survived for longer than 5 years after the diagnosis, were identified and matched at a 1:4 ratio with normal controls. Stratified Cox models were used to assess the risk of CLI.

RESULTS

From 2000 to 2005, 1889 UC survivors who received surgery alone or surgery combined with radiotherapy (RT) were classified into younger (onset age < 50 years, n = 894) and older (onset age ≥ 50 years, n = 995) groups. While compared with normal controls, the younger patients with diabetes, hypertension, and receiving hormone replacement therapy (HRT) were more likely to develop CLI. In contrast, the risk of CLI was associated with adjuvant RT, obesity, hypertension, and HRT in the older group. Among the UC survivors, those who were diagnosed at an advanced age (> 65 years, aHR = 2.48, P = 0.011), had hypertension (aHR = 2.18, P = 0.008) or received HRT (aHR = 3.52, P = 0.020) were at a higher risk of CLI.

CONCLUSION

In this nationwide study, we found that the risk factors associated with CLI were similar in both cohorts except for adjuvant RT that was negligible in the younger group, but positive in the older group. Among the survivors, hypertension, advanced age, and HRT were more hazardous than RT. Secondary prevention should include CLI as a late complication in UC survivorship programs.

AAV-mediated expression of PFKFB3 in myofibers, but not endothelial cells, improves ischemic muscle function in mice with critical limb ischemia

6-Phosphofructo-2-kinase/fructose-2,6-bisphosphatase 3 (PFKFB3) is a powerful driver of angiogenesis through its modulation of glycolytic metabolism within endothelial cells. Recent work has demonstrated that PFKFB3 modulates the response to muscle ischemia, however the cell specificity of these effects is not fully understood. In this study, we tested the impact of viral mediated expression of PFKFB3, driven by gene promoters specific for myofibers or endothelial cells, on ischemic hindlimb revascularization and muscle function. We hypothesized that both endothelium- and muscle-specific expression of PFKFB3 would attenuate limb pathology following femoral artery ligation. Male and female BALB/cJ mice were injected with adeno-associated virus encoding the either a green fluorescent protein (GFP) or PFKFB3 driven by either the human skeletal actin (ACTA1) or cadherin-5 (Cdh5) promoters. Four weeks after AAV treatment, mice were subjected to unilateral femoral artery ligation and limb perfusion and muscle function were assessed. Both endothelium- and muscle-specific PFKFB3 expression resulted in significantly more perfused capillaries within the ischemic limb muscle, but neither changed myofiber size/area. Muscle-specific, but not endothelium-specific, PFKFB3 expression significantly improved maximal force production in ischemic muscle (P = 0.0005). Notably, there was a significant effect of sex on maximal force levels in both cohorts of mice (P = 0.0075 and P = 0.0481), indicating that female mice had higher ischemic muscle strength compared with male mice, regardless of treatment group. Taken together, these data demonstrate that although both muscle- and endothelium-specific expression of PFKFB3 enhanced ischemic revascularization, only muscle-specific PFKFB3 expression improved muscle function.NEW & NOTEWORTHY Critical limb ischemia (CLI) carries a significant risk for limb amputation, and treatment options remain limited. We tested the impact of expression of PFKFB3 in myofibers or endothelial cells on limb pathology in mice with CLI. Although both muscle and endothelium-specific PFKFB3 expression increased perfused capillary density, only muscle-specific PFKFB3 expression improve contractile function. Regardless of treatment, female mice demonstrated better recovery from limb ischemic compared with male mice.

Factors Affecting Penetration of Ciprofloxacin in Lower Extremity Ischemic Tissues

The aims of this study were to evaluate factors influencing the distribution of ciprofloxacin in tissue of patients suffering from varying degrees of peripheral arterial disease (PAD). Blood and tissue samples were collected from patients undergoing debridement or amputation procedures and the amount of ciprofloxacin in them was determined using high-performance liquid chromatography. All patients were administered a 200-mg dose of intravenous ciprofloxacin prior to the debridement or amputation procedure. Data, including patient gender, age, type of diabetes, presence of neuropathy, medications taken, and severity of PAD were collected. These data were then analyzed to determine factors influencing the concentrations of ciprofloxacin in tissue of the lower limbs. The Kruskal-Wallis test, Spearman correlation, and chi-square test were used to relate covariates and fixed factors with the concentration of ciprofloxacin in tissue. Following bivariate analysis, a 3-predictor regression model was fitted to predict tissue concentrations of ciprofloxacin given information about these predictors. Blood and tissue samples were collected from 50 patients having an average age of 68 years. Thirty-three patients were males and 35 patients suffered from type 2 diabetes. The average number of medications that these patients were taking was 10. The majority of patients (n = 35) were suffering from severe PAD. Tissue concentrations of ciprofloxacin were mainly related to plasma concentrations of ciprofloxacin, number of medications that the patients were taking and severity of PAD.

Pain-free treadmill exercise for patients with intermittent claudication: Are there gender differences?

Intermittent claudication, a common symptom of peripheral arterial disease, results in insufficient blood flow and oxygen supply to lower extremity muscles. Compared to men, women with peripheral arterial disease have a higher rate of mobility loss with peripheral arterial disease due to poorer lower extremity functioning. This study evaluates the effect of supervised pain-free treadmill exercise on improving performance in women with intermittent claudication due to peripheral arterial disease in comparison to men. A total of 26 participants (women, n = 9, 34.62%; mean age = 67.58 ± 5.59 years; averaging 23.46 ± 3.91 visits and 10.46 ± 0.99 weeks in the program) diagnosed with peripheral arterial disease, with symptoms of intermittent claudication, partook in a 45 min treadmill walk, twice per week, below the participant's minimal pain threshold. Female participants' change scores showed 752%, 278% and 115% improvement in mean walking distance, duration and rate, respectively. Men improved 334%, 149% and 80%, respectively. Significant differences (p < 0.05) in pre and post measurements within each group support positive outcomes. No significant differences between groups were observed (Cohen's d effect size > 0.80). Our results suggest that women reap similar benefits from this low-intensity treadmill program in comparison to men.

Impedance plethysmography as an alternative method for the diagnosis of peripheral arterial disease

BACKGROUND AND OBJECTIVE

In the diagnosis of peripheral artery disease (PAD), the ankle-brachial index (ABI) is considered as the standard, and other noninvasive methods have received too little attention. Therefore, the aim of the study was to determine the diagnostic accuracy of impedance plethysmography in diagnosing PAD and to compare this method with other methods.

MATERIALS AND METHODS

A total of 66 patients with a mean age of 76.1±9.6 years who had been treated for various cardiovascular diseases at Kaunas Clinical Hospital during 2011-2012 were enrolled into the study. All the patients were screened for PAD. Impedance plethysmography was performed with a new-generation Niccomo™ device. The receiver operating characteristic analysis was employed to determine the diagnostic accuracy of 4 parameters of impedance plethysmography: crest time (CT), crest width (CW), pulse amplitude (Pampl), and alternating blood flow (ABF).

RESULTS

There were a significant correlation between the ABI and the CT (r=-0.699, P<0.001), between the ABI and the ABF (r=0.552; P<0.001), and between the ABI and the Pampl only among men (r=0.652; P<0001). No correlation was found between the ABI and the CW. Among all the parameters, the CT had the highest sensitivity and specificity (73.2% and 96.0%, respectively). Other parameters had the following sensitivities and specificities: ABF, 61.0% and 96.0%; and Pampl, 90.0% and 20.0%, respectively.

CONCLUSIONS

Impedance plethysmography, especially its parameter CT, is an alternative noninvasive method in diagnosing PAD and could be used for the screening of patients with PAD.

Limb salvage in women

The prevalence of peripheral arterial occlusive disease (PAD) in women and men is equal. Studies to date present conflicting data of gender effects on the risk factors, clinical presentation, and treatment outcomes. Clinical trials have often failed to analyze results by gender or to recruit sufficient women to enable such an analysis. This review summarizes the management and outcome of limb salvage therapy with a particular focus in women.

Prognostic usefulness of clinical and subclinical peripheral arterial disease in men with stable coronary heart disease

The prognostic value of symptomatic peripheral arterial disease (PAD) in patients with coronary heart disease (CHD) is well documented, but few reports differentiating between symptomatic and asymptomatic forms of PAD are available. We investigated the respective prognostic effect of clinical and subclinical PAD on long-term all-cause mortality in patients with stable CHD. We analyzed 710 patients with stable CHD referred for hospitalization for CHD evaluation and management. As a part of the study, they completed questionnaires on medical history, underwent a standardized clinical examination, including ankle-brachial index (ABI) measurement, and provided a fasting blood sample. Three groups of patients were individualized: no PAD (no history of PAD and ABI >0.9 but ≤1.4); subclinical PAD (no history of PAD but abnormal ABI [i.e., ≤0.9 or >1.4); and clinical PAD (history of claudication, peripheral arterial surgery, or amputation due to PAD). Clinical and subclinical PAD was present in 83 (11.7%) and 181 (25.5%) patients, respectively. After a median follow-up of 7.2 years, 130 patients died. On multivariate analysis adjusted for age, hypertension, diabetes, dyslipidemia, smoking, left ventricular ejection fraction, CHD duration, heart rate, history of stroke or transient ischemic attack, and coronary revascularization, previous clinical PAD (hazard ratio 2.11, 95% confidence interval 1.28 to 3.47) and subclinical PAD (hazard ratio 1.65, 95% confidence interval 1.11 to 2.44) were significantly associated with increased all-cause mortality. In conclusion, our study has demonstrated that the detection of subclinical PAD by ABI in patients with stable CHD provides additional information for long-term mortality risk evaluation.

Cardiovascular disease in women: implications for improving health outcomes

OBJECTIVE

To collate data on women and cardiovascular disease in Australia and globally to inform public health campaigns and health care interventions.

DESIGN

Literature review.

RESULTS

Women with acute coronary syndromes show consistently poorer outcomes than men, independent of comorbidity and management, despite less anatomical obstruction of coronary arteries and relatively preserved left ventricular function. Higher mortality and complication rates are best documented amongst younger women and those with ST-segment-elevation myocardial infarction. Sex differences in atherogenesis and cardiovascular adaptation have been hypothesised, but not proven. Atrial fibrillation carries a relatively greater risk of stroke in women than in men, and anticoagulation therapy is associated with higher risk of bleeding complications. The degree of risk conferred by single cardiovascular risk factors and combinations of risk factors may differ between the sexes, and marked postmenopausal changes are seen in some risk factors. Sociocultural factors, delays in seeking care and differences in self-management behaviours may contribute to poorer outcomes in women. Differences in clinical management for women, including higher rates of misdiagnosis and less aggressive treatment, have been reported, but there is a lack of evidence to determine their effects on outcomes, especially in angina. Although enrolment of women in randomised clinical trials has increased since the 1970s, women remain underrepresented in cardiovascular clinical trials.

CONCLUSIONS

Improvement in the prevention and management of CVD in women will require a deeper understanding of women's needs by the community, health care professionals, researchers and government.

Exercise interventions for patients with peripheral arterial disease: a review of the literature

Peripheral arterial disease (PAD) is a common chronic cardiovascular condition that affects the lower extremities and can substantially limit daily activities and quality of life. Lifestyle interventions, including smoking cessation, diet modification, regular physical activity, and pharmacotherapy, are often prescribed to treat patients with PAD. Exercise interventions can be effective in increasing claudication onset time and maximal walking distance. Of the various types of exercise interventions available for patients with PAD, little is known about the differences that may exist between men and women in patient response to such interventions. The purpose of this literature review is to examine the current knowledge of exercise interventions for individuals with mild (Fontaine stages I-II) PAD and to consider any differences that may exist between men and women. Women with PAD present with a different clinical profile compared with men, but respond similarly to an acute bout of exercise and a training program. Patients with PAD should be encouraged to walk regularly; however, more research is needed to determine differences between men and women in their response to various exercise interventions.

Sex-specific time trends in first admission to hospital for peripheral artery disease in Scotland 1991–2007

Background

This study examined trends for all first hospital admissions for peripheral artery disease (PAD) in Scotland from 1991 to 2007 using the Scottish Morbidity Record.

Methods

First admissions to hospital for PAD were defined as an admission to hospital (inpatient and day-case) with a principal diagnosis of PAD, with no previous admission to hospital (principal or secondary diagnosis) for PAD in the previous 10 years.

Results

From 1991 to 2007, 41 593 individuals were admitted to hospital in Scotland for the first time for PAD. Some 23 016 (55·3 per cent) were men (mean(s.d.) age 65·7(11·7) years) and 18 577 were women (aged 70·4(12·8) years). For both sexes the population rate of first admissions to hospital for PAD declined over the study interval: from 66·7 per 100 000 in 1991-1993 to 39·7 per 100 000 in 2006-2007 among men, and from 43·5 to 29·1 per 100 000 respectively among women. After adjustment, the decline was estimated to be 42 per cent in men and 27 per cent in women (rate ratio for 2007 versus 1991: 0·58 (95 per cent confidence interval 0·55 to 0·62) in men and 0·73 (0·68 to 0·78) in women). The intervention rate fell from 80·8 to 74·4 per cent in men and from 77·9 to 64·9 per cent in women. The proportion of hospital admissions as an emergency or transfer increased, from 23·9 to 40·7 per cent among men and from 30·0 to 49·5 per cent among women.

Conclusion

First hospital admission for PAD in Scotland declined steadily and substantially between 1991 and 2007, with an increase in the proportion that was unplanned.

Peripheral arterial disease--what do we need to know?

Peripheral artery disease (PAD) results from progressive narrowing of arteries secondary to atherosclerosis and is defined as an Ankle Brachial Index of <0.9. PAD is highly prevalent and is an increasing burden on both the economy and the patient, especially given the rapid shift in demographics in the United States. Despite its prevalence and association with cardiovascular disease, PAD is still underdiagnosed and undertreated. This may, in part, be related to lack of recognition from the physician's side or paucity of evidence from clinical trials. It has been shown that medical therapy approved for cardiovascular disease is effective in the treatment of PAD and decreases cardiovascular events. Various revascularization strategies are also available for improving symptoms and quality of life in these patients, yet they are underutilized. In an attempt to increase its recognition, PAD has been considered a coronary artery disease equivalent. This article reviews the diagnosis and management of PAD. © 2011 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.