The Prevalence of Asymptomatic and Symptomatic Peripheral Arterial Disease and Peripheral Arterial Disease Risk Factors in the US Population

Comparisons of risk factors and outcomes between abdominal aortic aneurysm and peripheral arterial disease: a case-control study

Background

There is a paucity of data on direct comparison of clinical measures in patients with abdominal aortic aneurysm (AAA) and those with peripheral arterial disease (PAD). Here, we examine the risk factors and outcomes between these 2 conditions.

Methods

Group differences were examined by Fisher's exact tests with Bonferroni correction, postoperative complications (including delirium and pneumonia) and LOS by logistic regression, and mortality by Cox regression, adjusted for age, sex, smoking, co-morbidities and medications.

Results

In total, 160 men and 33 women aged 74.5years (SD = 9.4) were referred for preoperative cardiac assessment for AAA (n = 70) and PAD (n = 123). Vascular surgery was performed in 148 patients (70% of AAA; 80.5% of PAD). Myocardial infarct was more prevalent in AAA, and diabetes more in PAD, whilst atrial fibrillation, stroke, congestive heart failure and hypertension did not differ between groups. Compared to patients with PAD, there were higher proportions of patients with AAA prescribed with cardiovascular medications, and developed post-operative complications in hospital: odds ratio = 7.34 (95% CI, 2.26-23.84, P < .001), and stayed in hospital >1week: odds ratio = 2.60 (95% CI, 1.15-5.85, P = .021). Compared to those with AAA, patients with PAD were at greater risk of death in the entire sample: hazard ratio = 3.34 (95% CI, 1.64-6.79), and in those who underwent vascular surgery: hazard ratio = 4.90 (95% CI, 1.88-12.79). Left ventricular function did not relate to outcomes.

Conclusions

Differences between AAA and PAD in risk profile and management which may have a bearing on higher risk of death associated with PAD. More intensive cardiovascular management may help improve their outcomes.

The Ability of Clinical Decision Rules to Detect Peripheral Arterial Disease: A Narrative Review

Peripheral arterial disease (PAD) is a common cause of lower extremity wound. Consequently, PAD leads to a cause of leg amputation nowadays, especially in diabetic patients. In general practice (GP), confrontation with PAD prevention is a challenge. In general, ankle-brachial index (ABI) measurement can be used as a PAD diagnostic tool, but this takes some time. The tool is not generally available and this need to train healthcare workers to perform. Multiple independent predictors developed the diagnostic prediction model known as clinical decision rules (CDRs) to identify patients with high-risk PAD. This might therefore limit the number of patients (only high-risk patients) to refer for ABI evaluation. This narrative review summarized existing CDRs for PAD.

Association of lipids and lipid-lowering drugs with peripheral arterial disease: A Mendelian randomization study

BACKGROUND

It remains unclear whether lipid profiles and lipid-lowering medications are causally related to peripheral arterial disease (PAD).

OBJECTIVE

Explain whether there is a causal relationship between lipid status and lipid-lowering drugs and PAD.

METHODS

In this two-sample Mendelian randomization (MR) analysis, we assessed the causal relationship between lipid traits, including high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TGs), total cholesterol (TC), and LDL-associated genetic variants (HMGCR, NPC1L1, PCSK9, APOB), and the risk of PAD using genetic variants associated with these lipid markers. The study analyzed data from 1,654,960 individuals derived from the Global Lipid Genetics Consortium and the UK Biobank, ensuring a robust and comprehensive genetic insight into the effects of lipid dysfunction on PAD.

RESULTS

We found genetically predicted associations between HDL-C (OR: 0.83, 95% CI: 0.83-0.77), LDL-C (OR: 1.29, 95% CI: 1.12-1.50), TC (OR: 1.14, 95% CI: 1.01- 1.29), TG (OR: 1.16, 95% CI: 1.04-1.24), APOB (OR: 1.31, 95% CI: 1.16-1.48), and APOA1 (OR: 0.84, 95% CI: 0.77-0.97), and the risk of PAD. In addition, inhibition of PCSK9 was associated with a reduced risk of PAD (OR: 0.68, 95% CI: 0.57-0.79, P<0.001), while no association between the other three gene proxies of LDL inhibition including HMGCR (OR: 1.21, 95% CI: 0.87-1.69, P=0.250), NPC1L1 (OR: 0.77, 95% CI: 0.44-1.33, P=0.344), and APOB (OR: 1.01, 95% CI: 0.87-1.26, P=0.890), and the risk of PAD were found.

CONCLUSIONS

Based on genetic evidence, dyslipidemia is an important risk factor for PAD. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors may be an effective strategy for the treatment of PAD.

Systematic review of associations between concomitant rheumatoid arthritis and peripheral arterial disease, health-related quality of life and functional capacity

Patients with rheumatoid arthritis (RA) are at an increased risk of cardiovascular disease and vascular morbidity. The association between peripheral arterial disease (PAD) and RA has not been previously investigated within the scope of a review. Conjoined disease manifestations may impact patient well-being, perpetuating increased mortality and quality of life deficits. To investigate the association between RA and PAD, along with RA and the ankle-brachial pressure index (ABPI), the impact of disease concomitance on health-related quality of life (HRQOL) and functional capacity (FC) was also investigated. Individual study appraisal was completed using the Crowe Critical Appraisal Tool (CCAT). A level of evidence analysis was conducted using the American Society of Plastic Surgeons (ASPS) Evidence Rating Scale for Prognostic/Risk Studies. AMED^®, CINAHL^®, Health Source: Nursing/Academic Edition, MEDLINE^®, AHFS^®, Scopus, Web of Science, Cochrane Library and Google scholar. Ten studies produced a CCAT rating of ≥ 30 (75%) and were deemed high quality, while a single study demonstrated a score of 26 (65%) suggesting moderate quality. A grade "II" levels of evidence was awarded to positive association between RA and PAD. A gradation of "I" was awarded to the association between ABPI and RA. The impact of concomitant manifestations on HRQOL and FC did not qualify for a level of evidence analysis. The systematic inflammatory nature of RA likely contributes to the increased incidence of PAD within the population. Further investigations are required to ascertain the impact of conjoined disease manifestations on HRQOL and FC.

Symptomatic and asymptomatic peripheral artery disease and the risk of abdominal aortic aneurysm: The Atherosclerosis Risk in Communities (ARIC) study

BACKGROUND AND AIMS

Symptomatic peripheral artery disease (PAD) is a risk factor for abdominal aortic aneurysm (AAA). However, data on the association of asymptomatic PAD with AAA are limited. We explored the association of symptomatic and asymptomatic PAD with AAA.

METHODS

We primarily assessed a prospective association of symptomatic (based on clinical history) and asymptomatic (ankle-brachial index ≤0.9) PAD at baseline (1987-89 [ages 45-64 years]) with incident AAA in a biracial community-based cohort, the Atherosclerosis Risk in Communities Study. We secondarily investigated a cross-sectional association of PAD with ultrasound-based AAA (diameter≥3.0 cm) (2011-13 [ages 67-91 years]).

RESULTS

Of 14,148 participants (55.1% female, 25.5% black, 0.9% with symptomatic PAD) in our prospective analysis (median follow-up 22.5 years), 530 (3.7%) developed incident AAA. Symptomatic PAD had a higher hazard ratio (HR) of incident AAA [4.91 (95%CI 2.88-8.37)], as did asymptomatic PAD with ABI≤0.9 [2.33 (1.55-3.51)], compared to the reference ABI>1.1-1.2 in demographically-adjusted models. Crude 15-year cumulative incidence of AAA in these three groups were 12.3%, 3.9%, and 1.5%, respectively. The associations remained significant after accounting for other potential confounders [corresponding HR 2.96 (95%CI 1.73-5.07) and 1.52 (95%CI 1.00-2.30), respectively]. The cross-sectional analysis demonstrated similar patterns with ultrasound-based AAA [odds ratio 2.46 (95%CI 1.26-4.81) for symptomatic PAD and 3.98 (1.96-8.08) for asymptomatic PAD in a demographically-adjusted model].

CONCLUSIONS

Our prospective and cross-sectional data show elevated risk of AAA in both symptomatic and asymptomatic PAD. Our data support the current recommendation of AAA screening in symptomatic PAD patients and suggest the potential extension to asymptomatic PAD patients as well.

Activity data from wearables as an indicator of functional capacity in patients with cardiovascular disease

Background

Smartphone and wearable-based activity data provide an opportunity to remotely monitor functional capacity in patients. In this study, we assessed the ability of a home-based 6-minute walk test (6MWT) as well as passively collected activity data to supplement or even replace the in-clinic 6MWTs in patients with cardiovascular disease.

Methods

We enrolled 110 participants who were scheduled for vascular or cardiac procedures. Each participant was supplied with an iPhone and an Apple Watch running the VascTrac research app and was followed for 6 months. Supervised 6MWTs were performed during clinic visits at scheduled intervals. Weekly at-home 6MWTs were performed via the VascTrac app. The app passively collected activity data such as daily step counts. Logistic regression with forward feature selection was used to assess at-home 6MWT and passive data as predictors for “frailty” as measured by the gold-standard supervised 6MWT. Frailty was defined as walking <300m on an in-clinic 6MWT.

Results

Under a supervised in-clinic setting, the smartphone and Apple Watch with the VascTrac app were able to accurately assess ‘frailty’ with sensitivity of 90% and specificity of 85%. Outside the clinic in an unsupervised setting, the home-based 6MWT is 83% sensitive and 60% specific in assessing “frailty.” Passive data collected at home were nearly as accurate at predicting frailty on a clinic-based 6MWT as was a home-based 6MWT, with area under curve (AUC) of 0.643 and 0.704, respectively.

Conclusions

In this longitudinal observational study, passive activity data acquired by an iPhone and Apple Watch were an accurate predictor of in-clinic 6MWT performance. This finding suggests that frailty and functional capacity could be monitored and evaluated remotely in patients with cardiovascular disease, enabling safer and higher resolution monitoring of patients.

Association between nontraditional lipid profiles and peripheral arterial disease in Chinese adults with hypertension

BACKGROUND

Data on the relationship between nontraditional lipid profiles [total cholesterol (TC)/high-density lipoprotein cholesterol (HDL-C) ratio, triglyceride (TG)/HDL-C ratio, low-density lipoprotein cholesterol (LDL-C)/HDL-C ratio, non-high-density lipoprotein cholesterol (non-HDL-C)] and the risk of peripheral artery disease (PAD) are limited. The present study investigated the relationship of nontraditional lipid indices with PAD in hypertensive patients.

METHODS

This cross-sectional study was performed among 10,900 adults with hypertension. Participants were diagnosed with PAD when their ankle-brachial index (ABI) was < 0.9. The association between nontraditional lipid profiles and PAD was examined using multivariate logistic regression analysis and the restricted cubic spline.

RESULTS

All nontraditional lipid indices were independently and positively associated with PAD in a dose-response fashion. After multivariable adjustment, the per SD increments of the TC/HDL-C, TG/HDL-C, LDL-C/HDL-C ratios and non-HDL-C were all significantly associated with 37, 14, 40, and 24% higher risk for PAD, respectively. The adjusted ORs (95% CI) for PAD were 1.77 (1.31, 2.40), 1.71 (1.25, 2.34), 2.03 (1.50, 2.74), and 1.70 (1.25, 2.31) when comparing the highest tertile to the lowest tertile of the TC/HDL-C, TG/HDL-C, LDL-C/HDL-C ratios and non-HDL-C, respectively.

CONCLUSIONS

Among Chinese hypertensive adults, all nontraditional lipid indices were positively associated with PAD, and the LDL-C/HDL-C and TC/HDL-C ratios were better than the other nontraditional lipid indices for predicting PAD. These findings may improve the risk stratification of cardiovascular disease and dyslipidemia management.

TRIAL REGISTRATION

CHiCTR, ChiCTR1800017274 . Registered 20 July 2018.

Use of the ankle-brachial index combined with the percentage of mean arterial pressure at the ankle to improve prediction of all-cause mortality in type 2 diabetes mellitus: an observational study

Background

Peripheral artery disease (PAD) in the lower extremities is a common complication of type 2 diabetes and has been shown to be associated with mortality. The ankle-brachial index (ABI) is a simple noninvasive method to screen PAD, but this method has limited sensitivity. We hypothesized that using the percentage of mean arterial pressure (%MAP) in combination with the ABI would improve the prediction of mortality.

Methods

We retrospectively collected data from patients with type 2 diabetes who had undergone ABI and  %MAP measurements at our hospital. We separated the cohort into four groups according to their ABI and  %MAP values, and we examined whether these indices were associated with mortality.

Results

A total of 5569 patients (mean age, 65 ± 11 years) were enrolled. During the follow-up period (median, 22.9 months), 266 (4.8%) of the enrolled patients died. The combination of ABI and  %MAP was significantly more effective than ABI alone for predicting mortality (C index of 0.62, 95% confidence interval [CI] of 0.57 to 0.65 vs. C index of 0.57, 95% CI of 0.53 to 0.62; P = 0.038). In multivariate analysis (with a reference group defined by ABI > 0.90 and  %MAP ≤ 45%), the highest risk of mortality was seen in patients with ABI ≤ 0.90 and  %MAP > 45% (hazard ratio = 2.045 [95% CI 1.420, 2.945], P < 0.001).

Conclusions

The use of  %MAP alongside ABI appears to significantly improve the prediction of all-cause mortality in patients with type 2 diabetes.

Concordance between automated oscillometric measurement of ankle-brachial index and traditional measurement by eco-Doppler in patients without peripheral artery disease

AIM

To evaluate the concordance between automated oscillometric measurement (WatchBP® Office ABI) of the ankle- brachial index (ABI) and the traditional measurement by eco-Doppler in a Spanish population without peripheral artery disease attended in primary care.

METHODS

The ABI was determined by both methods in a general population aged ≥ 18 years, from the RICARTO study. The intraclass correlation coefficient was calculated to assess the concordance between both techniques and the Bland-Altman plot was determined to analyze the agreement between them.

RESULTS

A total of 322 subjects (mean age 47.7 ± 16.0 years; 54.3% women) were included in the study. With regard to cardiovascular risk factors, 70.5% of subjects had dyslipidemia, 26.7% hypertension, 24.8% obesity, 8.4% diabetes and 25.5% were smokers. Mean ABI measured by eco-Doppler and the automated method were 1.17 ± 0.1 and 1.2 ± 0.1, respectively (mean differences - 0.03 ± 0.09; p < 0.001). The Pearson correlation coefficient and the intraclass correlation coefficient were in both cases 0.70.

CONCLUSIONS

The automated oscillometric measurement of ABI is a reliable and useful alternative to conventional eco-Doppler determination in the general population without peripheral artery disease attended in primary care.

Lifestyle and dietary risk factors for peripheral artery disease

Peripheral artery disease (PAD) usually refers to ischemia of the lower limb vessels. Currently, the estimated number of cases in the world is 202 million. PAD is the third leading cause of atherosclerotic cardiovascular morbidity. The measurement of the ankle-brachial index (ABI) is recommended as a first-line noninvasive test for screening and diagnosis of PAD. An ABI <0.90 is an independent predictor of cardiovascular events and this measurement is useful to identify patients at moderate to high risk of cardiovascular disease. However, there is insufficient evidence to assess the benefits and harms of screening for PAD with the ABI in asymptomatic adults. Lifestyle modifications, including smoking cessation, dietary changes and physical activity, are currently the most cost-effective interventions. Inverse associations with PAD have been reported for some subtypes of dietary fats, fiber, antioxidants (vitamins E and C), folate, vitamins B6, B12 and D, flavonoids, and fruits and vegetables. A possible inverse association between better adherence to the Mediterranean diet and the risk of symptomatic PAD has also been reported in a large randomized clinical trial. Therefore, a Mediterranean-style diet could be effective in the primary and secondary prevention of PAD, although further experimental studies are needed to better clarify this association.  (Circ J 2014; 78: 553-559).