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Mwipatayi BP, Barry IP, Hanna J, Macarulay R, Wong J, Thomas S, Vijayan V, Puttaswamy V, Ward NC. A sex-based analysis of 5-year outcomes following stenting for the treatment of aorto-iliac occlusive disease. Vascular 2023:17085381231194152. [PMID: 37548646 DOI: 10.1177/17085381231194152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate the impact of sex on mid-term outcomes following stenting for aorto-iliac occlusive disease (AIOD). METHODS The Covered versus Balloon Expandable Stent Trial (COBEST) compared the safety and efficacy of the covered stent (CS) with those of the bare metal stent (BMS) in the treatment of hemodynamically significant AIOD. It was identified that CS provided a significant benefit. The primary endpoint of our analysis was the rate of primary patency 5 years following stenting for AIOD (inclusive of both CS and BMS) in both sexes. RESULTS Of the 168 lesions treated, 103 (61%) were present in men and 65 (39%) were present in women. Of the concomitant comorbidities, diabetes mellitus was significantly more common in women (17.5% vs 41.5%, p = .006). Although chronic limb threatening ischemia (CLTI) at the time of intervention was more common in women, the difference was not significant (16.5% vs 24.6%, p = .395). Sex was not associated with the primary patency rate (male; 0.70, 95% confidence interval [CI]: 0.23-2.19, p = .543). When considering both male sex and the utilization of BMS, no significant impact was found on the primary patency rate (hazard ratio [HR]: 3.43, 95% CI: 0.69-17.10, p = .133). All-cause mortality at 60 months was 22.6% in men compared to 19.4% in women (p = .695). CONCLUSIONS No significant difference was identified in the primary patency rate between the sexes. Further investigation is warranted to ascertain whether sex-specific interventional guidelines are required in this regard.
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Affiliation(s)
- Bibombe Patrice Mwipatayi
- Department of Vascular Surgery, Royal Perth Hospital, Perth, WA, Australia
- School of Surgery, University of Western Australia, Perth, WA, Australia
| | - Ian Patrick Barry
- Department of Vascular Surgery, Royal Perth Hospital, Perth, WA, Australia
| | - Joseph Hanna
- Department of Vascular Surgery, Royal Perth Hospital, Perth, WA, Australia
| | - Reane Macarulay
- Department of Vascular Surgery, Royal Perth Hospital, Perth, WA, Australia
| | - Jackie Wong
- Department of Vascular Surgery, Royal Perth Hospital, Perth, WA, Australia
| | - Shannon Thomas
- Department of Vascular Surgery, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Vikram Vijayan
- Vascular Diagnostic Laboratory, Ng Teng Fong General Hospital, Singapore
| | - Vikram Puttaswamy
- Department of Vascular Surgery, Royal North Shore Hospital, Northern Sydney, NSW, Australia
| | - Natalie C Ward
- Dobney Hypertension Centre, Medical School, University of Western Australia, Perth, WA, Australia
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One simple claudication question as first step in Peripheral Arterial Disease (PAD) screening: A meta-analysis of the association with reduced Ankle Brachial Index (ABI) in 27,945 subjects. PLoS One 2019; 14:e0224608. [PMID: 31682633 PMCID: PMC6827909 DOI: 10.1371/journal.pone.0224608] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 10/17/2019] [Indexed: 12/31/2022] Open
Abstract
Purpose and methods A meta-analysis using data from seven German population-based cohorts was performed by the German Epidemiological consortium of Peripheral Arterial Disease (GEPArD) to investigate whether one question about claudication is more efficient for PAD screening than established questionnaires. Claudication was defined on the basis of the answer to one question asking for pain in the leg during normal walking. This simple question was compared with established questionnaires, including the Edinburgh questionnaire. The associations of claudication with continuous ABI values and decreased ABI were analyzed by linear and logistic regression analysis, respectively. The results of the studies were pooled in a random effect meta-analysis, which included data from 27,945 individuals (14,052 women, age range 20–84 years). Results Meta-analysis revealed a significant negative association between claudication and ABI, which was stronger in men (β = -0.07; 95%CI -0.10, -0.04) than in women (β = -0.02; 95%CI -0.02, -0.01). Likewise, the presence of claudication symptoms was related to an increased odds of a decreased ABI in both men (Odds ratio = 5.40; 95%CI 4.20, 6.96) and women (Odds ratio = 1.99; 95%CI 1.58, 2.51). Conclusions Asking only one question about claudication was able to identify many individuals with a high likelihood of a reduced ABI with markedly higher sensitivity and only slightly reduced specificity compared to more complex questionnaires. At least in men, this question should be established as first screening step.
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Yandrapalli S, Pal S, Nabors C, Aronow WS. Drug treatment of hypertension in older patients with diabetes mellitus. Expert Opin Pharmacother 2018; 19:633-642. [PMID: 29578856 DOI: 10.1080/14656566.2018.1456529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Hypertension is more prevalent in the elderly (age>65 years) diabetic population than in the general population and shows an increasing prevalence with advancing age. Both diabetes mellitus (DM) and hypertension are independent risk factors for cardiovascular (CV) related morbidity and mortality. Optimal BP targets were not identified in elderly patients with DM and hypertension. AREAS COVERED In this review article, the authors briefly discuss the pathophysiology of hypertension in elderly diabetics, present evidence with various antihypertensive drug classes supporting the treatment of hypertension to reduce CV events in older diabetics, and then discuss the optimal target BP goals in these patients. EXPERT OPINION Clinicians should have a BP goal of less than 130/80 mm in all elderly patients with hypertension and DM, especially in those with high CV-risk. When medications are required for optimal BP control in addition to lifestyle measures, either thiazide diuretics, angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers, or calcium channel blockers should be considered as initial therapy. Combinations of medications are usually required in these patients because BP control is more difficult to achieve in diabetics than those without DM.
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Affiliation(s)
- Srikanth Yandrapalli
- a Cardiology Division, Department of Medicine , Westchester Medical Center/New York Medical College , Valhalla , NY , USA
| | - Suman Pal
- a Cardiology Division, Department of Medicine , Westchester Medical Center/New York Medical College , Valhalla , NY , USA
| | - Christopher Nabors
- a Cardiology Division, Department of Medicine , Westchester Medical Center/New York Medical College , Valhalla , NY , USA
| | - Wilbert S Aronow
- a Cardiology Division, Department of Medicine , Westchester Medical Center/New York Medical College , Valhalla , NY , USA
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Biscetti F, Gentileschi S, Bertucci F, Servillo M, Arena V, Angelini F, Stigliano E, Bonanno G, Scambia G, Sacchetti B, Pierelli L, Landolfi R, Flex A. The angiogenic properties of human adipose-derived stem cells (HASCs) are modulated by the High mobility group box protein 1 (HMGB1). Int J Cardiol 2017; 249:349-356. [PMID: 28967436 DOI: 10.1016/j.ijcard.2017.09.165] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 09/04/2017] [Accepted: 09/18/2017] [Indexed: 12/16/2022]
Abstract
Peripheral arterial disease (PAD), is a major health problem. Many studies have been focused on the possibilities of treatment offered by vascular regeneration. Human adipose-derived stem cells (HASCs), multipotent CD34+ stem cells found in the stromal-vascular fraction of adipose tissues, which are capable to differentiate into multiple mesenchymal cell types. The High mobility group box 1 protein (HMGB1) is a nuclear protein involved in angiogenesis. The aim of the study was to define the role of HMGB1 in cell therapy with HASCs, in an animal model of PAD. We induced unilateral ischemia in mice and we treated them with HASCs, with the specific HMGB1-inihibitor BoxA, with HMGB1 protein, and with the specific VEGF inhibitor sFlt1, alternately or concurrently. We measured the blood flow recovery in all mice. Immunohistochemical and ELISA analyses was performed to evaluate the number of vessels and the VEGF tissue content. None auto-amputation occurred and there have been no rejection reactions to the administration of HASCs. Animals co-treated with HASCs and HMGB1 protein had an improved blood flow recovery, compared to HASCs-treated mice. The post-ischemic angiogenesis was reduced when the HMGB1 pathway was blocked or when the VEGF activity was inhibited, in mice co-treated with HASCs and HMGB1. In conclusion, the HASCs treatment can be used in a mouse model of PAD to induce post-ischemic angiogenesis, modulating angiogenesis by HMGB1. This effect is mediated by VEGF activity. Although further data are needed, these findings shed light on possible new cell treatments for patients with PAD.
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Affiliation(s)
- Federico Biscetti
- Division of Rheumatology, Institute of Rheumatology & Related Sciences, Fondazione Policlinico Universitario "A. Gemelli", Catholic University School of Medicine, Rome, Italy; Laboratory of Vascular Biology and Genetics, Department of Medicine, Fondazione Policlinico Universitario "A. Gemelli", Catholic University School of Medicine, Rome, Italy.
| | - Stefano Gentileschi
- Division of Plastic Surgery, Fondazione Policlinico Universitario "A. Gemelli", Catholic University School of Medicine, Rome, Italy
| | - Flavio Bertucci
- Laboratory of Vascular Biology and Genetics, Department of Medicine, Fondazione Policlinico Universitario "A. Gemelli", Catholic University School of Medicine, Rome, Italy
| | - Maria Servillo
- Division of Plastic Surgery, Fondazione Policlinico Universitario "A. Gemelli", Catholic University School of Medicine, Rome, Italy
| | - Vincenzo Arena
- Department of Pathology, Fondazione Policlinico Universitario "A. Gemelli", Catholic University School of Medicine, Rome, Italy
| | - Flavia Angelini
- Laboratory of Vascular Biology and Genetics, Department of Medicine, Fondazione Policlinico Universitario "A. Gemelli", Catholic University School of Medicine, Rome, Italy
| | - Egidio Stigliano
- Department of Pathology, Fondazione Policlinico Universitario "A. Gemelli", Catholic University School of Medicine, Rome, Italy
| | - Giuseppina Bonanno
- Division of Gynecology, Fondazione Policlinico Universitario "A. Gemelli", Catholic University School of Medicine, Rome, Italy
| | - Giovanni Scambia
- Division of Gynecology, Fondazione Policlinico Universitario "A. Gemelli", Catholic University School of Medicine, Rome, Italy
| | | | - Luca Pierelli
- Immunohematology and Transfusion Medicine, San Camillo Forlanini Hospital, Rome, Italy; Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Raffaele Landolfi
- Department of Internal Medicine, Fondazione Policlinico Universitario "A. Gemelli", Catholic University School of Medicine, Rome, Italy
| | - Andrea Flex
- Laboratory of Vascular Biology and Genetics, Department of Medicine, Fondazione Policlinico Universitario "A. Gemelli", Catholic University School of Medicine, Rome, Italy; Department of Internal Medicine, Fondazione Policlinico Universitario "A. Gemelli", Catholic University School of Medicine, Rome, Italy
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Affiliation(s)
- GC Leng
- The Wolfson Unit for the Prevention of Peripheral Vascular Diseases, University of Edinburgh, UK
| | - FGR Fowkes
- The Wolfson Unit for the Prevention of Peripheral Vascular Diseases, University of Edinburgh, UK
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Lind P, Hedblad B, Stavenow L, Engström G, Janzon L, Ogren M, Lindgärde F. Incidence of Myocardial Infarction and Death in Relation to Walking-Induced Calf Pain and Plasma Levels of Inflammation-Sensitive Proteins. Angiology 2016; 56:507-16. [PMID: 16193189 DOI: 10.1177/000331970505600501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Walking-induced calf pain as well as levels of different inflammation-sensitive plasma proteins (ISPs) are related to cardiovascular disease (CVD). This prospective cohort study explored the relationship between ISPs and walking-related calf pain and the interrelationships between ISPs and calf pain in the prediction of death and incidence of coronary events (CE). In 5,725 apparently healthy men, 46 ±3.0 years old, plasma concentrations of orosomucoid (a1-acid glycoprotein), a1-antitrypsin, haptoglobin, fibrinogen, and ceruloplasmin were measured. Walking-induced calf pain was assessed by questionnaire. Mortality and incidence of CE were monitored over a mean follow-up of 18 years in subjects defined by the presence of calf pain and ISP level (0 to 1 or 2 to 5 ISP(s) in the top quartile). The prevalence of calf pain (7.3%) was significantly related to age, lifestyle, and traditional risk factors of CVD and ISP levels. The risk factor-adjusted relative risks for CE, CVD- and all-cause mortality were 1.89 (CI: 1.27 to 2.82), 2.90 (CI: 1.82 to 4.62), and 2.67 (CI: 1.97 to 3.57), respectively, for men with calf pain and high ISP levels (reference: no calf pain and low ISP levels). The corresponding risk for those with calf pain and low ISP levels were 1.34 (CI: 0.91 to 1.97), 1.47 (CI: 0.90 to 2.41), and 1.31 (CI: 0.95 to 1.81), respectively. These results indicate, on the one hand, that walking-induced calf pain is associated with high ISP levels and, on the other, that the risk of CVD in men with calf pain is substantially higher in those with high ISP levels than in those with low levels.
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Affiliation(s)
- Peter Lind
- Division of Medical Angiology, Department of Internal Medicine, Lund University, Malmö University Hospital, Malmö, Sweden.
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Fabris F, Zanocchi M, Bo M, Poli L, Fonte G. Peripheral Atherosclerotic Disease: Aging and Risk Factors. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857449502900203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this study was to assess the prevalence of peripheral atherosclerotic disease (PAD) and its relation to principal cardiovascular risk factors, at different ages, in a sample of the general population. Ultrasonographic methods (continuous wave Doppler and high-resolution B-mode Doppler) were used to evaluate the ankle-to-arm ratio and to investigate the femoral district in 457 free-living subjects (231 men and 226 women, mean age 55.4 ±18.7 years) resident in the metropolitan area of Turin. PAD, detected by ankle-to-arm ratio, was observed in 148 subjects (32.4%). Femoral plaques were found in 180 subjects (39.4%). The overall prevalence of atherosclerosis, number of plaques, and percentage of stenosis were observed to increase with age (P < 0.0001). In the multiple logistic regression model, analysis of subjects under sixty-five years of age showed independent associations between femoral atherosclerosis and age (P < 0.0001), LDL cholesterol (P < 0.01), cigarette smoking (P < 0.05), and years of exposure to smoking (P < 0.05); analysis of subjects over sixty-five years of age showed positive and independent associations only with age (P < 0.001), male gender (P < 0.01), and cigarette smoking (P < 0.05). The authors conclude that there is a high prevalence of asymptomatic lower limb atherosclerosis in the general population, particularly among the very old. The association between risk factors and femoral atherosclerosis is less pronounced in the elderly than in younger subjects.
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Affiliation(s)
| | | | | | | | - Gianfranco Fonte
- Department of Geriatric Medicine, University of Turin, Molinette Hospital, Torino, Italy
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Howard DPJ, Banerjee A, Fairhead JF, Hands L, Silver LE, Rothwell PM. Population-Based Study of Incidence, Risk Factors, Outcome, and Prognosis of Ischemic Peripheral Arterial Events: Implications for Prevention. Circulation 2015; 132:1805-15. [PMID: 26350058 PMCID: PMC4633967 DOI: 10.1161/circulationaha.115.016424] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 08/24/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND There are few published data on the incidence and long-term outcomes of critical limb ischemia, acute limb ischemia, or acute visceral ischemia with which to inform health service planning, to monitor prevention, and to enable risk prediction. METHODS AND RESULTS In a prospective population-based study (Oxfordshire, UK; 2002-2012), we determined the incidence and outcome of all acute peripheral arterial events in a population of 92,728. Risk factors were assessed by comparison with the underlying population. A total of 510 acute events occurred in 386 patients requiring 803 interventions. Two hundred twenty-one patients (59.3%) were ≥75 years of age, and 98 (26.3%) were ≥85 years old. Two hundred thirty patients (62.3%) were independent before the event, but 270 (73.4%) were dead or dependent at the 6-month follow-up, and 328 (88.9%) were dead or dependent at 5 years. The 30-day survival was lowest for patients with acute visceral ischemia (28.2%) compared with acute limb ischemia (75.3%) and critical limb ischemia (92.6%; P<0.001). Risk factors (all P<0.001) were hypertension (age- and sex-adjusted risk ratio, 2.75; 95% confidence interval, 1.95-3.90), smoking (adjusted risk ratio, 2.14; 95% confidence interval, 1.37-3.34), and diabetes mellitus (adjusted risk ratio, 3.01; 95% confidence interval, 1.69-5.35), particularly for critical limb ischemia (adjusted risk ratio, 5.96; 95% confidence interval, 3.15-11.26). Two hundred eighty-eight patients (77.2%) had known previous cardiovascular disease, and 361 (96.8%) had vascular risk factors, but only 203 (54.4%) were on an antiplatelet and only 166 (44.5%) were on a statin. Although 260 patients (69.7%) were taking antihypertensives, 42.9% of all blood pressures recorded during the 5 years before the event were >140/90 mm Hg. Of 88 patients (23.6%) with incident cardioembolic events, 62 had known atrial fibrillation (diagnosed before the event), of whom only 14.5% were anticoagulated despite 82.3% having a CHA2DS2VASC score ≥2 without contraindications. CONCLUSIONS The clinical burden of peripheral arterial events is substantial. Although the vast majority of patients have known vascular disease in other territories and multiple treatable risk factors, premorbid control is poor.
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Affiliation(s)
- Dominic P J Howard
- From Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (D.P.J.H., A.B., J.F.F., L.E.S., P.M.R.); Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (D.P.J.H., L.H.); and Centre for Cardiovascular Sciences, University of Birmingham, UK (A.B.)
| | - Amitava Banerjee
- From Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (D.P.J.H., A.B., J.F.F., L.E.S., P.M.R.); Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (D.P.J.H., L.H.); and Centre for Cardiovascular Sciences, University of Birmingham, UK (A.B.)
| | - Jack F Fairhead
- From Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (D.P.J.H., A.B., J.F.F., L.E.S., P.M.R.); Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (D.P.J.H., L.H.); and Centre for Cardiovascular Sciences, University of Birmingham, UK (A.B.)
| | - Linda Hands
- From Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (D.P.J.H., A.B., J.F.F., L.E.S., P.M.R.); Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (D.P.J.H., L.H.); and Centre for Cardiovascular Sciences, University of Birmingham, UK (A.B.)
| | - Louise E Silver
- From Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (D.P.J.H., A.B., J.F.F., L.E.S., P.M.R.); Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (D.P.J.H., L.H.); and Centre for Cardiovascular Sciences, University of Birmingham, UK (A.B.)
| | - Peter M Rothwell
- From Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (D.P.J.H., A.B., J.F.F., L.E.S., P.M.R.); Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (D.P.J.H., L.H.); and Centre for Cardiovascular Sciences, University of Birmingham, UK (A.B.)
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Abstract
New data on the epidemiology of peripheral artery disease (PAD) are available, and they should be integrated with previous data. We provide an updated, integrated overview of the epidemiology of PAD, a focused literature review was conducted on the epidemiology of PAD. The PAD results were grouped into symptoms, diagnosis, prevalence, and incidence both in the United States and globally, risk factors, progression, coprevalence with other atherosclerotic disease, and association with incident cardiovascular morbidity and mortality. The most common symptom of PAD is intermittent claudication, but noninvasive measures, such as the ankle-brachial index, show that asymptomatic PAD is several times more common in the population than intermittent claudication. PAD prevalence and incidence are both sharply age-related, rising >10% among patients in their 60s and 70s. With aging of the global population, it seems likely that PAD will be increasingly common in the future. Prevalence seems to be higher among men than women for more severe or symptomatic disease. The major risk factors for PAD are similar to those for coronary and cerebrovascular disease, with some differences in the relative importance of factors. Smoking is a particularly strong risk factor for PAD, as is diabetes mellitus, and several newer risk markers have shown independent associations with PAD. PAD is strongly associated with concomitant coronary and cerebrovascular diseases. After adjustment for known cardiovascular disease risk factors, PAD is associated with an increased risk of incident coronary and cerebrovascular disease morbidity and mortality.
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Affiliation(s)
- Michael H Criqui
- From the Division of Preventive Medicine, Department of Family and Preventive Medicine, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, CA (M.H.C.); Department of Cardiology, Dupuytren University Hospital, Limoges, France (V.A.); and INSERM 1094, Tropical Neuroepidemiology, Limoges School of Medicine, Limoges, France (V.A.).
| | - Victor Aboyans
- From the Division of Preventive Medicine, Department of Family and Preventive Medicine, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, CA (M.H.C.); Department of Cardiology, Dupuytren University Hospital, Limoges, France (V.A.); and INSERM 1094, Tropical Neuroepidemiology, Limoges School of Medicine, Limoges, France (V.A.)
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Marcia S, Hirsch JA, Chandra RV, Marras M, Piras E, Anselmetti GC, Muto M, Saba L. Midterm Clinical and Radiologic Outcomes after Percutaneous Interspinous Spacer Treatment for Neurogenic Intermittent Claudication. J Vasc Interv Radiol 2015; 26:1687-93.e1-2. [PMID: 26119203 DOI: 10.1016/j.jvir.2015.05.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Revised: 04/22/2015] [Accepted: 05/07/2015] [Indexed: 01/20/2023] Open
Abstract
PURPOSE To evaluate the midterm clinical and radiologic outcome of percutaneous interspinous process spacer (IPS) treatment for neurogenic intermittent claudication (NIC) in patients who fail conservative treatment. METHODS Consecutive patients with NIC, lumbar spinal stenosis confirmed on magnetic resonance imaging, failure of conservative management for at least 6 months, and treatment with percutaneous IPS were included. Visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were recorded at baseline, 1 month, 1 year and 3 years after treatment. Spinal canal and foraminal cross-sectional areas were calculated from multidetector computed tomography at baseline and 1 year. RESULTS There were 80 patients treated with 94 IPS devices; 83% of patients received a single IPS; 78% of IPS devices were placed at L4-L5. An IPS dislocation was the single periprocedural major complication. VAS score of 8.1 ± 2 before treatment was reduced to 4.4 ± 2 at 1 month after treatment (P = .0001); ODI score of 23.3 ± 10 before treatment was reduced to 11.7 ± 8.5 at 1 month after treatment (P = .0001). These significant reductions were durable at 1-year and 3-year follow-up evaluations (P < .01). Spinal canal and foraminal cross-sectional area increased by 15% at 1 year (P = .0001). CONCLUSIONS Patients with NIC who failed conservative treatment and were treated with percutaneous IPS achieved significant gains in pain relief and reduced disability that remained durable at 3-year clinical follow-up evaluation. This outcome was accompanied by significant increases in spinal canal and foraminal cross-sectional areas at the treated level.
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Affiliation(s)
- Stefano Marcia
- Department of Radiology, SS. Trinità Hospital, Cagliari, Italy
| | - Joshua A Hirsch
- Neuroendovascular Program, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ronil V Chandra
- Neurovascular Surgery and Neuroradiology Services, Monash Health, Monash University, Melbourne, Australia
| | | | - Emanuele Piras
- Department of Radiology, SS. Trinità Hospital, Cagliari, Italy
| | | | - Mario Muto
- Department of Neuroradiology, Ospedale Cardarelli, Naples, Italy
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari-Polo di Monserrato s.s. 554 Monserrato, Cagliari 09045, Italy.
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Nadeau M, Rosas-Arellano MP, Gurr KR, Bailey SI, Taylor DC, Grewal R, Lawlor DK, Bailey CS. The reliability of differentiating neurogenic claudication from vascular claudication based on symptomatic presentation. Can J Surg 2014; 56:372-7. [PMID: 24284143 DOI: 10.1503/cjs.016512] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Intermittent claudication can be neurogenic or vascular. Physicians use a profile based on symptom attributes to differentiate the 2 types of claudication, and this guides their investigations for diagnosis of the underlying pathology. We evaluated the validity of these symptom attributes in differentiating neurogenic from vascular claudication. METHODS Patients with a diagnosis of lumbar spinal stenosis (LSS) or peripheral vascular disease (PVD) who reported claudication answered 14 questions characterizing their symptoms. We determined the sensitivity, specificity and positive and negative likelihood ratios (PLR and NLR) for neurogenic and vascular claudication for each symptom attribute. RESULTS We studied 53 patients. The most sensitive symptom attribute to rule out LSS was the absence of "triggering of pain with standing alone" (sensitivity 0.97, NLR 0.050). Pain alleviators and symptom location data showed a weak clinical significance for LSS and PVD. Constellation of symptoms yielded the strongest associations: patients with a positive shopping cart sign whose symptoms were located above the knees, triggered with standing alone and relieved with sitting had a strong likelihood of neurogenic claudication (PLR 13). Patients with symptoms in the calf that were relieved with standing alone had a strong likelihood of vascular claudication (PLR 20.0). CONCLUSION The classic symptom attributes used to differentiate neurogenic from vascular claudication are at best weakly valid independently. However, certain constellation of symptoms are much more indicative of etiology. These results can guide general practitioners in their evaluation of and investigation for claudication.
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Affiliation(s)
- Mélissa Nadeau
- The Division of Orthopaedics, Department of Surgery, The University of Western Ontario, London, Ont
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Abstract
BACKGROUND Peripheral arterial disease (PAD) causes considerable morbidity and mortality. Hypertension is a risk factor for PAD. Treatment for hypertension must be compatible with the symptoms of PAD. Controversy regarding the effects of beta-adrenoreceptor blockade for hypertension in patients with PAD has led many physicians to stop prescribing beta-adrenoreceptor blockers. Little is known about the effects of other classes of anti-hypertensive drugs in the presence of PAD. This is the second update of a Cochrane review first published in 2003. OBJECTIVES To determine the effects of anti-hypertensive drugs in patients with both raised blood pressure and symptomatic PAD in terms of the rate of cardiovascular events and death, symptoms of claudication and critical leg ischaemia, and progression of atherosclerotic PAD as measured by ankle brachial index (ABI) changes and the need for revascularisation (reconstructive surgery or angioplasty) or amputation. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Cochrane Peripheral Vascular Diseases Group Specialised Register (last searched March 2013) and CENTRAL (2013, Issue 2). SELECTION CRITERIA Randomised controlled trials (RCTs) of at least one anti-hypertensive treatment against placebo or two anti-hypertensive medications against each other, with interventions lasting at least one month. Trials had to include patients with symptomatic PAD. DATA COLLECTION AND ANALYSIS Data were extracted by one author (DAL) and checked by the other (GYHL). Potentially eligible studies were excluded when the results presentation prevented adequate extraction of data and enquiries to authors did not yield raw data. MAIN RESULTS Eight RCTs were included with a total of 3610 PAD patients. Four studies compared a recognised class of anti-hypertensive treatment with placebo and four studies compared two anti-hypertensive treatments with each other. Studies were not pooled due to the variation of the comparisons and the outcomes presented. Overall the quality of the available evidence was unclear, primarily as a result of a lack of detail in the study reports on the randomisation and blinding procedures and incomplete outcome data. Two studies compared angiotensin converting enzyme (ACE) inhibitors against placebo. In one study there was a significant reduction in the number of cardiovascular events in patients receiving ramipril (odds ratio (OR) 0.72, 95% confidence interval (CI) 0.58 to 0.91; n = 1725). In the second trial using perindopril (n = 52) there was a marginal increase in claudication distance but no change in ABI and a reduction in maximum walking distance. A trial comparing the calcium antagonist verapamil versus placebo in patients undergoing angioplasty (n = 96) suggested that verapamil reduced restenosis (per cent diameter stenosis (± SD) 48.0% ± 11.5 versus 69.6% ± 12.2; P < 0.01), although this was not reflected in the maintenance of a high ABI (0.76 ± 0.10 versus 0.72 ± 0.08 for verapamil versus placebo). Another study (n = 80) demonstrated no significant difference in arterial intima-media thickness (IMT) in men receiving the thiazide diuretic hydrochlorothiazide (HCTZ) compared to those receiving the alpha-adrenoreceptor blocker doxazosin (-0.12 ± 0.14 mm and -0.08 ± 0.13 mm, respectively; P = 0.66). A study (n = 36) comparing telmisartan to placebo found a significant improvement in maximum walking distance at 12 months with telmisartan (median (interquartile range (IQR)) 191 m (157 to 226) versus 103 m (76 to 164); P < 0.001) but no differences in ABI (median (IQR) 0.60 (0.60 to 0.77) versus 0.52 (0.48 to 0.67)) or arterial IMT (median (IQR) 0.08 cm (0.07 to 0.09) versus 0.09 cm (0.08 to 0.10)). Two studies compared the beta-adrenoreceptor blocker nebivolol with either the thiazide diuretic HCTZ or with metoprolol. Both studies found no significant differences in intermittent or absolute claudication distance, ABI, or all-cause mortality between the anti-hypertensives. A subgroup analysis of PAD patients (n = 2699) in a study which compared a calcium antagonist-based strategy (verapamil slow release (SR) ± trandolapril) to a beta-adrenoreceptor blocker-based strategy (atenolol ± hydrochlorothiazide) found no significant differences in the composite endpoints of death, non-fatal myocardial infarction or non-fatal stroke with or without revascularisation (OR 0.90, 95% CI 0.76 to 1.07 and OR 0.96, 95% CI 0.82 to 1.13, respectively). AUTHORS' CONCLUSIONS Evidence on the use of various anti-hypertensive drugs in people with PAD is poor so that it is unknown whether significant benefits or risks accrue. However, lack of data specifically examining outcomes in PAD patients should not detract from the overwhelming evidence on the benefit of treating hypertension and lowering blood pressure.
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Affiliation(s)
- Deirdre A Lane
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Dudley Road, Birmingham, UK, B18 7QH
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Biscetti F, Pecorini G, Straface G, Arena V, Stigliano E, Rutella S, Locatelli F, Angelini F, Ghirlanda G, Flex A. Cilostazol promotes angiogenesis after peripheral ischemia through a VEGF-dependent mechanism. Int J Cardiol 2013; 167:910-6. [DOI: 10.1016/j.ijcard.2012.03.103] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 03/06/2012] [Accepted: 03/08/2012] [Indexed: 11/27/2022]
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14
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Screening for Peripheral Arterial Disease in a Long-term Care Setting. TOPICS IN GERIATRIC REHABILITATION 2013. [DOI: 10.1097/tgr.0b013e31828aef76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Karason K, Peltonen M, Lindroos AK, Sjöström L, Lönn L, Torgerson JS. Effort-Related Calf Pain in the Obese and Long-Term Changes after Surgical Obesity Treatment**. ACTA ACUST UNITED AC 2012; 13:137-45. [PMID: 15761173 DOI: 10.1038/oby.2005.18] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare the prevalence of effort-related calf pain in an obese and a general population and to analyze the incidence of and recovery from such pain after surgical and conventional obesity treatment. RESEARCH METHODS AND PROCEDURES A random sample of 1135 subjects from a general population was compared with 6328 obese subjects in the Swedish Obese Subjects study. Obese subjects were followed longitudinally, and information about calf pain was obtained from surgically and conventionally treated patients for up to 6 years. RESULTS In both sexes, self-reported calf pain was more common in the obese than in the general population [odds ratios (ORs) 5.0 and 4.0 in men and women, respectively, p<0.001]. Obese patients undergoing surgery had a lower 6-year incidence of calf pain compared with the conventionally treated control group (ORs 0.39 and 0.61, p<0.05). Among subjects reporting symptoms at baseline, the 6-year recovery rate was higher in the surgical group compared with the control group (ORs 15.3 and 5.9, p<0.001). DISCUSSION Obese subjects have markedly more problems with effort-related calf pain than the general population. Surgical obesity treatment reduces the long-term risk of developing claudication symptoms and increases the likelihood of recovering from such symptoms.
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Affiliation(s)
- Kristjan Karason
- Department of Cardiology, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden.
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16
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Aronow WS. Peripheral arterial disease of the lower extremities. Arch Med Sci 2012; 8:375-88. [PMID: 22662015 PMCID: PMC3361053 DOI: 10.5114/aoms.2012.28568] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 10/05/2011] [Accepted: 10/17/2011] [Indexed: 11/17/2022] Open
Abstract
Persons with peripheral arterial disease (PAD) are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from coronary artery disease. Smoking should be stopped and hypertension, dyslipidemia, diabetes mellitus, and hypothyroidism treated. Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolemia. The serum low-density lipoprotein cholesterol should be reduced to < 70 mg/dl. Antiplatelet drugs such as aspirin or clopidogrel, angiotensin-converting enzyme inhibitors, and statins should be given to persons with PAD. β-Blockers should be given if coronary artery disease is present. Cilostazol improves exercise time until intermittent claudication. Exercise rehabilitation programs should be used. Revascularization should be performed if indicated.
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Brenner I, Parry M, Brown CA. Exercise interventions for patients with peripheral arterial disease: a review of the literature. PHYSICIAN SPORTSMED 2012; 40:41-55. [PMID: 22759605 DOI: 10.3810/psm.2012.05.1964] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Ingrid Brenner
- Trent University, Trent/Fleming School of Nursing, Peterborough, Ontario, Canada.
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Sarangi S, Srikant B, Rao DV, Joshi L, Usha G. Correlation between peripheral arterial disease and coronary artery disease using ankle brachial index-a study in Indian population. Indian Heart J 2012; 64:2-6. [PMID: 22572416 DOI: 10.1016/s0019-4832(12)60002-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To study the prevalence of peripheral arterial disease (PAD) of the lower limbs in a high-risk population and its correlation with coronary artery disease (CAD), using the ankle brachial index (ABI). METHODS The present study was conducted in randomly selected indoor patients >45 years of age with one or more risk factors for PAD admitted in the cardiology and medicine wards in a tertiary care institute. RESULTS Based on ABI <0.9, PAD was diagnosed in 32 of the 182 (18%) patients. Coronary artery disease was present in 15 cases of PAD which was statistically significant. CONCLUSION There is a definite and strong correlation between PAD and CAD. Correct diagnosis and supervision of patients with PAD is important for preventing the local progression of the disease and effective secondary prevention of future coronary and cerebrovascular events.
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Affiliation(s)
- Sharmistha Sarangi
- Department of General Medicine, Durgabai Deshmukh Hospital and Research Centre, Hyderabad, India
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Cimminiello C, Kownator S, Wautrecht JC, Carvounis CP, Kranendonk SE, Kindler B, Mangrella M, Borghi C. The PANDORA study: peripheral arterial disease in patients with non-high cardiovascular risk. Intern Emerg Med 2011; 6:509-19. [PMID: 21298363 DOI: 10.1007/s11739-011-0511-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Accepted: 01/05/2011] [Indexed: 10/18/2022]
Abstract
Few studies are available with sufficient sample size to accurately describe the prevalence of low ankle-brachial index (ABI) in patients at 'non-high' cardiovascular (CV) risk. The aim of this study was to evaluate the prevalence of asymptomatic peripheral arterial disease (PAD), as determined by using ABI, in this patient population. A non-interventional, cross-sectional, pan-European study was conducted in patients with ≥1 CV risk factor in addition to age, evaluating the prevalence of asymptomatic PAD (ABI ≤ 0.90). Secondary objectives included assessing the prevalence and treatment of CV risk factors. Patients were consecutively recruited during scheduled visits to the physician's office, or were randomly selected by the physician from a list of eligible patients. Patients with diabetes were excluded as this condition was deemed to be a secondary prevention risk. 10,287 patients were enrolled (9,816 evaluable: mean age 64.3 years; 53.5% male). Prevalence of asymptomatic PAD was 17.8% (99% CI 16.84-18.83). Factors significantly associated with asymptomatic PAD included hypertension, age, alcohol intake, family history of coronary heart disease, low levels of high-density lipoprotein-cholesterol, and smoking (p < 0.0001). Patients treated with statins were significantly less likely to have asymptomatic PAD than those who were not (odds ratio 0.62; 95% CI 0.50-0.76; p < 0.0001). Asymptomatic PAD was highly prevalent in patients with non-high CV risk, the majority of whom would not typically be candidates for ABI assessment. These patients should be carefully screened, and ABI measured, so that therapeutic interventions known to diminish their increased CV risk may be offered.
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Affiliation(s)
- Claudio Cimminiello
- Department of Medicine, Vimercate Hospital, via Cesare Battisti 23, Vimercate (MI) 20059, Italy.
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Banerjee A, Fowkes FG, Rothwell PM. Associations between peripheral artery disease and ischemic stroke: implications for primary and secondary prevention. Stroke 2010; 41:2102-7. [PMID: 20689082 DOI: 10.1161/strokeaha.110.582627] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Although peripheral artery disease (PAD) has a particularly poor prognosis compared with vascular disease in other territories, little attention is paid to its epidemiology, treatment, and prevention. Despite the high prevalence of PAD in patients with stroke, and of stroke in patients with PAD, PAD is omitted from all guidelines for treatment, prevention, and rehabilitation of stroke, although coronary artery disease risk is considered. Therefore, routine PAD screening is seldom undertaken and so disease is probably often missed. Summary of Review- This review evaluates epidemiology of PAD in patients with stroke and of stroke in patients with PAD. The role of the ankle-brachial pressure index; imaging and novel markers in risk prediction of PAD in patients with stroke; and treatment and prevention of PAD are reviewed. CONCLUSIONS In both primary and secondary prevention settings, PAD indicates a high risk of future events. Data on which additional preventive measures are beneficial in this patient group are lacking, but the presence of PAD does have implications for current management in both primary and secondary prevention of stroke.
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Affiliation(s)
- Amitava Banerjee
- Stroke Prevention Research Unit, University of Oxford, Oxford, UK
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21
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Duran NE, Duran I, Gürel E, Gündüz S, Göl G, Biteker M, Özkan M. Coronary artery disease in patients with peripheral artery disease. Heart Lung 2010; 39:116-20. [DOI: 10.1016/j.hrtlng.2009.07.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2007] [Revised: 05/27/2008] [Accepted: 07/07/2009] [Indexed: 10/20/2022]
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St-Pierre AC, Cantin B, Lamarche B, Auger D, Després JP, Dagenais GR. Intermittent claudication: From its risk factors to its long-term prognosis in men. The Quebec Cardiovascular Study. Can J Cardiol 2010; 26:17-21. [PMID: 20101352 PMCID: PMC2827219 DOI: 10.1016/s0828-282x(10)70328-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Accepted: 05/17/2009] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The natural history of intermittent claudication, from its risk factors to its cardiovascular prognosis, has been reported in few prospective studies. OBJECTIVE To assess incident intermittent claudication, as well as its risk factors and long-term prognosis in men. METHODS A random sample of 4376 men 35 to 64 years of age from Quebec City (Quebec), who were free of cardiovascular disease (CVD), was evaluated in 1974 for CVD risk factors and followed until 1998. To assess the prognosis, the event rates between 1985 and 1998 were computed among men with incident claudication without other CVD, incident survivors of a first myocardial infarction (MI) without other CVD and men free of CVD between 1974 and 1985. RESULTS From 1974 to 1998, 300 men developed intermittent claudication. Tobacco consumption, high systolic blood pressure and diabetes at least doubled the adjusted RR (aRR) of intermittent claudication. In 1985, there were 80 claudicants, 2868 men free of CVD and 68 survivors of a first MI. During the 13-year follow-up, a new CVD occurred in 48.8% of the claudicants, in 18.9% of men without CVD (aRR 2.08; 95% CI 1.48 to 2.90) and in 45.6% of MI survivors (aRR compared with claudicants 1.12; 95% CI 0.69 to 1.79). There was also no significant difference between claudicants and MI survivors for fatal CVD, nonfatal CVD and total mortality. CONCLUSIONS Men with intermittent claudication are at high risk for CVD that may be equivalent to men with previous MI.
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Affiliation(s)
| | - Bernard Cantin
- Institut universitaire de cardiologie et de pneumologie de Québec
| | - Benoît Lamarche
- Institut des neutraceutiques et aliments fonctionnels, Université Laval, Quebec City, Quebec
| | - Dominique Auger
- Institut universitaire de cardiologie et de pneumologie de Québec
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Aboyans V, Salazar J, Lacroix P. [Obliterating arterial disease of the legs in women]. Presse Med 2009; 39:263-70. [PMID: 20015610 DOI: 10.1016/j.lpm.2009.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2009] [Revised: 04/07/2009] [Accepted: 04/08/2009] [Indexed: 10/20/2022] Open
Abstract
The widespread use of the ankle-brachial index (ABI) enabled to reveal the high prevalence of lower extremities peripheral arterial disease (PAD) in women, even higher than in men in several series. Nonetheless, the use of a same ABI threshold for men and women may overestimate the prevalence of subclinical PAD in women. Conversely, the clinical manifestations of PAD are more often atypical in women, with as a result, a delayed diagnosis and management. The level of association between cardiovascular disease risk factors and PAD is similar in both genders. To date, there is no evidence for any association between PAD and different hormonal events in women. Despite an inverse association between hormonal replacement therapy (HRT) after menopause and PAD in epidemiological studies, the trials failed to evidence any protective effect of HRT to prevent PAD. Women with PAD are advised to discontinue HRT in case of limb revascularization. The long-term local and functional prognosis of PAD seems more severe in women, but this is partly explained by a delayed onset of the disease, occurring at a later age. Similarly, the general cardiovascular prognosis PAD is also poorer in women than in men.
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Affiliation(s)
- Victor Aboyans
- Service de chirurgie thoracique et cardiovasculaire et angiologie, Hôpital universitaire Dupuytren, CHU de Limoges, F-87042 Limoges Cedex, France.
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Safety and Short-term Outcomes following Controlled Blunt Microdissection Revascularization of Symptomatic Arterial Occlusions of the Pelvis and Lower Extremities. J Vasc Interv Radiol 2009; 20:1541-7. [DOI: 10.1016/j.jvir.2009.08.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Revised: 07/06/2009] [Accepted: 08/21/2009] [Indexed: 11/20/2022] Open
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Alvarez-Fernández LJ, Vallina-Victorero Vázquez MJ, Ramos Gallo MJ, Santiago MV. [Implications of the REACH registry for vascular surgery]. Med Clin (Barc) 2009; 132 Suppl 2:25-9. [PMID: 19631835 DOI: 10.1016/s0025-7753(09)71749-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Because of the increase in life expectancy, peripheral artery disease (PAD) has become a major health problem. A study performed in Spain in persons aged more than 65 years old found an overall prevalence of PAD of 9.9%. The most important risk factors for PAD were smoking, diabetes mellitus, advanced age, hyperlipidemia and hypertension. Treatment includes smoking cessation, exercise, statins, platelet antiaggregants, cilostazol or hemorheologic agents, and revascularization techniques. Data from the Spanish arm of REACH indicate that the PAD subgroup shows the poorest control of blood pressure and cholesterol and that use of platelet antiaggregants and statins is lowest in these patients, indicating that therapeutic and preventive strategies are not being correctly applied.
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Abstract
Peripheral arterial disease (PAD) is chronic arterial occlusive disease of the lower extremities caused by atherosclerosis whose prevalence increases with age. Only one-half of women with PAD are symptomatic. Symptomatic and asymptomatic women with PAD are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from coronary artery disease. Modifiable risk factors that predispose women to PAD include active cigarette smoking, passive smoking, diabetes mellitus, hypertension, dyslipidemia, increased plasma homocysteine levels and hypothyroidism. With regard to management, women who smoke should be encouraged to quit and referred to a smoking cessation program. Hypertension, diabetes mellitus, dyslipidemia, and hypothyroidism require treatment. Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in women with PAD and hypercholesterolemia. Anti-platelet drugs such as aspirin or especially clopidogrel, angiotensin-converting enzyme inhibitors and statins should be given to all women with PAD. Beta blockers are recommended if coronary artery disease is present. Exercise rehabilitation programs and cilostazol increase exercise time until intermittent claudication develops. Chelation therapy should be avoided as it is ineffective. Indications for lower extremity percutaneous transluminal angioplasty or bypass surgery in women are (1) incapacitating claudication interfering with work or lifestyle; and (2) limb salvage in women with limb-threatening ischemia as manifested by rest pain, non-healing ulcers, and/or infection or gangrene. Future research includes investigation of mechanisms underlying why women have a higher risk of graft failure and major amputation.
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Affiliation(s)
- Wilbert S Aronow
- Department of Medicine, Divisions of Cardiology, Geriatrics, and Pulmonary/Critical Care, New York Medical College, Macy Pavilion, Room 138, Valhalla, NY, USA.
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Abstract
BACKGROUND Peripheral arterial disease (PAD) causes considerable morbidity and mortality. Hypertension is a risk factor for PAD. Treatment for hypertension must be compatible with the symptoms of PAD. Controversy regarding the effects of beta-blockade for hypertension in patients with PAD has led many physicians to stop prescribing beta-blockers. Little is known about the effects of other classes of anti-hypertensive drugs in the presence of PAD. This is an update of a Cochrane review first published in 2003. OBJECTIVES To determine the effects of anti-hypertensive drugs on cardiovascular events and death, symptoms of claudication, critical leg ischaemia, progression of PAD and revascularisation or amputation in people with hypertension and PAD SEARCH STRATEGY: The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched May 2009) and the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 2). The authors studied abstracts of cardiology meetings. SELECTION CRITERIA Randomised controlled trials of at least one anti-hypertensive treatment against placebo, or two anti-hypertensive medications against each other, with interventions lasting at least one month. Trials had to include patients with symptomatic PAD. DATA COLLECTION AND ANALYSIS Data were extracted by one author (DAL) and checked by the other (GYHL). Eligible studies were excluded when results presentation prevented adequate extraction of data and enquiries to authors did not yield raw data. MAIN RESULTS Four studies were included. Two compared ACE inhibitors against placebo. In the HOPE study there was a significant reduction in the number of cardiovascular events in 168 patients receiving ramipril (OR 0.72, 95% confidence interval 0.58 to 0.91). In the second trial using perindopril in a small numbers of patients, there was a marginal increase in claudication distance but no change in ankle brachial pressure index (ABPI) and a reduction in maximum walking distance.The third trial in patients undergoing angioplasty suggested that the calcium antagonist verapamil reduced restenosis, although this was not reflected in the maintenance of a high ABPI. Another small study demonstrated no significant difference in arterial intima-media thickness with men receiving the thiazide diuretic hydrochlorathiazide compared to those receiving the alpha-adrenoreceptor blocker doxazosin. AUTHORS' CONCLUSIONS Evidence on various anti-hypertensive drugs in people with PAD is poor so that it is unknown whether significant benefits or risks accrue from their use. Lack of data specifically examining outcomes in PAD patients should not detract from the compelling evidence of the benefit of treating hypertension and lowering blood pressure.
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Affiliation(s)
- Deirdre A Lane
- Haemostasis Thrombosis and Vascular Biology Unit, University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Dudley Road, Birmingham, UK, B18 7QH
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Tilloy E, Montaye M, Kee F, Bingham A, Arveiler D, Ruidavets JB, Evans A, Haas B, Ferrières J, Ducimetière P, Amouyel P, Dallongeville J. Contribution of cardiovascular risk factors to coronary risk in patients with intermittent claudication in the PRIME Cohort Study of European men. Atherosclerosis 2009; 206:563-8. [DOI: 10.1016/j.atherosclerosis.2009.03.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Revised: 03/19/2009] [Accepted: 03/21/2009] [Indexed: 11/24/2022]
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Jonason T, Ringqvist I. Diabetes mellitus and intermittent claudication. Relation between peripheral vascular complications and location of the occlusive atherosclerosis in the legs. ACTA MEDICA SCANDINAVICA 2009; 218:217-21. [PMID: 4061125 DOI: 10.1111/j.0954-6820.1985.tb08850.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Forty-seven diabetic patients with intermittent claudication without rest pain or gangrene at the initial examination were followed up over a six-year period. They were compared with 224 non-diabetic patients with intermittent claudication. The cumulative proportions of patients with gangrene were 31% in the diabetic group and 5% in the control group (p less than 0.001). The corresponding figures for rest pain and/or gangrene were 40 and 18%, respectively (p less than 0.001). The frequency of aorto-iliac and multiple stenoses was higher among diabetic patients who developed peripheral vascular complications (rest pain, gangrene) than in the control group. The frequency of multiple stenoses was also higher in the former subgroup than in diabetics without such complications. In conclusion, the degree of involvement of the large vessels in occlusive arterial disease influences the risk of development of peripheral vascular complications in diabetic patients with intermittent claudication.
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Siitonen O, Uusitupa M, Pyörälä K, Voutilainen E, Länsimies E. Peripheral arterial disease and its relationship to cardiovascular risk factors and coronary heart disease in newly diagnosed non-insulin-dependent diabetics. ACTA MEDICA SCANDINAVICA 2009; 220:205-12. [PMID: 3776696 DOI: 10.1111/j.0954-6820.1986.tb02752.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The prevalence of peripheral arterial disease and its relationship to cardiovascular risk factors was investigated in 133 patients aged 45-64 years with newly diagnosed non-insulin-dependent diabetes and in 144 randomly selected non-diabetic subjects of the same age. History of intermittent claudication, absent foot pulses, decreased ankle-arm blood pressure ratio (less than 0.9) and radiologically detectable arterial calcifications of the lower limbs were used as indicators of the presence of peripheral arterial disease. Peripheral arterial disease tended to be somewhat more common in men with newly diagnosed non-insulin-dependent diabetes than in non-diabetic men, whereas no difference was found in prevalence of peripheral arterial disease between diabetic and non-diabetic women. The association of various indicators of peripheral arterial disease with cardiovascular risk factors and coronary heart disease was low or absent.
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Lassila R, Lepäntalo M, Lindfors O. Peripheral arterial disease--natural outcome. ACTA MEDICA SCANDINAVICA 2009; 220:295-301. [PMID: 3799236 DOI: 10.1111/j.0954-6820.1986.tb02768.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Three hundred and twelve patients with peripheral arterial disease were followed up for 8 3/4 years or more (maximum 11 3/4 years) to assess the natural history of the disease and factors determining its outcome. Of the 312 patients, 188 (69%) died during the follow-up, 68% of the deaths having cardiovascular causes. The 10-year relative cumulative survival rate was 0.61 for males and 0.48 for females. The role of smoking as a risk factor could not be analysed without bias. In addition to known risk factors diabetes mellitus, cerebrovascular disease and coronary heart disease, the degree of peripheral arterial disease itself also proved to be a risk factor among men. The expected life lost for men with intermittent claudication was 20%, but 44.3% for men with advanced lower limb ischaemia (p less than 0.01). This difference could not be explained by the well-known association of advanced ischaemia and diabetes mellitus. The present results therefore suggest that the state of advanced ischaemia indicates larger involvement of the whole of the arterial tree and predicts fatal cardiovascular events among these patients.
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SAMUELSSON OLA, WILHELMSEN LARS, PENNERT KJELL, BERGLUND GÖRAN. Angina Pectoris, Intermittent Claudication and Congestive Heart Failure in Middle-aged Male Hypertensives. ACTA ACUST UNITED AC 2009. [DOI: 10.1111/j.0954-6820.1987.tb01241.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Cacoub P, Cambou JP, Kownator S, Belliard JP, Beregi JP, Branchereau A, Carpentier P, Léger P, Luizy F, Maïza D, Mihci E, Herrmann MA, Priollet P. Prevalence of peripheral arterial disease in high-risk patients using ankle-brachial index in general practice: a cross-sectional study. Int J Clin Pract 2009; 63:63-70. [PMID: 19125994 PMCID: PMC2705819 DOI: 10.1111/j.1742-1241.2008.01953.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
AIMS The deleterious nature of peripheral arterial disease (PAD) is compounded by a status of underdiagnosed and undertreated disease. We evaluated the prevalence and predictive factors of PAD in high-risk patients using the ankle-brachial index (ABI). METHODS The ABI was measured by general practitioners in France (May 2005-February 2006) in 5679 adults aged 55 years or older and considered at high risk. The primary outcome was prevalence of PAD (ABI strictly below 0.90). RESULTS In all, 21.3% patients had signs or symptoms suggestive of PAD, 42.1% had previous history of atherothrombotic disease and 36.6% had two or more cardiovascular risk factors. Prevalence of PAD was 27.8% overall, ranging from 10.4% in patients with cardiovascular risk factors only to approximately 38% in each other subgroup. Prevalence differed depending on the localization of atherothrombotic events: it was 57.1-75.0% in patients with past history of symptomatic PAD; 24.6-31.1% in those who had experienced cerebrovascular and/or coronary events. Regarding the classical cardiovascular risk factors, PAD was more frequent when smoking and hypercholesterolemia history were reported. PAD prevalence was also higher in patients with history of abdominal aortic aneurysm, renal hypertension or atherothrombotic event. Intermittent claudication, lack of one pulse in the lower limbs, smoking, diabetes and renovascular hypertension were the main factors predictive of low ABI. CONCLUSIONS Given the elevated prevalence of PAD in high-risk patients and easiness of diagnosis using ABI in primary care, undoubtedly better awareness would help preserve individual cardiovascular health and achieve public health goals.
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Affiliation(s)
- P Cacoub
- Pierre et Marie Curie, Paris 6, University, Paris, France.
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Abstract
Hypertension is a common comorbidity in persons with diabetes mellitus, and its prevalence increases with advancing age. Both diabetes mellitus and hypertension are independent risk factors for development in older persons of coronary artery disease, ischemic stroke, peripheral arterial disease, and of congestive heart failure. This article reviews studies addressing the implications of hypertension and the older diabetic.
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Affiliation(s)
- Wilbert S Aronow
- Divisions of Cardiology, Geriatrics, and Pulmonary/Critical Care, Department of Medicine, Westchester Medical Center/New York Medical College, Macy Pavilion, Room 138, Valhalla, NY 10595, USA.
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Sobel M, Verhaeghe R. Antithrombotic Therapy for Peripheral Artery Occlusive Disease. Chest 2008; 133:815S-843S. [DOI: 10.1378/chest.08-0686] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Gardner AW, Montgomery PS, Parker DE. Physical activity is a predictor of all-cause mortality in patients with intermittent claudication. J Vasc Surg 2008; 47:117-22. [PMID: 18178462 DOI: 10.1016/j.jvs.2007.09.033] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2007] [Revised: 08/30/2007] [Accepted: 09/09/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We examined whether all-cause mortality was predicted by physical activity level in peripheral arterial disease (PAD) patients limited by intermittent claudication. METHODS This retrospective, natural history follow-up study determined survival status of each patient. Patients with stable symptoms of intermittent claudication were evaluated in the Geriatrics, Research, Education, and Clinical Center at the Maryland Veterans Affairs Health Care System (MVAHCS) at Baltimore between 1994 and 2002, and were classified into a physically sedentary group (n = 299) or a physically active group (n =135), and followed in 2004 using the Social Security Death Index. RESULTS Median follow-up was 5.33 years (range = 0.25 to 8.33 years) for the physically active group, and 5.0 years (range = 0.17 to 8.5 years) for the sedentary group. At follow-up, 108 patients (24.9%) had died, consisting of 86 (28.8%) in the sedentary group and 22 (16.3%) in the active group. Unadjusted risk of mortality was lower (P = .005) in the physically active group (hazard ratio [HR] = 0.510, 95% CI = 0.319 to 0.816). In multivariate Cox proportional hazards analysis, age (HR = 1.045, 95% CI = 1.019 to 1.072, P < 0.001), body mass index (BMI) (HR = 0.943, 95% CI = 0.902 to 0.986, P = 0.009), ankle-brachial index (ABI) (HR = 0.202, 95% CI = 0.064 to 0.632, p = 0.006), and physical activity status (HR = 0.595, 95% CI = 0.370 to 0.955, P = .031) were predictors of mortality. CONCLUSION Patients limited by intermittent claudication who engage in any amount of weekly physical activity beyond light intensity at baseline have a lower mortality rate than their sedentary counterparts who perform either no physical activity or only light-intensity activities. The protective effect of physical activity persists even after adjusting for other predictors of mortality, which include age, ABI, and BMI.
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Affiliation(s)
- Andrew W Gardner
- CMRI Metabolic Research Center, University of Oklahoma Health Sciences Center, 1122 NE 13th Street, Oklahoma City, OK 73117, USA.
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Arterial Disease of the Lower Extremity. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kollerits B, Heinrich J, Pichler M, Rantner B, Klein-Weigel P, Wölke G, Brasche S, Strube G, Kronenberg F. Intermittent claudication in the Erfurt Male Cohort (ERFORT) Study: its determinants and the impact on mortality. A population-based prospective cohort study with 30 years of follow-up. Atherosclerosis 2007; 198:214-22. [PMID: 17950299 DOI: 10.1016/j.atherosclerosis.2007.09.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2007] [Revised: 08/31/2007] [Accepted: 09/06/2007] [Indexed: 11/28/2022]
Abstract
AIMS Intermittent claudication (IC) is the most common symptom of peripheral arterial disease and is associated with an increased mortality. Within the Erfurt Male Cohort (ERFORT) Study, one of the most long-lasting population-based prospective cohort studies in Europe, we investigated (i) which variables predict the development of incident IC determined by the WHO Rose questionnaire over a period of 15 years and (ii) if IC is predictive for 30 years all-cause mortality. METHODS The baseline survey examined a random population-based sample of 1160 males aged 40-59 years with three follow-up examinations 5, 10 and 15 years after enrollment using each time the Rose questionnaire. RESULTS An adjusted Cox regression analysis revealed smoking (HR (95% CI), 2.20 (1.24-3.92), p=0.01), diabetes mellitus (HR (95% CI), 4.68 (1.61-13.63), p=0.01) and coronary heart disease (HR (95% CI), 2.74 (1.08-6.96), p=0.03) to be significantly associated with incident IC. Participants with an IC had an significantly increased age-adjusted 30 years all-cause mortality (HR (95% CI), 1.56 (1.16-2.10), p=0.003). This association remained still significantly predictive after adjustment for other cardiovascular risk factors. CONCLUSIONS Mainly smoking and diabetes mellitus are associated with incident IC. A positive Rose questionnaire is a strong predictor for all-cause mortality over 30 years. The simplicity of their use makes questionnaires highly attractive for identification of high-risk patients in primary health care.
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Affiliation(s)
- Barbara Kollerits
- Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology, Innsbruck Medical University, Schöpfstr. 41, A-6020 Innsbruck, Austria
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Sritara P, Sritara C, Woodward M, Wangsuphachart S, Barzi F, Hengprasith B, Yipintsoi T. Prevalence and Risk Factors of Peripheral Arterial Disease in a Selected Thai Population. Angiology 2007; 58:572-8. [DOI: 10.1177/0003319707303652] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Peripheral arterial disease (PAD) is a condition with high mortality, but it is amenable to secondary prevention. Data on its prevalence in Thailand are scarce. To study the prevalence of PAD in a middle-class, urban Thai population, a cross-sectional study was conducted at the Electric Generating Authority of Thailand's head plant, Nonthaburi, in 2002 and 2003 on all surviving and contactable employees and former employees who had participated in the first cardiovascular risk factors survey in 1985. Participants completed a structured questionnaire detailing their medical history, and they underwent a physical examination. A diagnosis of PAD was made when the ankle-brachial index (ABI) was < 0.9. Ankle-brachial index data were available for 98% of participants in the survey; 75% were men, and participants' ages ranged from 52 to 73 years. The overall prevalence of PAD was 5.2%. The age-standardized prevalence of PAD was 4% in men and 9% in women. Multiple logistic regression analysis found hypertension (OR = 1.7), female gender (OR = 1.9), current smoking (OR = 3.0), current alcohol drinking (OR = 0.41), and overweight (body mass index [BMI] > 25 kg/m 2, OR = 0.54) to be significant (P < .05) predictors of PAD. The prevalence of PAD in urban, middle-class Thais was similar to that in the population in developed countries.
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Affiliation(s)
- Piyamitr Sritara
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand,
| | - Chanika Sritara
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Mark Woodward
- George Institute for International Health, Sydney, NSW, Australia
| | | | - Federica Barzi
- George Institute for International Health, Sydney, NSW, Australia
| | | | - Tada Yipintsoi
- Prince of Songkhla University, Hat Yai, Songkhla, Thailand
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Sigvant B, Wiberg-Hedman K, Bergqvist D, Rolandsson O, Andersson B, Persson E, Wahlberg E. A population-based study of peripheral arterial disease prevalence with special focus on critical limb ischemia and sex differences. J Vasc Surg 2007; 45:1185-91. [PMID: 17543683 DOI: 10.1016/j.jvs.2007.02.004] [Citation(s) in RCA: 243] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2006] [Accepted: 02/05/2007] [Indexed: 11/21/2022]
Abstract
OBJECTIVE A population-based point-prevalence study was conducted to determine the prevalence of peripheral arterial disease (PAD) in Sweden, with special attention to critical limb ischemia and sex differences. METHODS An age-standardized randomly selected population sample of 8000 women and men, aged 60 to 90 years, from four different regions in Sweden was invited to participate. The sample had the same age and gender distribution as the Swedish population in this age group. Participating subjects completed questionnaires on medical history, present medication, and symptoms, and their ankle-brachial index (ABI) was measured. Subjects were analyzed for presence of PAD according to reported symptoms and an ABI<0.9. RESULTS A total of 5080 subjects were included, giving a participation rate of 64%. The prevalence of any PAD, asymptomatic PAD, intermittent claudication, and severe limb ischemia was, respectively, 18% (95% confidence interval [CI], 16% to 20%) 11% (9% to 13%), 7% (6.5 to 7%) and 1.2% (1% to 1.5%). Women had a higher prevalence than men when PAD was diagnosed with ABI only; that is, asymptomatic PAD (12.6% vs 9.4%, P=.03) and severe limb ischemia (1.5% vs 0.8%, P<.008). The prevalence of any PAD was 7.9% in the age group 60 to 65 years and increased to 47.2% among the age group 85 to 90 years. Severe limb ischemia occurred in 0.3% in the youngest age group, was highest in the age group 80 to 84 years at 3.3%, and declined to 2.5% among the oldest. The prevalence of PAD differed between regions (P<.0001). CONCLUSIONS PAD is common in Sweden, and almost a fifth of all elderly individuals have some stage of this disease. Women are more often afflicted than men. The prevalence of severe ischemia, as a measure of critical limb ischemia, is about 1% the population.
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Affiliation(s)
- Birgitta Sigvant
- Department of Surgery, Central Hospital Karlstad, Karlstad, and Uppsala University Hospital, Sweden.
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Green S, Askew CD, Walker PJ. Effect of type 2 diabetes mellitus on exercise intolerance and the physiological responses to exercise in peripheral arterial disease. Diabetologia 2007; 50:859-66. [PMID: 17237939 DOI: 10.1007/s00125-006-0587-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2006] [Accepted: 11/23/2006] [Indexed: 11/24/2022]
Abstract
AIMS/HYPOTHESIS There are conflicting data about the effect of type 2 diabetes mellitus on exercise tolerance in peripheral arterial disease. To elucidate this problem, we compared the tolerance and physiological responses to treadmill and cycle exercise in 31 patients with peripheral arterial disease and intermittent claudication. MATERIALS AND METHODS One group of these patients had type 2 diabetes (n = 12) and its members were matched for sex and age with a group of patients who did not have diabetes (n = 12). Since BMI and body weight were greater in the diabetic group (28.4 +/- 3.7 vs 25.2 +/- 2.4 kg/m(2); 84.0 +/- 14.6 vs 73.8 +/- 8.0 kg), we also studied a third, 'heavy' group of non-diabetic patients with claudication of similar age (n = 7; BMI = 30.9 +/- 5.3 kg/m(2); body weight = 85.2 +/- 8.2 kg). RESULTS Compared with the 'light' non-diabetic group, maximum treadmill times were shorter for the diabetic and heavy non-diabetic groups (1,448 vs 845 and 915 s; ANOVA p = 0.01); maximum cycle time also tended to be shorter (ANOVA, p = 0.08) in the diabetic and heavy non-diabetic groups (median = 1,231 vs 730 and 797 s). The majority of physiological responses assessed were not different between the groups, although the time constant of oxygen uptake during submaximal treadmill and cycle exercise was significantly larger (ANOVA p < 0.05) for the diabetic group. CONCLUSIONS/INTERPRETATION These data demonstrate that exercise tolerance is lower in diabetic than non-diabetic patients with claudication, but that this difference is due to obesity rather than diabetes itself.
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Affiliation(s)
- S Green
- School of Biological, Biomedical and Molecular Sciences, University of New England, Armidale, New South Wales, Australia.
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Kundhal KK, Chin SL, Harrison L, Nowacki B, Doobay B, Titley J, Cinà C, Anand SS. Patterns of medical therapy in patients with peripheral artery disease in a tertiary care centre in Canada. Can J Cardiol 2007; 23:357-61. [PMID: 17440640 PMCID: PMC2649185 DOI: 10.1016/s0828-282x(07)70768-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2006] [Accepted: 05/28/2006] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Patients with peripheral artery disease (PAD) of the lower extremities are among the highest risk vascular patients for fatal and nonfatal myocardial infarction and stroke, and have been traditionally undertreated from a medical perspective. Recent evidence suggests that the incidence of cardiovascular death, myocardial infarction and stroke can be substantially reduced among PAD patients if they are treated with antiplatelet therapy, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins), angiotensin-converting enzyme inhibitors (ACEIs) and in some instances, beta-blockers. OBJECTIVES To characterize practice patterns of drug therapy (antiplatelet, statin, ACEI and beta-blocker) among PAD patients admitted to a tertiary care hospital and to determine the 'care gap', defined as the proportion of patients who did not receive therapy among those who were eligible for it. DESIGN AND METHODS Patients with PAD (International Classification of Diseases code 440.2) admitted to the Hamilton General Hospital (Hamilton, Ontario) from January 2001 to January 2002 were considered for inclusion into the present study. Information was collected during hospitalization and by chart review. RESULTS Data from 217 patients were used. The mean (+/- SD) age of participants was 68.6+/-11.9 years, and 41% were women. The primary reason for admission to hospital was peripheral artery bypass surgery (67%). Of these patients, 79% were current smokers or had a prior history of tobacco use, 60% had at least two cardiovascular risk factors (hypertension, cholesterol, diabetes or smoking) and 45% had undergone prior peripheral artery bypass surgery, amputation or carotid endarterectomy. Three-quarters of the patients had established coronary or cerebrovascular disease, or at least two cardiovascular risk factors. At the time of discharge, of those patients eligible for medical therapies, 16% did not receive antiplatelet or anticoagulant agents, 69% did not receive statins, 48% did not receive ACEIs and 49% did not receive beta-blockers. CONCLUSIONS Patients with PAD represent a high-risk group in which more than 75% have established coronary or cerebrovascular disease, or multiple cardiovascular risk factors. Although the use of antiplatelet agents is common, the use of statins, ACEIs and beta-blockers may be improved.
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Affiliation(s)
- Kiran K Kundhal
- Department of Medicine, Faculty of Health Sciences, McMaster University, and Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Ontario
| | - Siu Lim Chin
- Department of Medicine, Faculty of Health Sciences, McMaster University, and Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Ontario
| | - Lisa Harrison
- Department of Vascular Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ontario
| | - Barbara Nowacki
- Department of Medicine, Faculty of Health Sciences, McMaster University, and Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Ontario
| | - Budhendra Doobay
- Department of Vascular Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ontario
| | - Jacques Titley
- Department of Vascular Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ontario
| | - Claudio Cinà
- Department of Vascular Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ontario
| | - Sonia S Anand
- Department of Medicine, Faculty of Health Sciences, McMaster University, and Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Ontario
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Estudio de prevalencia de isquemia crónica de miembros inferiores y de aneurisma de aorta abdominal en mayores de 65 años. ANGIOLOGIA 2007. [DOI: 10.1016/s0003-3170(07)75049-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
Peripheral arterial disease (PAD) may be asymptomatic, may be associated with intermittent claudication or may be associated with critical limb ischaemia. Coronary artery disease (CAD) and other atherosclerotic vascular disorders may coexist with PAD. Persons with PAD are at increased risk for all-cause mortality, cardiovascular mortality and mortality from CAD. Smoking should be stopped and hypertension, diabetes mellitus, dyslipidaemia and hypothyroidism treated. HMG-CoA reductase inhibitors (statins) reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolaemia. Antiplatelet drugs such as aspirin or clopidogrel (especially the latter), ACE inhibitors and statins should be given to all persons with PAD. beta-Adrenoceptor antagonists should be given if CAD is present. The phosphodiesterase type 3 inhibitor cilostazol improves exercise time until intermittent claudication. Chelation therapy should be avoided. Correct implementation of medical therapy significantly reduces the excess mortality associated with PAD. In addition, medical therapy may result in significant improvements in walking ability that may obviate the need for lower extremity angioplasty with stenting and bypass surgery.
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Affiliation(s)
- Wilbert S Aronow
- Department of Medicine, Cardiology Division, New York Medical College, Valhalla, New York 10595, USA.
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Aboyans V, Criqui MH. Can we improve cardiovascular risk prediction beyond risk equations in the physician's office? J Clin Epidemiol 2006; 59:547-58. [PMID: 16713516 DOI: 10.1016/j.jclinepi.2005.11.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2005] [Revised: 10/09/2005] [Accepted: 11/07/2005] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Beyond a global estimation of the cardiovascular risk through the assessment of major risk factors and their integration in dedicated risk scales or equations, the use of specific markers provides additive prognostic information at an individual level, including predisposing factors, which are not included in the risk equations as well as the individual susceptibility to their long-term exposure. However, the majority of these markers require specific devices and skills, which are not widely available in primary care. METHODS Some clinical and/or "low-cost" parameters are shown to be valuable risk markers, and their use could refine the risk estimation in a physician's office. Several epidemiologic studies suggest the heart rate, the pulse pressure and the ankle-brachial index are effective cardiovascular risk markers. The arms systolic pressure asymmetry could also be a useful marker of risk. RESULTS AND CONCLUSIONS Through a general review, the authors evaluate the potential of these clinical markers, including their use in combination for more accurate risk determination.
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Affiliation(s)
- Victor Aboyans
- Department of Thoracic and Cardiovascular Surgery and Angiology, Dupuytren University Hospital, Limoges, France.
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Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WRC, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006; 113:e463-654. [PMID: 16549646 DOI: 10.1161/circulationaha.106.174526] [Citation(s) in RCA: 2167] [Impact Index Per Article: 120.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2005 Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): A Collaborative Report from the American Association for Vascular Surgery/Society for Vascular Surgery,⁎Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). J Am Coll Cardiol 2006. [DOI: 10.1016/j.jacc.2006.02.024] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Shinohara K, Shoji T, Kimoto E, Yokoyama H, Fujiwara S, Hatsuda S, Maeno T, Shoji T, Fukumoto S, Emoto M, Koyama H, Nishizawa Y. Effect of atorvastatin on regional arterial stiffness in patients with type 2 diabetes mellitus. J Atheroscler Thromb 2006; 12:205-10. [PMID: 16141624 DOI: 10.5551/jat.12.205] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE A statin, a potent lipid-lowering drug, improves pain-free walking distance in patients with peripheral arterial disease (PAD) without increasing the ankle-brachial pressure index (ABI). Arterial stiffness affects the blood flow of peripheral arteries. The purpose of this study was to evaluate the effect of cholesterol-lowering with atorvastatin on regional arterial stiffness in patients with type 2 diabetes mellitus. METHODS The subjects were 22 type 2 diabetic patients with hypercholesterolemia, who received atorvastatin at a daily dose of 10 mg for 6 months. Before and after the treatment with atorvastatin, we measured pulse wave velocity (PWV) in the heart-brachial, heart-carotid, heart-femoral and femoral-ankle segments. RESULTS Following treatment with atorvastatin, femoral-ankle PWV showed a significant reduction. The PWV of other arterial segments tended to decrease, although the changes were not statistically significant. We found no significant changes in blood pressure, heart rate, ABI, or plasma concentrations of glucose, L-arginine and asymmetric dimethylarginine (ADMA), an endogenous inhibitor of endothelial function. CONCLUSIONS Atorvastatin treatment was associated with an improvement in the stiffness of leg arteries in type 2 diabetes mellitus. This may partly explain the statin-mediated improvement of walking performance in those with PAD.
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Affiliation(s)
- Kayo Shinohara
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
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Meru AV, Mittra S, Thyagarajan B, Chugh A. Intermittent claudication: an overview. Atherosclerosis 2005; 187:221-37. [PMID: 16386260 DOI: 10.1016/j.atherosclerosis.2005.11.027] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2005] [Revised: 10/26/2005] [Accepted: 11/20/2005] [Indexed: 11/26/2022]
Abstract
Intermittent claudication (IC) is defined by leg muscle pain, cramping and fatigue brought on by ambulation/exercise; relieved on rest; and caused by inadequate blood supply and is the primary symptom of peripheral arterial disease (PAD). PAD has a detrimental effect on the quality of life. PAD is a debilitating atherosclerotic disease of the lower limbs and is associated with an increased risk of cardiovascular morbidity and mortality. IC is an extremely important marker of atheroma. Up to 60% patients with IC have significant underlying coronary and/or carotid disease and 40% of all patients suffering from IC die or suffer a stroke within 5 years of presentation. The therapeutic intervention of IC essentially aims at providing symptomatic relief and reducing the systemic cardiovascular complications. Although exercise therapy is one of the most efficacious conservative treatments for claudication, the pharmacotherapeutic goals can be best achieved through an increase in the walking capacity to improve quality of life and a decrease in rates of amputation. In the development of treatment for IC, an aggressive non-pharmacological intervention and pharmacological treatment of the risk factors associated with IC are considered. In the next 2 years, the results of major trials of drugs that stabilize and regress atherosclerosis such as statins and angiotensin converting enzyme inhibitors, and anti-platelet agents, recombinant growth factors and immune modulators will be available for IC. Levocarnitine (l-carnitine) and a derivative, propionyl levocarnitine, are emerging agents that increase the pain-free walking and improve the quality of life in IC patients by working at the metabolism and exercise performance of ischemic muscles. This article provides a comprehensive review of the pathophysiology involved, diagnosis of IC and existing and emerging pharmacotherapies with rationale for their use in its treatment.
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Affiliation(s)
- Ashwinkumar V Meru
- New Drug Discovery Research, Department of Pharmacology, Ranbaxy Laboratories Limited, R&D, Plot 20, Sector 18, Udyog Vihar Industrial Area, Gurgaon 122001, Haryana, India.
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