Ankle-brachial index and the incidence of cardiovascular events in the Mediterranean low cardiovascular risk population ARTPER cohort

Development of a new non invasive prognostic stroke scale (NIPSS) including triage elements for sleep apnea and peripheral artery disease

BACKGROUND

Although sleep apnea and peripheral artery disease are prognostic factors for stroke, their added benefit in the acute stage to further prognosticate strokes has not been evaluated.

OBJECTIVES

We tested the accuracy in the acute stroke stage of a novel score called the Non-Invasive Prognostic Stroke Scale (NIPSS).

PATIENTS AND METHODS

Prospective cohort with imaging-confirmed ischemic stroke. Clinical data, sleep apnea risk score (STOPBANG) and blood pressure measures were collected at baseline. Primary outcome was the 90-day modified Rankin Scale (mRS), with poor outcome defined as mRS 3-6. Area under the ROC curve (AUC) was calculated for NIPSS and compared to six other stroke prognostic scores in our cohort: SPAN-100 index, S-SMART, SOAR, ASTRAL, THRIVE, and Dutch Stroke scores.

RESULTS

We enrolled 386 participants. After 90 days, there were 56% with poor outcome, more frequently older, female predominant and with higher admission National Institute of Health Stroke Scale (NIHSS). Four variables remained significantly associated with primary endpoint in the multivariable model: age (OR 1.87), NIHSS (OR 7.08), STOPBANG category (OR 1.61), and ankle-braquial index (OR 2.11). NIPSS AUC was 0.86 (0.82-0.89); 0.83 (0.79-0.87) with bootstrapping. When compared to the other scores, NIPSS, ASTRAL, S-SMART and DUTCH scores had good abilities in predicting poor outcome, with AUC of 0.86, 0.86, 0.83 and 0.82, respectively. THRIVE, SOAR and SPAN-100 scores were fairly predictive.

DISCUSSION AND CONCLUSIONS

Non-invasive and easily acquired emergency room data can predict clinical outcome after stroke. NIPSS performed equal to or better than other prognostic stroke scales.

[Evolution of the prevalence of peripheral artery disease in clinical practice: A descriptive population study with real databases (SIDIAP-CMBD)]

OBJECTIVE

To evaluate, with real world data (SIDIAP and CMBD), the evolution of the prevalence of peripheral arterial disease (PAD) in the Catalan population and the cardiovascular risk factors present in people with this pathology.

DESIGN

Longitudinal descriptive population study. SITE: Primary health care.

PARTICIPANTS

Patients listed in SIDIAP and CMBD with a diagnosis of peripheral artery disease between 2008 and 2018 ≥ 35 years, as well as those without a diagnosis, but with an ABI < 0.9 in SIDIAP.

INTERVENTIONS AND MAIN MEASUREMENTS

Main variable AP (ICD-9, ICD-10). Sociodemographic data, risk factors and cardiovascular disease, drug use and prevalent cardiovascular events at the time of diagnosis.

RESULTS

141,520 patients were studied. 75% had hypertension, 58% were smokers or former smokers, and 23% had a myocardial infarction. The global prevalence increased from 1.15% in 2008 to 3.10% in 2018. The prevalence of PAD increased with age, with a moderate increase at younger ages, and more pronounced in > 55 years, exceeding 10% in > 85 years.

CONCLUSION

This is a population study where it is observed that the evolution of the prevalence of peripheral artery disease has presented a constant increase during the years 2008-2018, being higher in men, especially from 55 years of age. Studies with large databases can facilitate the design and implementation of new policies in national health systems.

Total White Blood Cell Count is Associated with Arterial Stiffness Among Hypertensive Patients

The association between white blood cell (WBC) count and arterial stiffness in patients with hypertension is not well-documented. We aimed to examine the relationships of total WBC count with arterial stiffness and risk of macrovascular damage in hypertensive patients. A total of 631 hypertensive adults (mean age: 65.6 years) were included in the present study. Arterial stiffness was determined by brachial-ankle pulse wave velocity (baPWV) and ankle-brachial index (ABI). Macrovascular damage was defined as baPWV >1.8 m/s or ABI <.9. The dose-response associations were assessed by multivariate linear or logistic regression models. After multivariate adjustments, we observed a dose-response relationship between increasing total WBC count and arterial stiffness. Participants in the highest tertile of total WBC count showed a significantly elevated baPWV (β = .088; 95% CI: .021, .154; P_trend = .010) and reduced ABI (β = -.027; 95% CI: -.046, -.008; P_trend = .005), as compared with those in the first tertile. The association was similar in different subgroups. In addition, elevated total WBC count was related to a greater risk of macrovascular damage, as indicated by baPWV >1.8 m/s (OR = 1.86; 95% CI: 1.15, 2.99, comparing the extreme tertiles). Our data suggest that elevated total WBC count was related to arterial stiffness among individuals with hypertension.

Protocol of the Inner Mongolian Healthy Aging Study (IMAGINS): a longitudinal cohort study

BACKGROUND

Cardiovascular diseases (CVDs) remain the leading cause of premature mortality and burden of diseases in the world. The Inner Mongolia Autonomous Region is located in northern China, constitute 17.66% individuals with Mongolian, which have unique diet and lifestyles. Therefore, the Inner Mongolian Healthy Aging Study (IMAGINS) was designed to explore risk factors for chronic diseases and evaluate the effectiveness of health management on CVDs in population at high-risk.

METHODS

The IMAGINS is an ongoing and prospective cohort study of men and women aged ≥35 years from Inner Mongolian Autonomous Region, northern China. This study performed in investigating risk factors for CVDs, screening and providing health management strategy for high-risk population of CVDs. The IMAGINS began in September 2015 and scheduled to recruiting and follow-up outcome until 2030. For general population, a long-term follow-up will be conducted every 5 years to collect the information above and data on clinical outcomes. For high-risk population, comprehensive health managements were performed and scheduled to follow-up annually. All IMAGINS participants are followed for incident CVDs and death.

DISCUSSION

The IMAGINS is designed to increase understanding how cardiovascular-related risk factors contribute to the development of CVDs and the positive effect of health management strategy for high-risk CVD participants. Key features of this study include (i) a carefully characterized cohort between high risk of CVDs and non-high risk population; (ii) detailed measurement of CVDs risk factors and health management strategies for high risk population; (iii) long-term follow-up of CVDs and death. The IMAGINS represents a good research opportunity to investigate clinical and genetic factors in high-risk population, might providing basis for the prevention and control of non-communicable diseases.

Disparate effects of ankle-brachial index on mortality in the 'very old' and 'younger old' populations-the PolSenior survey

To assess the relationship between ankle-brachial index (ABI) and up to 10-year mortality in older individuals below and above the age of 80 years. In a multicenter survey of health status in the community dwelling subjects aged 55-59 and 65 + years in Poland, we assessed baseline medical history including risk-factors. We measured ABI, and serum creatinine, cholesterol, NT-proBNP, and interleukin-6 (IL-6) concentrations. We assessed mortality based on public registry. Between 2009 and 2019, 27.3% of 561 participants < 80 years, and 79.4% of 291 participants ≥ 80 years, died (p < 0.001); 67.8, 41.5, and 40.3% in the ABI groups < 0.9, 0.9-1.4, and > 1.4, respectively (p < 0.01). In the unadjusted Cox models, ABI was associated with mortality in the entire group, and < 80 years. In the entire group, analysis adjusted for age and sex showed mortality risk increased by 11% per year, and 50% with male sex. Mortality decreased by 37% per 1 unit ABI increase. In the group of people ≥ 80 years, only age was significantly associated with mortality (p < 0.001). In stepwise regression ABI < 0.9, male sex, active smoking, and NT-proBNP level were associated with risk of death < 80 years. In the ≥ 80 years old, mortality risk was associated with older age, and higher levels of IL-6, but not ABI. The ABI < 0.9 is associated with higher mortality in older people, but not among the oldest-old. In the oldest age group, age is the strongest predictor of death. In this age group, inflammageing is of importance.

The relationship between hepatic fibrosis and arterial stiffness in hemodialysis patients

INTRODUCTION

The main cause of death in hemodialysis patients is cardiovascular diseases. Increased arterial stiffness is a predictor of cardiovascular events for hemodialysis patients. Among the nondialysis patient population, arterial stiffness increases in those with hepatic fibrosis and nonalcoholic fatty liver disease. This study aims to examine the relationship between hepatic fibrosis and arterial stiffness in hemodialysis patients for the first time in the literature.

MATERIAL AND METHOD

The study includes chronic hemodialysis patients over 18 years of age who had been treated for hemodialysis for at least 6 months. Patients with chronic liver disease, chronic viral hepatitis (HBV and HCV), alcohol use, or liver disease accompanied by polycystic kidney disease and active infection were excluded. Hepatic fibrosis scores were measured using the FibroScan device. Single-cuff Mobil-o-Graph was used for measurement of arterial stiffness.

RESULTS

Fifty-nine patients were enrolled; 54.2% of the patients were male, and the mean age was 53.9 ± 12.9 years. Thirty-nine percent of the patients had diabetes. Average pulse wave velocity (PWV) value of the patients was 8.3 ± 1.6 m/s, and it had positive correlation with age, CAP score, fibrosis score, and body mass index and showed negative correlation to albumin. It was seen that the patients with a PWV value ≥ 10 m/s have significantly higher CAP score compared with the patients with a PWV < 10 m/s. When the factors predicting PWV were examined in the regression analysis, age and systolic blood pressure were found to be determinants.

CONCLUSION

Increased hepatic fibrosis in hemodialysis patients is associated with increased arterial stiffness, but this relationship is not independent.

Long-Term Morbidity and Mortality after First and Recurrent Cardiovascular Events in the ARTPER Cohort

Background: Cardiovascular events are a major cause of mortality and morbidity worldwide. The risk of recurrence after a first cardiovascular event has been documented in the international literature, although not as extensively in a Mediterranean population-based cohort with low cardiovascular risk. There is also ample, albeit contradictory, research on the recurrence of stroke and myocardial infarctions (MI) after a first event and the factors associated with such recurrence, including the role of pathological Ankle-Brachial Index (ABI). Methods: The Peripheral Arterial ARTPER study is aimed at deepening our knowledge of patient evolution after a first cardiovascular event in a Mediterranean population with low cardiovascular risk treated at a primary care centre. We study overall recurrence, cardiac and cerebral recurrence. We studied participants in the ARTPER prospective observational cohort, excluding patients without cardiovascular events or with unconfirmed events and patients who presented arterial calcification at baseline or who died. In total, we analyzed 520 people with at least one cardiovascular event, focusing on the presence and type of recurrence, the risk factors associated with recurrence and the behavior of the ankle-brachial index (ABI) as a predictor of risk. Results: Between 2006 and 2017, 46% of patients with a first cardiovascular event experienced a recurrence of some type; most recurrences fell within the same category as the first event. The risk of recurrence after an MI was greater than after a stroke. In our study, recurrence increased with age, the presence of peripheral arterial disease (PAD), diabetes and the use of antiplatelets. Diabetes mellitus was associated with all types of recurrence. Additionally, patients with an ABI < 0.9 presented more recurrences than those with an ABI ≥ 0.9. Conclusions: In short, following a cardiac event, recurrence usually takes the form of another cardiac event. However, after having a stroke, the chance of having another stroke or having a cardiac event is similar. Lastly, ABI < 0.9 may be considered a predictor of recurrence risk.

Costs and effects of cardiovascular risk reclassification using the ankle-brachial index (ABI) in addition to the Framingham risk scoring in women

BACKGROUND AND AIMS

Ankle brachial index (ABI) is a simple and cheap parameter to assess the presence of atherosclerosis. It could also help correctly reclassify the cardiovascular risk when added to the Framingham risk score (FRS). Recent evidence has demonstrated improvement in prediction performance of ABI when added to FRS, particularly in women. However, no studies have been published yet evaluating the cost-effectiveness of this approach. This study attempts to fill in this gap by assessing the cost-effectiveness of ABI measurements in primary prevention in women.

METHODS

We developed a Markov model to compare two different strategies for assessing the cardiovascular risk (low, intermediate and high) among women in the general population: 1) FRS strategy, and 2) FRS + ABI strategy; and the relative impact associated with interventions for preventing CV events in intermediate and high-risk categories.

RESULTS

In the base-case analysis, FRS + ABI reported an additional cost of € 110 and a gain of 0.0039 QALYs per patient, resulting in an ICER of € 27.986/QALY, when compared to FRS alone. The ICER improved to €1.641/QALY when using a lifetime horizon. The effectiveness of preventive CV disease interventions reported also a significant impact. A 32% reduction of CV events was the minimum value estimated to maintain FRS + ABI as a cost-effective strategy.

CONCLUSIONS

The addition of ABI to FRS is a cost-effective approach in women classified at low and intermediate risk with FRS only. This new approach gives the possibility to reclassify and allocate them into the appropriate risk group and treatment.

Toe pressure should be part of a vascular surgeon's first-line investigation in the assessment of lower extremity artery disease and cardiovascular risk of a patient

OBJECTIVE

Toe pressure (TP) is an accurate indicator of the peripheral vascular status of a patient and thus cardiovascular risk, with less susceptibility to errors than ankle-brachial index (ABI). This study aimed to analyze how ABI and TP measurements associate with overall survival and cardiovascular death and to analyze the TP of patients with ABI of 0.9 to 1.3.

METHODS

The first ABI and TP measurements of a consecutive 6784 patients treated at the Helsinki University Hospital vascular surgery clinic between 1990 and 2009 were analyzed. Helsinki University Vascular Registry and the national Cause of Death Registry provided the data.

RESULTS

The poorest survival was in patients with ABI >1.3 (10-year survival, 15.3%; hazard ratio, 2.2; 95% confidence interval, 1.9-2.6; P < .0001; reference group, ABI 0.9-1.3), followed by the patients with TP <30 mm Hg (10-year survival, 19.6%; hazard ratio, 2.0; 95% confidence interval, 1.7-2.2; P < .0001; reference group, TP ≥80 mm Hg). The best 10-year survival was in patients with TP ≥80 mm Hg (43.9%). Of the 642 patients with normal ABI (0.9-1.3), 18.7% had a TP <50 mm Hg. The highest cardiovascular death rate (64.6%) was in the patients with TP <30 mm Hg, and it was significantly lower than for the patients with TP >50 mm Hg.

CONCLUSIONS

Low TP is associated significantly with survival and cardiovascular mortality. Patients with a normal ABI may have lower extremity artery disease (LEAD) and a considerable risk for a cardiovascular event. If only the ABI is measured in addition to clinical examination, a substantial proportion of patients may be left without LEAD diagnosis or adequate treatment of cardiovascular risk factors. Thus, especially if ABI is normal, LEAD is excluded only if TPs are also measured and are normal.

[Prognostic importance of diagnosticated peripheral arterial disease through the ankle brachial index in spanish general population]

OBJECTIVE

The objectives have been to determine the prognostic value of having a low ankle-brachial index (ABI) for different cardiovascular diseases and whether it improves the predictive capacity of the main cardiovascular risk scores proposed for Spain.

DESIGN

Population-based cohort study LOCATION: A health area of the province of Badajoz (Spain) PARTICIPANTS: 2,833 subjects, representative of residents, between 25 and 79 years old, MEASUREMENTS: The ABI was measured at baseline and the first episode of ischemic heart disease or stroke, cardiovascular and total mortality, was recorded during 7 years of follow-up. The hazard ratio (HR) adjusted for cardiovascular risk factors and net reclassification index (NRI) by category, clinical and continuous for the risk functions REGICOR, FRESCO coronary heart disease, FRESCO cardiovascular disease and SCORE, were calculated.

RESULTS

2,665 subjects were analysed after excluding people with cardiovascular history and loss of follow-up. Low ABI was associated with adjusted HR (95% CI): 6.45 (3.00 - 13.86), 2.60 (1.15 - 5.91), 3.43 (1.39 - 8.44), 2.21 (1.27 - 3.86) for stroke, ischemic heart disease, cardiovascular mortality and total mortality respectively. The ABI improved the NRI (95% CI) in the intermediate risk category according to FRESCO cardiovascular equation by 24.1% (10.1 - 38.2).

CONCLUSIONS

Low ABI is associated with a significant increase in the risk of stroke, ischemic heart disease, cardiovascular mortality and total mortality in our population. The inclusion of ABI improved the reclassification of people at intermediate risk, according to FRESCO cardiovascular, so its use in that risk category would be justified.

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

INTRODUCTION

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

Ankle-brachial index and incident heart failure with reduced versus preserved ejection fraction: The Multi-Ethnic Study of Atherosclerosis

This study investigated the relationship between ankle-brachial index (ABI) and risk for heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). ABI has previously been associated with mortality, cardiovascular disease (CVD), and overall HF but the relationship between ABI and risk of HF stratified by EF has not been well characterized. We analyzed data from 6553 participants (53% female; mean age 62 ± 10 years) enrolled in the Multi-Ethnic Study of Atherosclerosis (MESA) who were free of known clinical CVD/HF at baseline (2000-2002) and had baseline ABI measured. Participants were classified as low (≤ 0.90), borderline-low (0.91-1.00), normal (1.01-1.40), and high (> 1.40) ABI. Incident hospitalized HF was determined over a median follow-up of 14 years; we classified HF events (n = 321) as HFrEF with EF < 50% (n = 155, 54%) or HFpEF with EF ⩾ 50% (n = 133, 46%). Low ABI was associated with incident HFrEF (hazard ratio (HR): 2.02, 95% CI 1.19-3.40, p = 0.01) and had no significant association with HFpEF (HR: 0.67, 95% CI 0.30-1.48, p = 0.32). Borderline-low and high ABI were not significantly associated with HFrEF or HFpEF. Cubic spline analyses showed association with both low and high ABI for HFrEF and high ABI for HFpEF. A 1 SD lower ABI (for ABI < 1.1) was associated with incident HFrEF in multivariable analysis (HR: 1.27, 95% CI 1.05-1.54) but was not significant after additionally adjusting for interim myocardial infarction (HR: 1.21, 95% CI 0.99-1.48). Low ABI was associated with higher risk for incident HFrEF but not HFpEF in persons free of known CVD. Future studies of a larger size are needed for high ABI analyses.

Oscillometric and Doppler Ankle Brachial Indexes as predictors of all-cause mortality in a Primary Care population

BACKGROUND

Doppler Ankle Brachial Index (ABI), the non-invasive reference standard for peripheral arterial disease (PAD) in Primary Care, has proved good capacity to predict all-cause mortality. However, the role of oscillometric ABI is uncertain. This study aims to evaluate the ability of oscillometric and Doppler ABI to predict all-cause mortality in a Primary Care population.

METHODS

Oscillometric and Doppler ABI were measured in 203 consecutive subjects with ≥1 cardiovascular risk factors or intermittent claudication. Pathologic ABI was defined when ABI was ≤0.9 or ≥1.4, and when the oscillometer was unable to record a value (oscillometric error). All-cause mortality was ascertained through examination of electronic medical records or telephone contact.

RESULTS

After analyzing 602.9 subjects/year, all-cause mortality was recorded in 17 (8.4%) patients. Kaplan-Meier survival curves for oscillometric (Log-Rank test χ2=66.02, P<0.001) and Doppler ABI (Log-Rank test χ2=42.30, P<0.001) showed that a pathologic ABI is associated with all-cause mortality. After adjusting for covariates, the hazard ratio in multivariable Cox regression were 4.52 (95% CI: 1.67-12.18, P=0.003) and 2.08 (95% CI: 0.83-5.18, P=0.117) for oscillometric and Doppler ABI models, respectively. When introducing oscillometric and Doppler ABI simultaneously in the Cox regression model, only oscillometric ABI was an independent predictor with a hazard ratio=7.90 (95% CI: 1.79-34.83, P=0.006). Regarding Doppler ABI, no significant differences were found in all-cause mortality between low ABI (≤0.9) and calcified ABI (≥1.4), (Log-Rank test χ2=0.98, P=0.322).

CONCLUSIONS

Oscillometric ABI predicted all-cause mortality in a Primary Care population even better than Doppler ABI, irrespective of cardiovascular risk factors. Oscillometric ABI, due to a high feasibility, could routinely identify high-risk patients to implement preventive measures.

Low, borderline and normal ankle-brachial index as a predictor of incidents outcomes in the Mediterranean based-population ARTPER cohort after 9 years follow-up

BACKGROUND

Guidelines recommended adopting the same cardiovascular risk modification strategies used for coronary disease in case of low Ankle-brachial index (ABI), but here exist few studies on long-term cardiovascular outcomes in patients with borderline ABI and even fewer on the general population.

AIM

The aim of the present study was to analyze the relationship between long-term cardiovascular events and low, borderline and normal ABI after a 9-year follow up of a Mediterranean population with low cardiovascular risk.

DESIGN AND SETTING

A population-based prospective cohort study was performed in the province of Barcelona, Spain.

METHOD

A total of 3,786 subjects >49 years were recruited from 2006-2008. Baseline ABI was 1.08 ± 0.16. Subjects were followed from the time of enrollment to the end of follow-up in 2016 via phone calls every 6 months, systematic reviews of primary-care and hospital medical records and analysis of the SIDIAP (Information System for Primary Care Research) database to confirm the possible appearance of cardiovascular events.

RESULTS

3146 individuals participated in the study. 2,420 (77%) subjects had normal ABI, 524 (17%) had borderline ABI, and 202 (6.4%) had low ABI. In comparison with normal and borderline subjects, patients with lower ABI had more comorbidities, such as hypertension, hypercholesterolemia and diabetes. Cumulative MACE incidence at 9 years was 20% in patients with low ABI, 6% in borderline ABI and 5% in normal ABI. The annual MACE incidence after 9 years follow-up was significantly higher in people with low ABI (26.9/1000py) (p<0.001) than in borderline (6.6/1000py) and in normal ABI (5.6/1000py). Subjects with borderline ABI are at significantly higher risk for coronary disease (HR: 1.58; 95% CI: 1.02-2, 43; p = 0,040) compared to subjects with normal ABI, after adjustment.

CONCLUSION

The results of the present study support that low ABI was independently associated with higher incidence of MACE, ICE, cardiovascular and no cardiovascular mortality; while borderline ABI had significantly moderate risk for coronary disease than normal ABI.

Reference values of vessel diameters, stenosis prevalence, and arterial variations of the lower limb arteries in a male population sample using contrast-enhanced MR angiography

Introduction

Morphological characterization of leg arteries is of significant importance to detect vascular remodeling triggered by atherosclerotic changes. We determined reference values of vessel diameters and assessed prevalence of stenosis and arterial variations of the lower limb arteries in a healthy male population sample.

Methods

Gadolinium-enhanced magnetic resonance angiography at 1.5 Tesla was performed in 756 male participants (median age = 52 years, range = 21–82 years) of the population-based Study of Health in Pomerania. Vessel diameters were measured in 9 predefined segments of the pelvic and leg arteries and 95th percentiles were used for upper reference values of means of left and right side arteries.

Results

Reference values of vascular diameters decreased from proximal to distal arteries: common iliac = 1.18cm; internal iliac = 0.75cm; external iliac = 1.03cm; proximal femoral = 1.02cm; distal femoral = 0.77cm; popliteal = 0.69cm; anterior tibial = 0.42cm; posterior tibial = 0.38cm; fibular = 0.40cm. Body-surface area indexed reference values increased with age in all segments. A number of 53 subjects (7.0%) had at least one stenosis, mainly in the lower leg arteries anterior tibial (n = 28, 3.7%), posterior tibial (n = 18, 2.4%) and fibular (n = 20, 2.6%). The risk of stenosis increased considerably with age (odds ratio = 1.08; p<0.001). The most common arterial variant was type I-A in both legs (n = 620, 82%).

Conclusion

We present reference values for different pelvic and leg artery segment diameters in men that decrease from proximal to distal and increase with age. Stenoses were most prevalent in lower leg arteries and type I-A was the most common variant in the lower leg.

Contribution of the ankle-brachial index to improve the prediction of coronary risk: The ARTPER cohort

BACKGROUND

The different cardiovascular risk prediction scales currently available are not sufficiently sensitive.

AIM

The aim of the present study was to analyze the contribution of the ankle-brachial index (ABI) added to the Framingham and REGICOR risk scales for the reclassification of cardiovascular risk after a 9-year follow up of a Mediterranean population with low cardiovascular risk.

DESIGN AND SETTING

A population-based prospective cohort study was performed in the province of Barcelona, Spain.

METHOD

A total of 3,786 subjects >49 years were recruited from 2006-2008. Baseline ABI was performed and cardiovascular risk was calculated with the Framingham and REGICOR scales. The participants were followed until November 2016 by telephone and review of the clinical history every 6 months to confirm the possible appearance of cardiovascular events.

RESULTS

2,716 individuals participated in the study. There were 126 incidental cases of first coronary events (5%) during follow up. The incidence of coronary events in patients with ABI <0.9 was 4-fold greater than that of subjects with a normal ABI (17.2/1,000 persons-year versus 4.8/1,000 persons-year). Improvement in the predictive capacity of REGICOR scale was observed on including ABI in the model, obtaining a net reclassification improvement of 7% (95% confidence interval 0%-13%) for REGICOR+ ABI. Framingham + ABI obtained a NRI of 4% (-2%-11%).

CONCLUSION

The results of the present study support the addition of the ABI as a tool to help in the reclassification of cardiovascular risk and to confirm the greater incidence of coronary events in patients with ABI < 0.9.

Relationship of peripheral and coronary artery disease to cardiovascular events in patients with atrial fibrillation

BACKGROUND

To investigate the impact of concomitant asymptomatic peripheral artery disease (PAD) and pre-existing coronary artery disease (CAD) on cardiovascular events (CVEs) in atrial fibrillation (AF) patients.

METHODS

Prospective multicenter study including 1138 anticoagulated AF patients. PAD was diagnosed by can ankle-brachial index (ABI)≤0.9, and CAD as a documented myocardial infarction (MI) or cardiac revascularization. The cohort was divided into 4 groups: group 0 (n=717) with no previous CAD and ABI >0.9; group 1 (n=168) no previous CAD and ABI≤0.9; group 2 (n=183) previous CAD and ABI >0.9: and group 3 (n=70) previous CAD and ABI≤0.9. The primary endpoint was a composite of CVEs.

RESULTS

Mean age was 72.6years and 41.3% were female. History of CAD was present in 253 (22.2%) patients, and 238 (20.9%) had an ABI≤0.9. Patients with previous CAD were more likely to have a low ABI compared to those without (OR:1.6, 95%CI 1.2-2.3, P=0.003). Median follow-up was 35.9months (IQR 19.2-57.2, 3819 patient-years), and 145 CVEs were recorded (3.8%/year 95%CI 3.2-4.5). Survival analysis showed a progressive increase in the rate of CVEs in the four groups (log-rank test P<0.001). Multivariable Cox regression analysis showed that as compared to group 0, group 1 (HR:1.8, 95%CI 1.1-2.9, P=0.01), group 2 (HR:2.2, 95%CI 1.4-3.4, P=0.001) and group 3 (HR:2.4, 95%CI 1.4-4.4, P=0.003) were associated with progressive greater risk of CVEs.

CONCLUSION

Patients with concomitant CAD and asymptomatic PAD are at high risk of CVEs, with a progressive risk with vascular disease burden where PAD was associated with CAD.

Factors influencing pathological ankle-brachial index values along the chronic kidney disease spectrum: the NEFRONA study

Background

The ankle-brachial index (ABI) is widely used to diagnose subclinical peripheral artery disease (PAD) in the general population, but data assessing its prevalence and related factors in different chronic kidney disease (CKD) stages are scarce. The aim of this study is to evaluate the prevalence and associated factors of pathological ABI values in CKD patients.

Methods

NEFRONA is a multicentre prospective project that included 2445 CKD patients from 81 centres and 559 non-CKD subjects from 9 primary care centres across Spain. A trained team collected clinical and laboratory data, performed vascular ultrasounds and measured the ABI.

Results

PAD prevalence was higher in CKD than in controls (28.0 versus 12.3%, P < 0.001). Prevalence increased in more advanced CKD stages, due to more patients with an ABI ≥1.4, rather than ≤0.9. Diabetes was the only factor predicting both pathological values in all CKD stages. Age, female sex, carotid plaques, higher carotid intima-media thickness, higher high-sensitivity C-reactive protein (hsCRP) and triglycerides, and lower 25-hydroxi-vitamin D were independently associated with an ABI ≤0.9. Higher phosphate and hsCRP, lower low-density lipoprotein (LDL)-cholesterol and dialysis were associated with an ABI ≥1.4. A stratified analysis showed different associated factors in each CKD stage, with phosphate being especially important in earlier CKD, and LDL-cholesterol being an independent predictor only in Sage 5D CKD.

Conclusions

Asymptomatic PAD is very prevalent in all CKD stages, but factors related to a low or high pathological ABI differ, revealing different pathogenic pathways. Diabetes, dyslipidaemia, inflammation and mineral-bone disorders play a role in the appearance of PAD in CKD.

Diagnostic Accuracy Study of an Oscillometric Ankle-Brachial Index in Peripheral Arterial Disease: The Influence of Oscillometric Errors and Calcified Legs

BACKGROUND

Peripheral arterial disease (PAD) is an indicator of widespread atherosclerosis. However, most individuals with PAD, in spite of being at high cardiovascular risk, are asymptomatic. This fact, together with the limitations of the Doppler ankle-brachial index (ABI), contributes to PAD underdiagnose. The aim of this study was to compare oscillometric ABI and Doppler ABI to diagnose peripheral arterial disease, and also to examine the influence of oscillometric errors and calcified legs on the PAD diagnoses.

METHODS AND FINDINGS

We measured the ankle-brachial indexes of 90 volunteers (n = 180 legs, age 70 ± 14 years, 43% diabetics) using both oscillometer OMRON-M3 and Doppler. For concordance analyses we used the Bland and Altman method, and also estimated the intraclass correlation coefficient. Receiver Operating Characteristic Curves were used to examine the diagnostic performance of both methods. The ABI means were 1.06 ± 0.14 and 1.04 ± 0.16 (p = 0.034) measured by oscillometer and Doppler ABIs respectively, with limits of agreement of ± 0.20 and intraclass correlation coefficient = 0.769. Oscillometer yielded 23 "error" measurements, and also overestimated the measurements in low ankle pressures. Using Doppler as gold standard, oscillometer performance for diagnosis of PAD showed an Area Under Curve = 0.944 (sensitivity: 66.7%, specificity: 96.8%). Moreover, when considered calcified legs and oscillometric "error" readings as arteriopathy equivalents, sensitivity rose to 78.2%, maintaining specificity in 96%. The best oscillometer cut-off point was 0.96 (sensitivity: 87%, specificity: 91%, positive likelihood ratio: 9.66 and negative likelihood ratio: 0.14).

CONCLUSION

Despite its limitations, oscillometric ABI could be a useful tool for the diagnosis of PAD, particularly when considering calcified legs and oscillometric "errors" readings as peripheral arterial disease equivalents.

Association between novel arterial stiffness indices and risk factors of cardiovascular disease

BACKGROUND

Prevention and early detection of arterial stiffness are required to avoid severe cardiovascular events. Recently, new noninvasive arterial stiffness indices, the arterial pressure volume index (API) and the arterial velocity pulse index (AVI), have been developed. The purpose of this study was to examine the clinical validity of these new indices by investigating the association between known risk factors of cardiovascular disease (CVD) and API or AVI in a large population.

METHODS

This cross-sectional survey included 7248 adults who underwent an annual medical checkup at a single medical institution. API and AVI were measured using cuff oscillometry by trained nurses. We used correlation coefficients, t-tests, and multiple regression analyses to evaluate associations, and calculated intraclass correlation coefficients (ICC) to examine test-retest reliabilities of these indices.

RESULTS

Mean age was 45.5 years (SD = 5.8), and 4083 (56.3 %) participants were men, while 3165 were women. Mean values of API and AVI were 25.1 (SD = 7.0) and 16.6 (SD = 5.4), respectively. API was strongly correlated with body mass index (BMI), systolic blood pressure (sBP), and diastolic blood pressure (dBP) (r > 0.3, p < 0.001). AVI was strongly correlated with age, sBP, and API (r > 0.3, p < 0.001). Multiple regression analyses showed that sex, age, BMI, and sBP were independently associated with API. Sex, age, BMI, sBP, fasting plasma glucose (FPG), and smoking condition were also independently associated with AVI. As reliabilities of measurements, the ICC of API was 0.74, and the ICC of AVI was 0.80.

CONCLUSIONS

These new noninvasive arterial stiffness indices, which had high test-retest reliabilities, were associated with known risk factors of CVD. Further study is warranted to determine the clinical validity of these indices.

China suboptimal health cohort study: rationale, design and baseline characteristics

BACKGROUND

Suboptimal health status (SHS) is a physical state between health and disease, characterized by the perception of health complaints, general weakness, chronic fatigue and low energy levels. SHS is proposed by the ancient concept of traditional Chinese medicine (TCM) from the perspective of preservative, predictive and personalized (precision) medicine. We previously created the suboptimal health status questionnaire 25 (SHSQ-25), a novel instrument to measure SHS, validated in various populations. SHSQ-25 thus affords a window of opportunity for early detection and intervention, contributing to the reduction of chronic disease burdens.

METHODS/DESIGN

To investigate the causative effect of SHS in non-communicable chronic diseases (NCD), we initiated the China suboptimal health cohort study (COACS), a longitudinal study starting from 2013. Phase I of the study involved a cross-sectional survey aimed at identifying the risk/protective factors associated with SHS; and Phase II: a longitudinal yearly follow-up study investigating how SHS contributes to the incidence and pattern of NCD.

RESULTS

(1) Cross-sectional survey: in total, 4313 participants (53.8 % women) aged from 18 to 65 years were included in the cohort. The prevalence of SHS was 9.0 % using SHS score of 35 as threshold. Women showed a significantly higher prevalence of SHS (10.6 % in the female vs. 7.2 % in the male, P < 0.001). Risk factors for chronic diseases such as socioeconomic status, marital status, highest education completed, physical activity, salt intake, blood pressure and triglycerides differed significantly between subjects of SHS (SHS score ≥35) and those of ideal health (SHS score <35). (2) Follow up: the primary and secondary outcomes will be monitored from 2015 to 2024.

CONCLUSIONS

The sex-specific difference in prevalence of SHS might partly explain the gender difference of incidence of certain chronic diseases. The COACS will enable a thorough characterization of SHS and establish a cohort that will be used for longitudinal analyses of the interaction between the genetic, lifestyle and environmental factors that contribute to the onset and etiology of targeted chronic diseases. The study together with the designed prospective cohort provides a chance to characterize and evaluate the effect of SHS systemically, and it thus generates an unprecedented opportunity for the early detection and prevention of chronic disease.

Prognostic significance of ankle brachial pressure index: A systematic review and meta-analysis

Purpose To synthesize and quantify the excess risk of morbidity and mortality in individuals with low ankle-brachial pressure index. Methods Electronic databases were searched to identify studies investigating morbidity and mortality outcomes in individuals undergoing ankle-brachial pressure index measurement. Meta-analysis of the outcomes was performed using fixed- or random-effects models. Uncertainties related to varying follow-up periods among the studies were resolved by meta-analysis of time-to-event outcomes. Results Forty-three observational cohort studies, enrolling 94,254 participants, were selected. A low ankle-brachial pressure index (<0.9) was associated with a significant risk of all-cause mortality (risk ratio: 2.52, 95% CI 2.26-2.82, P < 0.00001); cardiovascular mortality (risk ratio: 2.94, 95% CI 2.72-3.18, P < 0.00001); cerebrovascular event (risk ratio: 2.17, 95% CI 1.90-2.47, P < 0.00001); myocardial infarction (risk ratio: 2.28, 95% CI 2.07-2.51, P < 0.00001); fatal myocardial infarction (risk ratio: 2.81, 95% CI 2.33-3.40, P < 0.00001); fatal stroke (risk ratio: 2.28, 95% CI 1.80-2.89, P < 0.00001); and the composite of myocardial infarction, stroke, and death (risk ratio: 2.29, 95% CI 1.87-2.81, P < 0.00001). Similar findings resulted from analyses of individuals with asymptomatic PAD, individuals with cardiovascular or cerebrovascular co-morbidity, and patients with diabetes. Conclusions A low ankle-brachial pressure index is associated with an increased risk of subsequent cardiovascular and cerebrovascular morbidity and mortality. Randomised controlled trials are required to investigate the effectiveness of screening for PAD in asymptomatic and undiagnosed individuals and to evaluate benefits of early treatment of screen-detected PAD.

Relationship between low Ankle-Brachial Index and rapid renal function decline in patients with atrial fibrillation: a prospective multicentre cohort study

OBJECTIVE

To investigate the relationship between Ankle-Brachial Index (ABI) and renal function progression in patients with atrial fibrillation (AF).

DESIGN

Observational prospective multicentre cohort study.

SETTING

Atherothrombosis Center of I Clinica Medica of 'Sapienza' University of Rome; Department of Medical and Surgical Sciences of University Magna Græcia of Catanzaro; Atrial Fibrillation Registry for Ankle-Brachial Index Prevalence Assessment-Collaborative Italian Study.

PARTICIPANTS

897 AF patients on treatment with vitamin K antagonists.

MAIN OUTCOME MEASURES

The relationship between basal ABI and renal function progression, assessed by the estimated Glomerular Filtration Rate (eGFR) calculated with the CKD-EPI formula at baseline and after 2 years of follow-up. The rapid decline in eGFR, defined as a decline in eGFR >5 mL/min/1.73 m(2)/year, and incident eGFR<60 mL/min/1.73 m(2) were primary and secondary end points, respectively.

RESULTS

Mean age was 71.8±9.0 years and 41.8% were women. Low ABI (ie, ≤0.90) was present in 194 (21.6%) patients. Baseline median eGFR was 72.7 mL/min/1.73 m(2), and 28.7% patients had an eGFR<60 mL/min/1.73 m(2). Annual decline of eGFR was -2.0 (IQR -7.4/-0.4) mL/min/1.73 m(2)/year, and 32.4% patients had a rapid decline in eGFR. Multivariable logistic regression analysis showed that ABI ≤0.90 (OR 1.516 (95% CI 1.075 to 2.139), p=0.018) and arterial hypertension (OR 1.830 95% CI 1.113 to 3.009, p=0.017) predicted a rapid eGFR decline, with an inverse association for angiotensin converting enzyme (ACE) inhibitors/angiotensin receptor blockers (OR 0.662 95% CI 0.464 to 0.944, p=0.023). Among the 639 patients with AF with eGFR >60 mL/min/1.73 m(2), 153 (23.9%) had a reduction of the eGFR <60 mL/min/1.73 m(2). ABI ≤0.90 was also an independent predictor for incident eGFR<60 mL/min/1.73 m(2) (HR 1.851, 95% CI 1.205 to 2.845, p=0.005).

CONCLUSIONS

In patients with AF, an ABI ≤0.90 is independently associated with a rapid decline in renal function and incident eGFR<60 mL/min/1.73 m(2). ABI measurement may help identify patients with AF at risk of renal function deterioration.

TRIAL REGISTRATION NUMBER

NCT01161251.

The Relationship Between High Pulse Pressure and Low Ankle-Brachial Index. Potential Utility in Screening for Peripheral Artery Disease in Population-Based Studies

INTRODUCTION

The ankle-brachial index (ABI) is a reliable screening procedure for peripheral artery disease detection. However, ABI testing is time-consuming and requires trained personnel, which may preclude its routine use in population-based surveys. Preliminary data suggest a relationship between ABI values and pulse pressure (PP) levels.

AIM

To assess whether PP calculation might help to detect persons who need ABI screening in population-based studies.

METHODS

All Atahualpa residents aged ≥60 years were identified during a door-to-door survey and invited to undergo ABI testing. Non-consented persons and those with ABI ≥1.4 were excluded. Using generalized linear and logistic regression models adjusted for demographics and cardiovascular risk factors, as well as receiver operator characteristics curve analysis, we evaluated the association between PP values and ABI, as well as the reliability of PP to identify candidates for ABI testing.

RESULTS

Out of 239 participants (mean age 70 ± 8 years, 62 % women), 46 (19 %) had an ABI ≤0.9 and 136 (57 %) had PP >65 mmHg, with a negative relationship between them (R = -0.386, p < 0.0001). A PP >65 mmHg was associated with an ABI ≤ 0.9 in the logistic regression model (OR 3.46, 95 % CI 1.07-11.2, p = 0.038). Continuous PP levels also correlated negatively with ABI (β -0.0014, 95 % CI -0.0024 to -0.0004, p = 0.005). The sensitivity of a PP >65 mmHg to predict a low ABI was 85 %, and the specificity was 50 %. In contrast, the sensitivity of blood pressure ≥140/90 mmHg was 27 % and the specificity was 10 %. The area under the curve for the predictive value of a PP >65 mmHg was 0.673 (95 % CI 0.609-0.736), and that of a blood pressure ≥140/90 mmHg was 0.371 (95 % CI 0.30-0.443), with a significant difference between them (p < 0.0001).

CONCLUSIONS

PP calculation may be a simple tool to detect candidates for ABI testing in population-based studies.

Prevalence, correlates, and prognosis of peripheral artery disease in rural ecuador-rationale, protocol, and phase I results of a population-based survey: an atahualpa project-ancillary study

Background. Little is known on the prevalence of peripheral artery disease (PAD) in developing countries. Study design. Population-based study in Atahualpa. In Phase I, the Edinburgh claudication questionnaire (ECQ) was used for detection of suspected symptomatic PAD; persons with a negative ECQ but a pulse pressure ≥65 mmHg were suspected of asymptomatic PAD. In Phase II, the ankle-brachial index will be used to test reliability of screening instruments and to determine PAD prevalence. In Phase III, participants will be followed up to estimate the relevance of PAD as a predictor of vascular outcomes. Results. During Phase I, 665 Atahualpa residents aged ≥40 years were enrolled (mean age: 59.5 ± 12.6 years, 58% women). A poor cardiovascular health status was noticed in 464 (70%) persons of which 27 (4%) had a stroke and 14 (2%) had ischemic heart disease. Forty-four subjects (7%) had suspected symptomatic PAD and 170 (26%) had suspected asymptomatic PAD. Individuals with suspected PAD were older, more often women, and had a worse cardiovascular profile than those with nonsuspected PAD. Conclusions. Prevalence of suspected PAD in this underserved population is high. Subsequent phases of this study will determine whether prompt detection of PAD is useful to reduce the incidence of catastrophic vascular diseases in the region.

The cardio-ankle vascular index and ankle-brachial index in young russians

AIM

A noninvasive approach to assess atherosclerosis in young people is of great concern. The cardio-ankle vascular index (CAVI) and ankle-brachial index (ABI) reflect the arterial conditions, although the CAVI has not fully been studied in Russian populations. This study aimed to determine the CAVI and ABI in young Russians, to compare these findings with those in their Japanese peers and to investigate the lifestyle correlates and genetic associations with the CAVI and ABI in the Russians.

METHODS

In addition to several atherosclerotic parameters and self-reported lifestyle factors, the CAVI and ABI levels were measured in 114 Russians (mean 21 years). Four gene polymorphisms, including cholesteryl ester transfer protein (CETP) Taq1B polymorphism, were typed in some of the subjects.

RESULTS

The Russians exhibited significantly higher CAVI levels compared to their Japanese counterparts (5.87 vs. 5.36; p＜0.05), while the ABI levels were similar between the two populations. In the Russians, the ABI was significantly correlated with the mean blood pressure (r=-0.26) and heart rate (r=-0.43), while the CAVI did not show such correlations. No significant associations existed between lifestyle-related factors and the CAVI or ABI levels. A lower ABI level was found in carriers with the T-allele of CETP Taq1B in the Russians.

CONCLUSIONS

The reference CAVI value can be specified for individual ethnic populations. Our findings suggest that Russians may develop atherosclerosis-related conditions at a younger age compared to Japanese subjects, although this must be verified in additional studies. The possible association between CETP polymorphisms and the ABI deserves further investigation.

Lifestyle and dietary risk factors for peripheral artery disease

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