Ankle-Brachial Index: Diagnostic Tool of Peripheral Arterial Disease and Predictor of Cardiovascular Risk-An Update of Current Knowledge

The ankle-brachial index (ABI) was introduced as a screening method for the diagnosis of lower extremity peripheral arterial disease (PAD). Later findings recognized ABI as a prognostic marker of adverse cardiovascular events due to its relation to atherosclerosis in other vascular territories. This narrative review aims to appraise the validity, reliability, and utility of ABI in the detection of PAD and the determination of global atherosclerotic cardiovascular risk. While the ABI value can be influenced by different physiological characteristics including age, sex, body position, and techniques used for ABI determination, it has high specificity and reproducibility in the assessment of vascular patients. In conclusion, when used correctly, the ABI remains a reliable and invaluable indicator of lower-limb perfusion and a useful tool for predicting the risk of future cardiovascular events. However, its underutilization in clinical settings is noteworthy.

Evaluation of Risk Factors for Major Amputation in Patients With Diabetes and Peripheral Artery Disease Receiving Antiplatelet Therapy - Post Hoc Analysis of a Prospective Observational Multicenter Cohort Study (SEASON)

BACKGROUND

Guidelines for peripheral arterial disease (PAD) recommend long-term antiplatelet therapy in symptomatic patients to reduce cardiovascular morbidity and mortality risk. Although diabetes is a known risk factor for PAD, PAD has been undertreated in these patients. This study aimed to evaluate risk factors for major amputation in patients with diabetes undergoing antiplatelet therapy for PAD.

METHODS AND RESULTS

This retrospective analysis of a 2-year observational cohort study (1,745 clinics in Japan, September 2009-2013) evaluated predictors of amputation in patients with diabetes undergoing antiplatelet therapy for PAD. Among 4,016 eligible patients, 52 had an amputation during follow-up. Amputation risk (Cox regression analysis) was predicted at baseline by history of lower extremity revascularization/amputation (hazard ratio [HR]: 2.92; 95% confidence interval [CI]: 1.39, 6.14), chronic kidney disease (HR: 4.19; 95% CI: 1.95, 8.97), and comorbid cerebrovascular and heart disease (HR: 3.32; 95% CI: 1.19, 9.30), and was unaffected by choice of oral antiplatelet therapy. In patients with PAD and diabetes, amputation event rate was highest for those with ankle-brachial pressure index (ABI) <0.40 and progressively decreased at higher ABI cut-offs.

CONCLUSIONS

These findings inform real-world understanding of PAD in diabetic patients receiving antiplatelet therapy in Japan, and showed that ABI <0.4 was the strongest risk factor for amputation.

Independent Factors of Changes of Ankle-Brachial Index in Peripheral Arterial Occlusive Disease in Elderly Patients with or without Diabetes

Peripheral arterial disease (PAD) belongs to the commonly-occurring pathologies associated with elderly age. A simple tool for defining the severity of PAD is the ankle-brachial index (ABI). The purpose of this research was to determine independent factors of changes of ABI in elderly patients with occlusive PAD disease (PAOD) with and without diabetes. The research was carried out on 49 elderly patients with PAOD, including 29 patients with type 2 diabetes, and 20 patients without diabetes. The concentration of interleukin-6 (IL-6), E-selectin, fibrinogen, and C-reactive protein (CRP) in the blood serum was marked. In all patients, the independent factors of changes of ABI were determined with the use of the multiple logistic regression analysis. Our results show that in the group of patients with PAOD suffering from diabetes, it was demonstrated that the ABI was related to age, the duration of the symptoms of PAD, body mass index (BMI), low-density lipoprotein cholesterol, fibrinogen, and sex (determination coefficient R² = 0.699). In patients with PAOD without diabetes, the ABI was related to age, the duration of the symptoms of PAD, the levels of CRP, E-selectin, high-density lipoprotein cholesterol, and the glomerular filtration rate(determination coefficient R² = 0.844). We conclude that in elderly patients with PAOD with and without diabetes, the participation of independent factors related to the ABI is diversified; in patients with diabetes, the concentration of IL-6 and fibrinogen is lower, and the concentration of E-selectin is higher than in patients without diabetes.

Cilostazol does not improve peripheral arterial disease-linked oxidative stress

AIM

Cilostazol is a drug widely used to treat peripheral arterial disease (PAD) in patients with advanced atherosclerosis. It is an inhibitor of platelet aggregation and causes arterial vasodilatation. It has been speculated that cilostazol might act to improve oxidative stress in these patients.

METHODS

We analyzed 25 patients with demonstrated lower limb peripheral arterial disease to determine whether lipid peroxidation (LPO) or total antioxidant capacity (TAC) were modified after 6 months of cilostazol treatment (postintervention phase) with respect to the basal phase.

RESULTS

Analysis of plasma samples determined that LPO levels decreased significantly over the postintervention phase (26±15 vs. 11±7 pM, P=0.0003). However, when TAC levels were analyzed, no significant differences were observed (0.80±0.21 vs. 0.85±0.17 mM, P=0.42). Under basal conditions, LPO showed a positive correlation to treatment as judged by the ankle-brachial index (r=0.800, P=0.002) as well as uric acid (r=0.508, P=0.03) and CRP (r=0.481, P=0.05) levels. In contrast, TAC negatively correlated with triglycerides (r=-0.879, P<0.0001) and microalbuminuria (r=-0.868, P<0.0001). In the postintervention phase, TAC negatively correlated with HbA1c (r=-0.570, P=0.02) and triglycerides (r=-0.864, P<0.0001).

CONCLUSIONS

Our data indicate that cilostazol treatment does not improve oxidative stress in PAD patients after 6 months of treatment. However, lipid peroxidation and total antioxidant capacity were affected by cilostrazol treatment, which could be related to altered reactive oxygen species production. Further research may be needed to determine the critical dose of cilostazol to clarify the protective role of this drug in PAD.

Surface-enhanced Raman spectral biomarkers correlate with Ankle Brachial Index and characterize leg muscle biochemical composition of patients with peripheral arterial disease

Peripheral arterial disease (PAD) is characterized by atherosclerotic blockages of the arteries supplying the lower extremities, which cause a progressive accumulation of ischemic injury to the skeletal muscles of the lower limbs. This injury includes altered metabolic processes, damaged organelles, and compromised bioenergetics in the affected muscles. The objective of this study was to explore the association of Raman spectral signatures of muscle biochemistry with the severity of atherosclerosis in the legs as determined by the Ankle Brachial Index (ABI) and clinical presentation. We collected muscle biopsies from the gastrocnemius (calf muscle) of five patients with clinically diagnosed claudication, five patients with clinically diagnosed critical limb ischemia (CLI), and five control patients who did not have PAD. A partial least squares regression (PLSR) model was able to predict patient ABI with a correlation coefficient of 0.99 during training and a correlation coefficient of 0.85 using a full cross‐validation. When using the first three PLS factor scores in combination with linear discriminant analysis, the discriminant model was able to correctly classify the control, claudicating, and CLI patients with 100% accuracy, using a full cross‐validation procedure. Raman spectroscopy is capable of detecting and measuring unique biochemical signatures of skeletal muscle. These signatures can discriminate control muscles from PAD muscles and correlate with the ABI and clinical presentation of the PAD patient. Raman spectroscopy provides novel spectral biomarkers that may complement existing methods for diagnosis and monitoring treatment of PAD patients.

Raman spectroscopy is capable of detecting and measuring unique biochemical signatures of skeletal muscle. These signatures can discriminate control muscles from peripheral arterial disease (PAD) muscles and correlate with the ABI and clinical presentation of the PAD patient. Raman spectroscopy provides novel spectral biomarkers that may complement existing methods for diagnosis and monitoring treatment of PAD patients.

Implementation of best medical therapy for cardiovascular risk factors in vascular surgery patients treated in a tertiary referral regional unit

OBJECTIVE

Current clinical evidence reports that antiplatelet, statin, angiotensin-converting enzyme inhibitor and beta blockade therapies have advantageous effects on vascular surgery patient morbidity and mortality. Unfortunately, such patients appear to be less likely to receive optimal medical management when compared with coronary artery disease patients. This study assessed medical therapy prescribing in patients attending a regional vascular surgery unit.

METHODS

A retrospective review between February 2010 and February 2011 was performed for patients undergoing aortic aneurysm, carotid, peripheral arterial and amputation surgeries. Gender, age, smoking history, body mass index and cardiovascular risk factors were documented from inpatient charts. Current admission medications and subsequent modification by the vascular team were recorded.

RESULTS

Two hundred and forty-four patients (male = 165, mean age = 71 years) were identified. Prevalence of hypertension, hypercholesterolaemia, myocardial infarction, angina, stroke and diabetes was higher than in the general population. A total of 201 (82.3%) patients were on antiplatelets or antithrombotics upon admission to the vascular ward, which was improved to 231 (94.6%) patients on discharge. A total of 180 (73.7%) patients were on lipid-lowering therapy upon admission, which was improved to 213 (87.2%) patients on discharge. A total of 115 (47.1%) patients were on ACE-inhibitor or angiotensin 2 receptor blocker medications on admission and this was improved to 118 (48.3%) upon discharge. A total of 87 (35.6%) patients were on a beta-blocker, which was improved to 93 (38.1%) patients upon discharge.

CONCLUSION

Despite increased implementation of best medical therapy in the community with compliance rates greater than 73% for aspirin and statin therapy, further improvement is warranted. Vascular surgeons should remain vigilant for further opportunities to optimise medical therapy in this high-risk patient group particularly with antithrombotic, lipid lowering and antihypertensive therapies.

Patterns of disease distribution of lower extremity peripheral arterial disease

Peripheral arterial disease (PAD) is a common manifestation of atherosclerosis that is associated with an increased risk of mortality and cardiovascular (CV) events. Peripheral arterial disease involves the arteries distal to the aortic bifurcation in a nonuniform manner. Studies have shown that symptoms and prognosis of patients with PAD vary according to the location and size of the affected artery. Several modalities have been used to identify the location of PAD, including noninvasive evaluations and invasive procedures. Peripheral arterial disease has a risk factor profile similar to that associated with coronary artery disease (ie, age, gender, diabetes, smoking, hypertension, and hyperlipidemia). Many studies have shown that the distribution, extent, and progression of PAD are influenced by CV risk factors but the findings are not consistent. Management strategies for PAD are different for proximal and distal PAD. The objective of this review is to discuss the patterns of diseases distribution in patients with PAD.

Prevalence and risk factors of asymptomatic peripheral arterial disease in patients with COPD in Taiwan

AIM

Chronic obstructive pulmonary disease (COPD) is an independent risk factor for cardiovascular morbidity and mortality. The aim of this study was to determine the prevalence of asymptomatic peripheral arterial disease (PAD) and the associated risk factors for patients with COPD.

METHODS

This prospective cross-sectional study enrolled 427 COPD patients (mean age: 70.0 years) without PAD symptoms consecutively. Demographic data, lung function and cardiovascular risk factors were recorded. The ankle-brachial index (ABI) was used to detect PAD (ABI<0.90).

RESULTS

The overall prevalence of asymptomatic PAD in the COPD patients was 8% (2.5% in the younger participants (<65 years of age, n = 118) and 10% in the elderly participants (≥65 years of age, n = 309). The COPD patients with asymptomatic PAD had a significantly higher rate of hyperlipidemia (47.1% vs. 10.4%) and hypertension (79.4% vs. 45.8%) than those without asymptomatic PAD (p<0.05). There was no significant difference in lung function (forced vital capacity and forced expiratory volume in one second) between the two groups. In multivariate logistic regression, hyperlipidemia was the strongest independent factor for PAD (odds ratio (OR): 6.89, p<0.005), followed by old age (OR: 4.80), hypertension (OR: 3.39) and smoking burden (pack-years, OR: 1.02).

CONCLUSIONS

The prevalence of asymptomatic PAD among COPD patients in Taiwan is lower than in Western countries. Hyperlipidemia, old age, hypertension, and smoking burden were the associated cardiovascular risk factors. However, there was no association between lung function and PAD in the COPD patients.

Training to Measure Ankle–Brachial Index at the Undergraduate Level

We examined the effectiveness of teaching ankle–brachial index (ABI) measurement to medical students. ABI was estimated in 28 lower limbs by an experienced vascular surgeon. After a 2-week training course, 5 fourth-year students repeated the estimations and their results were compared with that of the trainer’s. There was no difference in ABI values between trainees and trainer for subjects with mild-to-moderate peripheral arterial disease (PAD; 0.77 ± 0.22 vs 0.77 ± 0.19, respectively, P = .95). In the 4 normal limbs, ABI was 1.37 ± 0.12 and 1.16 ± 0.11, as measured by the trainer and the trainees, respectively ( P < .00001). In subjects with severe PAD, trainees tended to overestimate ABI ( P = .0002) in the beginning of the educational process, but this was no longer the case at a later stage of the training with no difference in ABI values between the 2 examiner groups ( P = .09). In conclusion, training of medical students in ABI measurement can be helpful toward accurate estimation of PAD and merits further practice.

Novel risk factors for premature peripheral arterial occlusive disease in non-diabetic patients: a case-control study

Background

This study aimed to determine the prevalence of genetic and environmental vascular risk factors in non diabetic patients with premature peripheral arterial disease, either peripheral arterial occlusive disease or thromboangiitis obliterans, the two main entities of peripheral arterial disease, and to established whether some of them are specifically associated with one or another of the premature peripheral arterial disease subgroups.

Methods and Results

This study included 113 non diabetic patients with premature peripheral arterial disease (diagnosis <45-year old) presenting either a peripheral arterial occlusive disease (N = 64) or a thromboangiitis obliterans (N = 49), and 241 controls matched for age and gender. Both patient groups demonstrated common traits including cigarette smoking, low physical activity, decreased levels of HDL-cholesterol, apolipoprotein A–I, pyridoxal 5′-phosphate (active form of B6 vitamin) and zinc. Premature peripheral arterial occlusive disease was characterized by the presence of a family history of peripheral arterial and carotid artery diseases (OR 2.3 and 5.8 respectively, 95% CI), high lipoprotein (a) levels above 300 mg/L (OR 2.3, 95% CI), the presence of the factor V Leiden (OR 5.1, 95% CI) and the glycoprotein Ia^{807T,837T,873A} allele (OR 2.3, 95% CI). In thromboangiitis obliterans group, more patients were regular consumers of cannabis (OR 3.5, 95% CI) and higher levels in plasma copper has been shown (OR 6.5, 95% CI).

Conclusions

According to our results from a non exhaustive list of study parameters, we might hypothesize for 1) a genetic basis for premature peripheral arterial occlusive disease development and 2) the prevalence of environmental factors in the development of thromboangiitis obliterans (tobacco and cannabis). Moreover, for the first time, we demonstrated that the 807T/837T/873A allele of platelet glycoprotein Ia may confer an additional risk for development of peripheral atherosclerosis in premature peripheral arterial occlusive disease.

Prevalence of Asymptomatic Peripheral Arterial Disease and Related Risk Factors in Younger and Elderly Patients in Taiwan

We determined the prevalence of asymptomatic peripheral arterial disease (PAD) and cardiovascular risk factors in Taiwan. Ambulatory participants (n = 1915) without symptoms of PAD were enrolled (mean age of 61.2 years). The ankle-brachial index (ABI) was used to detect the PAD (ABI < 0.90). The overall prevalence of asymptomatic PAD was 5.4% (2.8% in the younger participants [<65 years of age, n = 1021] and 8.4% in the elderly participants [≥65 years of age, n = 894]). Younger participants with asymptomatic PAD had a significantly higher rate of hypertension (55.2% vs 30%) and obesity (31% vs 13.3%) than those without asymptomatic PAD ( P < .05). Elderly participants with asymptomatic PAD had a significantly higher rate of diabetes mellitus (36% vs 21.2%) and hypertension (69.3% vs 55.4%) than those without asymptomatic PAD ( P < .05). Asymptomatic PAD is prevalent among elderly Taiwanese individuals. Overall, age was the strongest risk factor for the development of asymptomatic PAD.

Relationship between high-sensitivity C-reactive protein and risk factors in patients with peripheral arterial disease--a cross-sectional study

We investigated whether patients with peripheral arterial disease (PAD) with various serum levels of high-sensitivity C-reactive protein (hsCRP) differ in the frequency of atherosclerotic risk factors. Among 388 patients, hsCRP levels were (1) low, <1 mg/L, in 41 (10.6%) participants; (2) medium, from 1 to 3 mg/L, in 152 (39.2%) participants, and (3) high, >3 mg/L, in 195 (50.2%) individuals. According to multivariate logistic regression analysis, in comparison with patients with hsCRP level ≤3.0 mg/L, those with higher hsCRP levels had more frequently a severe form of PAD (gangrene, P ranged from .045 to <.001; ankle-brachial index ≤.40, P = .059) and had more frequently some of atherosclerotic risk factors (metabolic syndrome, P = .007; hypertension, P = .013; abdominal obesity, P = .007; high levels of uric acid, P = .022; high level of fibrinogen, P < .001; and depression, P = .015).

C-reactive protein and the Framingham coronary risk score in patients newly diagnosed with intermittent claudication: a prospective study

OBJECTIVE

To investigate the relationship between serum C-reactive protein (CRP) levels and the calculated 10-year Framingham risk score (FRS) in patients newly diagnosed with intermittent claudication.

METHODS

Serum CRP levels were measured in 90 patients newly diagnosed with intermittent claudication over a 12-month period. In all, 76 patients (53 males [70%], mean age 63.3 ± 9.3) were included in the analysis.

RESULTS

Log-transformed CRP levels significantly correlated with total FRS (r = .34, P = .002). Participants were divided into 4 groups according to log-CRP levels. Analysis of variance showed a statistically significant difference between the 4 groups in terms of mean FRS, P = .003. Post hoc comparisons indicated that group 1 was significantly different from group 4, P = .002. Analysis of covariance showed a significant difference between the 4 groups of log-CRP levels in terms of mean FRS, P = .008.

CONCLUSION

There is an increased 10-year risk of coronary heart disease associated with increased plasma concentration of CRP in patients newly diagnosed with intermittent claudication.

Outcomes and Risk Prediction Model for Peripheral Arterial Disease in Patients with Stable Coronary Artery Disease

We used the National Heart, Lung, and Blood Institute Limited Access Dataset of Prevention of Events with Angiotensin-Converting Enzyme Inhibition (PEACE) Trial (n = 8290) which included patients with stable coronary artery disease (CAD) and preserved ejection fraction (>40%). We identified risk factors for the development of critical peripheral arterial disease (PAD; those needing angioplasty, bypass grafting, or aneurysm repair) and formulated a risk score by multivariate analyses. A total of 220 patients (2.8%) developed critical PAD over a mean follow-up of 4.7 years. Significant predictors of critical PAD were history of intermittent claudication, smoking, hypertension (HTN), coronary-artery bypass grafting (CABG), diabetes, age, serum cholesterol, and body mass index (BMI). Incident critical PAD was associated with increased composite outcome of cardiovascular death, myocardial infarction, percutaneous transluminal coronary angioplasty, or CABG (hazard ratio 1.82, 95% CI 1.50-2.22, P < .001). Risk assessment using our score may identify CAD patients at risk for critical PAD events.

Assessing the long-term outcomes of minor lower limb amputations: a 5-year study

Our aim was to assess the long-term outcome for minor forefoot amputations. A retrospective study of 126 patients who had such amputations between 1999 and 2004 was performed. Patients were divided into 2 groups, diabetic (group A: 79 patients) and nondiabetic (group B: 47 patients). Angiograms were requested in 45 patients in group A compared with 31 patients in group B (P = ·77). In group A, 11 patients underwent further ipsilateral amputations compared with 30 patients in group B (P = ·02.). The 2 groups were equally likely to have vascular reconstruction (35% vs 37%). The overall 5-year mortality was 27%, with 58% of deaths occurring within the first year. This study shows that foot amputees have high mortality and reintervention rates. Adequate utilization of vascular services, extra vigilance in the prevention of complications, and risk factor modifications are required to improve postoperative outcomes.

The Management of Asymptomatic Carotid Plaque Disease: Our Assumptions When We are Less Radical

The management of asymptomatic carotid artery stenosis (CAS) has been the subject of extensive debate. Current evidence suggests that the annual risk of stroke in patients with CAS and without previous cerebrovascular symptoms is 1% which makes carotid endarterectomy unjustifiable. Conservative treatment with statins and antiplatelets, the identification of the high risk individuals as well as aggressive life style modifications are considered sufficient measures for the protection of these patients. However, there are reasons to believe that this approach may be less effective than we think. Best medical treatment is only effective when compliance is adequate and lipid or blood pressure target levels are achieved. However this is not always the case and the same applies regarding life style modification changes such as smoking. In addition, there is no consensus regarding the identification of the high risk individuals despite recent encouraging evidence. The introduction of a structured network of risk factor modification clinics in conjunction with the vascular clinics and the identification of ways to objectively risk-stratify patients with asymptomatic CAS could enable us to optimize the management of these patients when we decide to be less radical.

Do Novel Risk Biomarkers Reflect the Severity of Peripheral Arterial Disease?

The association between novel atherosclerotic risk biomarkers and severity of peripheral arterial disease (PAD) was assessed. Patients (n = 133) with PAD were recruited. Established risk biomarkers including low- and high-density cholesterol, triglycerides, and blood pressure were measured. Novel risk biomarkers including plasma C-reactive protein, von Willebrand factor (vWF), interleukin 6, red cell folate (RCF), vitamin B12, total homocysteine (tHcy), and Hcy genotypes were also determined. The severity of PAD was evaluated, using ankle—brachial pressure index (ABPI), brachial—knee, and brachial—ankle pulse wave velocity (bk- and ba-PWV). Plasma tHcy and systolic blood pressure had a positive independent correlation with bk-PWV (β = +0.56, P = .02 and β = +0.38, P < .001, respectively). Red cell folate had an independent inverse correlation with bk-PWV (β = —0.01, P = .01). Systolic blood pressure showed an independent positive correlation with ba-PWV only after adjustment for other risk biomarkers (β = +0.1, P = .04). Novel markers, plasma tHcy, and RCF levels correlated with the severity of PAD.

Reduced high-density lipoprotein level is linked to worse ankle brachial index and peak oxygen uptake in postmenopausal women with peripheral arterial disease

Women with peripheral arterial disease (PAD) have more limited physical function than men but the mechanisms involved are not clear. We determined whether alterations in lipid components, such as decreased high-density lipoprotein cholesterol (HDL-C), are associated with worsening intermittent claudication (IC) in postmenopausal women with PAD. Our cross-sectional cohort study included 69 postmenopausal women with IC (Fontaine stage II). A treadmill test was used to measure initial claudication distance (ICD), absolute claudication distance (ACD), peak oxygen uptake, and ankle systolic blood pressure. High-density lipoprotein cholesterol correlated with ankle brachial index ([ABI]; R = .29, P = .019). No other lipid profile components were associated with exercise performance and hemodynamic measures. Among women with HDL-C <50 mg/dL (n = 43), the median peak oxygen uptake level was significantly lower (P = .021) relative to women with normal HDL-C >50 mg/dL (n = 26). Lower HDL-C levels are associated with worse ABI and decreased peak oxygen uptake in postmenopausal women with PAD.

Cilostazol increases tissue blood flow in contracting rabbit gastrocnemius muscle

BACKGROUND

The mechanisms underlying the ability of cilostazol to improve walking distance in patients with intermittent claudication (IC) are not fully understood, but may be related to its phosphodiesterase type 3 (PDE3) and adenosine uptake inhibition. In the present study the effect of cilostazol on blood flow and interstitial adenosine concentration was compared with that of the PDE3 inhibitor, milrinone, and the adenosine uptake inhibitor, draflazine.

METHODS AND RESULTS

Rabbit gastrocnemius muscle blood flow was measured under resting, contracting and ischemic conditions. Interstitial adenosine was sampled by microdialysis. None of the drugs affected tissue blood flow at rest. Blood flow in electrically stimulated muscle was 2- to 3-fold higher in vehicle-, milrinone- and draflazine-treated animals. However, cilostazol caused an 8-fold increase. Ligation of the femoral artery decreased blood flow in the stimulated muscle in all groups to a similar degree. Cilostazol and draflazine increased the dialysate adenosine concentration during the first 10 min of muscle contraction, but had no effect during ischemia, most likely because of the high AMP deaminase activity in skeletal muscle.

CONCLUSIONS

Cilostazol increases blood flow in the gastrocnemius muscle during contraction and it is this effect that may be partially responsible for the improved walking distance in IC patients. (Circ J 2010; 74: 181 - 187).

Kidney function and estimated vascular risk in patients with primary dyslipidemia

BACKGROUND

Chronic kidney disease (CKD) is associated with increased vascular risk. Some studies suggested that considering markers of CKD might improve the predictive accuracy of the Framingham risk equation.

AIM

To evaluate the links between kidney function and risk stratification in patients with primary dyslipidemia.

METHODS

Dyslipidemic patients (n = 156; 83 men) who were non-smokers, did not have diabetes mellitus or evident vascular disease and were not on lipid-lowering or antihypertensive agents were recruited. Creatinine clearance (CrCl) was estimated using the Cockcroft-Gault equation. Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) equation. We estimated vascular risk using the Framingham equation.

RESULTS

In both men and women, there was a significant negative correlation between estimated Framingham risk and both eGFR and CrCl (p < 0.001 for all correlations). When men were divided according to creatinine tertiles, there were no significant differences in any parameter between groups. When men were divided according to either eGFR or CrCl tertiles, all estimated Framingham risks significantly increased as renal function declined (p<0.001 for all trends). When women were divided according to creatinine tertiles, all estimated Framingham risks except for stroke significantly increased as creatinine levels increased. When women were divided according to either eGFR or CrCl tertiles, all estimated Framingham risks significantly increased as renal function declined.

CONCLUSIONS

Estimated vascular risk increases as renal function declines. The possibility that incorporating kidney function in the Framingham equation will improve risk stratification requires further evaluation.

Relationship between Peripheral Arterial Disease and Metabolic Syndrome

The aim of the study was to estimate the prevalence of metabolic syndrome among 388 patients with peripheral arterial disease, to determine the relationship between the number of metabolic syndrome components (metabolic syndrome score) and the degree of established and some of the emerging vascular risk factors, and to estimate whether there was any relationship of metabolic syndrome score and other vascular risk factors with the severity of peripheral arterial disease clinical manifestations. Metabolic syndrome was present in 59.8% of the patients with peripheral arterial disease. All metabolic syndrome components were significantly related to metabolic syndrome score. The same was true for the body weight, body mass index, percentage of body fat, total cholesterol/high-density lipoprotein cholesterol ratio, uric acid, and percentage of patients with high-sensitivity C-reactive protein. The metabolic syndrome score was also significantly, but inversely, related to high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and smoking. The degree of peripheral arterial disease clinical manifestations was not related to metabolic syndrome score, but gangrene was significantly positively associated with increased fasting glucose, high-sensitivity C-reactive protein, and lower education.

Significance of Close Surveillance of Patients with Peripheral Arterial Disease

Background.

Peripheral arterial disease (PAD) indicates generalized atherosclerosis but is still underdiagnosed and undertreated.

Methods.

Data were collected from patients with PAD from the Department of Cardiology and Angiology, University of Heidelberg, Germany. The prevalence of cardiovascular risk factors and medication were documented.

Results.

Atherogenic risk factors, cardiovascular disease, and cerebrovascular disease were highly prevalent. By continuous care at the university clinic, in addition to family medicine treatment, the use of platelet inhibitors, antihypertensives, and lipid-lowering therapy was increased. Ankle—brachial index and walking distance improved.

Conclusion.

Long-term treatment at the university clinic had positive effects on atherogenic risk factors. The regular use of secondary preventive medication was improved. Still, this patient population remained undertreated and showed a high incidence of vascular event rates and a need for vascular interventions. This study implies the importance of both specialists and general practitioners in the care of these individuals.

Do Different Vascular Risk Factors Affect All Arteries Equally?

Established vascular risk factors (ie, smoking, hypertension, diabetes mellitus, and dyslipidemia) play an important role in the development of vascular disease. Emerging evidence suggests that some of these risk factors may have a more intense effect on specific arterial beds, a finding that holds implications for a prognostic role for certain types of vascular disease.