Risk factors for peripheral arterial disease in elderly patients with Type-2 diabetes mellitus: A clinical study

Burden of peripheral artery disease and risk factors among patients with diabetes mellitus in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Diabetes is a non-communicable disease that presents a substantial public health challenge on a global scale. Peripheral artery disease is a significant macrovascular problem in diabetes mellitus characterized by atherosclerotic narrowing of the artery in the lower extremities, leading to compromised distal perfusion, primarily caused by atherosclerosis, and resulting in impaired functional capacity. Although existing studies on, peripheral artery disease among patients with diabetes mellitus are available, the results have been inconsistent.

OBJECTIVE

To determine the pooled burden and associated factors of peripheral artery disease among patients with diabetes mellitus in sub-Saharan Africa.

METHODS

A systematic review and meta-analysis were performed following the guidelines established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. To identify papers published in English up to August 10, 2024, the electronic databases of Medline, Science Direct, Excerpta Medica Database, Cochrane Library, African Journals Online, and Google Scholar were searched. A random-effects model was employed to estimate the pooled prevalence and associated factors of peripheral artery disease. To test for heterogeneity between studies and publication bias, forest plots and funnel plots were used.

RESULTS

This study revealed that the pooled prevalence of peripheral artery disease among patients with diabetes mellitus was 32.97% (95% CI 29.7, 36.24), reflecting the significant impact of diabetes mellitus on vascular health. Age (OR = 2.51, 95% CI = 3.41-12.09), increased level of low density lipoprotein (OR = 1.64, 95% CI = 1.05-13.09), BMI (OR = 3.03, 95% CI = 1.74-7.56), and illness duration exceeding 10 years (OR = 2.44, 95% CI = 1.12-5.13), were the significant predictors.

CONCLUSION

Despite the alarming prevalence of peripheral artery disease among patients with diabetes in sub-Saharan Africa, it remains underdiagnosed; therefore, increased awareness, proactive screening initiatives, and management strategies within the clinical setting are necessary.

CLINICAL TRIAL NUMBER

Not applicable.

PROSPERO

CRD42024594577.

Effects of concurrent training on glycemic and vascular parameters among patients with T2DM-associated Peripheral Artery Disease

Objective

To evaluate the effects of CT to improve HbA1C and ABI among the T2DM-associated PAD population.

Methods

A randomized, single-blinded, two-arm trial was conducted at the Department of Rehabilitation Sciences of Dr. Ziauddin Hospital in Karachi between July to September 2023. A total of 80 T2DM-associated PAD patients were included and randomly divided into Experimental Group (n=40) and Control Group (n=40), using the sealed envelope method. Experimental group patients received Concurrent Training (CT), whereas Control Group patients underwent Aerobic Training (AT) for 12 weeks. Both groups received thirty-minute sessions three times a week that was progressed to 60 minutes over 12 weeks. HbA1C and ABI were measured at baseline and after 12 weeks.

Results

Analysis revealed an average age of 46.75±3.59 and the duration of T2DM for developing PAD is 14.82±2.23 on average. Findings revealed that both training groups were significantly effective (p<0.000) at 95% CI in improving glycemic and vascular parameters after 12 weeks. Subsequently, findings showed that the CT group showed more significant improvement than AT group in improving HbA1C for glycemic control (p=0.002, CT: pre: 9.53±1.406, post: 7.81±0.81, AT: pre: 8.74±0.908, post: 8.15±0.83) and ABI for systemic blood flow (p=0.0001, CT: pre: 0.84±0.03, post: 0.94±0.03, AT: pre: 0.82±0.02, post: 0.86±0.02).

Conclusion

CT showed a two-fold improvement in glycemic control and arterial blood flow than AT group, which represents that CT is an effective therapeutic approach for T2DM-associated Fontain's stage IIa PAD rehabilitation.

Epidemiology and Burden of Peripheral Artery Disease in People With Type 2 Diabetes: A Systematic Literature Review

Type 2 diabetes (T2D) and lower-extremity peripheral artery disease (PAD) are growing global health problems associated with considerable cardiovascular (CV) and limb-related morbidity and mortality, poor quality of life and high healthcare resource use and costs. Diabetes is a well-known risk factor for PAD, and the occurrence of PAD in people with T2D further increases the risk of long-term complications. As the available evidence is primarily focused on the overall PAD population, we undertook a systematic review to describe the burden of comorbid PAD in people with T2D. The MEDLINE, Embase and Cochrane Library databases were searched for studies including people with T2D and comorbid PAD published from 2012 to November 2021, with no restriction on PAD definition, study design or country. Hand searching of conference proceedings, reference lists of included publications and relevant identified reviews and global burden of disease reports complemented the searches. We identified 86 eligible studies, mostly observational and conducted in Asia and Europe, presenting data on the epidemiology (n = 62) and on the clinical (n = 29), humanistic (n = 12) and economic burden (n = 12) of PAD in people with T2D. The most common definition of PAD relied on ankle-brachial index values ≤ 0.9 (alone or with other parameters). Incidence and prevalence varied substantially across studies; nonetheless, four large multinational randomised controlled trials found that 12.5%-22% of people with T2D had comorbid PAD. The presence of PAD in people with T2D was a major cause of lower-limb and CV complications and of all-cause and CV mortality. Overall, PAD was associated with poor quality of life, and with substantial healthcare resource use and costs. To our knowledge, this systematic review provides the most comprehensive overview of the evidence on the burden of PAD in people with T2D to date. In this population, there is an urgent unmet need for disease-modifying agents to improve outcomes.

Correlation between serum 25-hydroxyvitamin D level and peripheral arterial disease in patients with type 2 diabetes mellitus: a single-center retrospective study

OBJECTIVE

To investigate the association between serum 25-hydroxyvitamin D (25(OH)D) level and peripheral arterial disease (PAD) in patients with type 2 diabetes mellitus (T2DM).

METHODS

This retrospective study analyzed data from 752 T2DM patients treated at Shaoyang Central Hospital between September 2020 and September 2023. Patients were divided into two groups: those with T2DM alone and those with T2DM and PAD. We compared demographic data, biochemical indices, and ankle-brachial index (ABI) values. Pearson correlation and multivariate logistic regression with a forward likelihood ratio method assessed the relationship and risk factors. The predictive value of serum 25(OH)D levels for PAD was evaluated using receiver operating characteristic (ROC) analysis.

RESULTS

The T2DM+PAD group was older and had a longer duration of diabetes compared to the T2DM group. This group also had lower BMI, diastolic blood pressure, and ABI values, but higher levels of low-density lipoprotein cholesterol (LDL-C) and total cholesterol (TC) (all P<0.05). Serum 25(OH)D levels were significantly lower in the T2DM+PAD group (P<0.05). ABI negatively correlated with age, diabetes duration, LDL-C, and TC, and positively with BMI and 25(OH)D levels (all P<0.05). Older age, lower BMI, higher LDL-C, and lower 25(OH)D levels were independent risk factors for PAD (ORs: 1.060, 0.781, 1.083, and 0.959, respectively; all P<0.05). The risk of PAD was significantly higher in the 25(OH)D deficiency group (P<0.05). The AUC for serum 25(OH)D in predicting PAD occurrence was 0.629.

CONCLUSION

Lower serum 25(OH)D levels are associated with higher risk of PAD in patients with T2DM. Early identification and management of 25(OH)D deficiency may be crucial for preventing PAD in this population.

Diabetic peripheral arterial disease in COVID-19 pandemic

Both diabetes and peripheral arterial disease (PAD) have complex interactions with COVID-19. PAD is one of the most important underlying factors in the development of diabetic foot. The COVID-19 pandemic has also caused an increase in cardiovascular complications in those with chronic diseases, including diabetics, due to both the thrombophilic course of the viral disease and the lockdown measures applied for prevention. Since both COVID-19 and diabetes mellitus predispose to thrombosis, PAD is likely to have a more severe course in diabetic patients with COVID-19. The aim of our study is to discuss the complications, prophylaxis, and treatment of PAD, which is a serious complication of diabetes, during the pandemic period.

Optimal tactics for surgical revascularisation in diabetic angiopathy of the lower limbs

OBJECTIVE

Aim: This study aims to compare the efficacy of conservative treatment methods versus advanced surgical interventions, including revascularising automyelotransplantation and stem cell therapy, in improving vascular patency and the quality of life in patients with diabetic angiopathy.

PATIENTS AND METHODS

Materials and Methods: The research analyzed 68 patients with angiopathies under medical supervision from January 2007 to December 2017 at the National Scientific Center of Surgery named after A.N. Syzganov. Participants, aged 4 to 49, were divided into two groups based on angiographic blood flow characteristics: one with accelerated and another with delayed blood flow. A comprehensive participant selection process was implemented to ensure a representative sample. Sensitivity analysis was conducted to validate the findings' robustness.

RESULTS

Results: The main group demonstrated notable success in limb salvage, with 90.9% avoiding high limb amputation post-revascularising automyelotransplantation. Moreover, 16.7% of patients experienced healing of trophic ulcers and toe necrosis. The use of stem cells from adipose tissue and fetal tissue progenitor cells showed promising results in reducing pain and increasing pain-free walking distance, alongside the formation of collateral vascular networks.

CONCLUSION

Conclusions: The study concludes that advanced surgical interventions and stem cell therapies significantly enhance treatment outcomes in patients with diabetic angiopathy compared to conventional conservative treatments. These findings highlight the potential of personalized and innovative approaches in managing vascular complications associated with diabetes, offering new avenues for reducing disability and improving patient quality of life. Future research should focus on further refining these therapeutic strategies and exploring their integration into clinical practice.

Common and contrast determinants of peripheral artery disease and diabetic peripheral neuropathy in North Central Nigeria

BACKGROUND

Peripheral artery disease (PAD) and diabetic peripheral neuropathy (DPN) are two of the leading causes of non-traumatic amputation worldwide with tremendous negative effects on the quality of life, psychosocial well-being of persons with diabetes mellitus; and a great burden on health care expenditure. It is therefore imperative, to identify the common and contrast determinants of PAD and DPN in order to ease adoption of common and specific strategies for their early prevention.

METHODS

This was a multi-center cross-sectional study which involved the consecutive enrolment of one thousand and forty (1040) participants following consent and waiver of ethical approval. Relevant medical history, anthropometric measurements, other clinical examinations including measurement of ankle-brachial index (ABI) and neurological examinations were undertaken. IBM SPSS version 23 was used for statistical analysis and logistic regression was used to assess for the common and contrast determinants of PAD and DPN. Significance level used was p < 0.05.

RESULTS

Multiple stepwise logistic regression showed that common predictors of PAD vs DPN respectively include age, odds ratio (OR) 1.51 vs 1.99, 95 % confidence interval (CI) 1.18-2.34 vs 1.35-2.54, p = 0.033 vs 0.003; duration of DM (OR 1.51 vs 2.01, CI 1.23-1.85 vs 1.00-3.02, p = <.001 vs 0.032); central obesity (OR 9.77 vs 1.12, CI 5.07-18.82 vs 1.08-3.25, p = <.001 vs 0.047); poor SBP control (OR 2.47 vs 1.78, CI 1.26-4.87 vs 1.18-3.31, p = .016 vs 0.001); poor DBP control (OR 2.45 vs 1.45, CI 1.24-4.84 vs 1.13-2.59, p = .010 vs 0.006); poor 2HrPP control (OR 3.43 vs 2.83, CI 1.79-6.56 vs 1.31-4.17, p = <.001 vs 0.001); poor HbA1c control (OR 2.59 vs 2.31, CI 1.50-5.71 vs 1.47-3.69, p = <.001 vs 0.004). Common negative predictors or probable protective factors of PAD and DPN respectively include statins (OR 3.01 vs 2.21, CI 1.99-9.19 vs 1.45-3.26, p = .023 vs 0.004); and antiplatelets (OR 7.14 vs 2.46, CI 3.03-15.61 vs 1.09-5.53, p = .008 vs 0.030). However, only DPN was significantly predicted by female gender (OR 1.94, CI 1.39-2.25, p = 0.023), height (OR 2.02, CI 1.85-2.20, p = 0.001), generalized obesity (OR 2.02, CI 1.58-2.79, p = 0.002), and poor FPG control (OR 2.43, CI 1.50-4.10, p = 0.004) CONCLUSION: Common determinants of PAD and DPN included age, duration of DM, central obesity, and poor control of SBP, DBP, and 2HrPP control. Additionally, the use of antiplatelets and statins use were common inverse determinants of PAD and DPN which means they may help protect against PAD and DPN. However, only DPN was significantly predicted by female gender, height, generalized obesity, and poor control of FPG.

Clinical characteristics and risk factors of lower extremity amputation in patients with diabetic foot

OBJECTIVES

To investigate the risk factors of lower limb amputation, and help physicians better understand the clinical characteristics of patients with diabetic foot, and make treatment strategies for these patients correctly.

METHODS

In this study, the inpatients with diabetic foot treated in our hospital form January 2013 to February 2021 were reviewed retrospectively. The patients were divided into amputation and conservative treatment groups. The variables of the patients, consisting of age, gender, smoking history, alcohol use, diabetes and ulcer duration, ulcer size, Wagner classification, ankle brachial index, previous amputation history, laboratory data, and medical comorbidities including hypertension, coronary artery disease, peripheral arterial disease, chronic renal insufficiency, retinopathy, and sequelae of cerebral infarction were selected for analysis to determine the risk factors of lower limb amputation.

RESULTS

In this study, a total of 856 patients with diabetic foot were enrolled, in which 487 patients received amputation surgeries, and the amputation rate was 56.9%. There were significant differences between the two groups in gender (p=0.014), smoking history (p=0.011), ulcer duration (p=0.023), ulcer size (p=0.000), Wagner classification (p=0.000), ABI (p=0.031), peripheral arterial disease (p=0.000), HDL-C (p=0.013), osteomyelitis (p=0.000), and fibrinogen (p=0.001). A stepwise multiple logistic regression analysis revealed that male gender (p=0.003), larger ulcer size (p=0.001), higher Wagner classification grades (p=0.002), higher rate of peripheral arterial disease (p=0.02) and osteomyelitis (p=0.0001), and increased fibrinogen level (p=0.004) were independent risk factors of lower limb amputation in patients with diabetic foot.

CONCLUSION

The diabetic foot patients with male sex, larger ulcer size, higher grade of Wagner classification, peripheral arterial disease or higher fibrinogen level may face higher risk of lower limb amputation.

Diabetes and peripheral artery disease: A review

Peripheral arterial disease (PAD) refers to partial or complete occlusion of the peripheral vessels of the upper and lower limbs. It usually occurs as part of systemic atherosclerosis in the coronary and cerebral arteries. The prevalence of PAD is expected to continue to increase in the foreseeable future owing to the rise in the occurrence of its major risk factors. Nonhealing ulcers, limb amputation and physical disability are some of its major complications. Diabetes mellitus (DM) remains a major risk for PAD, with DM patients having more than two-fold increased prevalence of PAD compared with the general population. The clinical presentation in people with DM also differs slightly from that in the general population. In addition, PAD in DM may lead to diabetic foot ulcers (DFUs), which precipitate hyperglycaemic emergencies and result in increased hospital admissions, reduced quality of life, and mortality. Despite the epidemiological and clinical importance of PAD, it remains largely under diagnosed and hence undertreated, possibly because it is largely asymptomatic. Emphasis has been placed on neuropathy as a cause of DFUs, however PAD is equally important. This review examines the epidemiology, pathophysiology and diagnosis of lower limb PAD in people with diabetes and relates these to the general population. It also highlights recent innovations in the management of PAD.