Can reactive hyperemia be used instead of exercise test in assessment of mild intermittent claudication

BACKGROUND AND AIMS

Purpose of the study was to find out if reactive hyperemia stress test could serve as an alternative for treadmill exercise test in assessment of mild intermittent claudication (IC).

MATERIAL AND METHODS

A total of 22 claudicants with resting ankle brachial index (ABI) ranging from 0.61 to 1.23 were stressed with progressive treadmill exercise test and suprasystolic thigh occlusion test to provoke reactive hyperemia. Immediate pressure measurements were obtained after the test.

RESULTS

ABI drop after progressive exercise test was in average 0.29 and after reactive hyperemia 0.16. The pressures indices after these stress tests correlated well (r = 0.82). The tests were equally good in detecting mild arteriosclerotic disease.

CONCLUSIONS

In conclusion, although postexercise ABI was able to detect mild atherosclerotic disease as the reason for IC with a better marginal than hyperemia test both methods are useful. In circumstances where the patient is for some reason unable to carry out treadmill test reactive hyperemia test is an alternative for differential diagnosis. This enables vascular surgeons to improve their diagnostics without vascular laboratory.

Assessment of intermittent claudication: a comparison of questionnaire, visual analogue scale and subjective estimate information with post-exercise ankle-brachial pressure index

In order to assess two simple methods of evaluation of claudication, a standard questionnaire and visual analogue scale, a comparison was made between them and the post-exercise pressure index used as a gold standard. Fifty-eight consecutive stable claudicants were recruited to the study, 51/58 having arterial insufficiency according to post-exercise pressure measurements. Both methods appeared to correlate rather poorly with post-exercise pressures. Thus visual analogue scale cannot be used alone to assess walking tolerance but as it offers qualitative information it may be used to supplement pressure measurements in the assessment of incapacity caused by intermittent claudication.

Distal pulse palpation: is it reliable?

The aim of this study was to evaluate the reliability of distal pulse palpation. The dorsalis pedis and the tibialis posterior arteries of 25 patients with suspected lower limb arterial disease were independently palpated by three vascular surgeons and three medical students in the outpatient clinic and by two vascular nurses and one physician in the vascular laboratory. The palpation findings were compared to the ankle/brachial index (ABI). Palpable and unpalpable pulses were best separated with ABI 0.76 as the cutoff point. The degree of misdiagnosis was unacceptably high, with an underdiagnosis of more than 30%. The agreement was highest (kappa 0. 68, good) among the vascular laboratory personnel in the peaceful vascular laboratory and lowest (kappa 0.38, fair) among the vascular surgeons in the busy outpatient clinic. The poor agreement and the high proportion of misdiagnosis obtained in the outpatient clinic argue against the use of pulse palpation as a single diagnostic method. Palpable pulses with low ABIs clearly state the need for more objective measurements whenever ischemia is suspected. Yet, by carefully palpating both pedal arteries under good, nonhurried conditions the reproducibility and accuracy of pulse palpation can be tolerable.

Poor reproducibility of exercise test in assessment of claudication

To assess reproducibility of the exercise test in intermittent claudication, a prospective, comparative, randomized study was undertaken. Ten patients with stable intermittent claudication of ischaemic origin were exercised on a flat surface (0-Ex), with 12% steady inclination (12-Ex) and with progressively increasing inclination (p-Ex) in a random order during three different sessions. The ankle-brachial index (ABI) at rest and after exercise (rABI, exABI), initial and maximum walking distance (IWD, MWD) and metabolic equivalent (MET) were obtained as the main outcome measures. The results were analysed using intraindividual coefficients of variation (CVs) and standard deviations (SDs). The ABI values of the worst extremity were used in evaluation of results. Reproducibility of the exercise ABI appeared to be good, especially during progressively increasing exercise, the mean CV being 9 +/- 5%. The best mean CV was observed during p-Ex (16% +/- 14%) for maximum walking distance. The mean CV for initial walking distances ranged from 30% to 54%. Treadmill exercise testing to measure walking distances is highly inaccurate and the value of exercise on the flat treadmill should be questioned. Graded exercise appeared to be the most reproducible in this respect. The ABI after exercise, however, was a reliable single parameter when assessing arterial insufficiency causing decreased walking capacity.