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Al-Sadawi M, Tao M, Dhaliwal S, Masson R, Bhagat AA, Parikh PB, Lawson WE, Reilly JP. Association of antiplatelet therapy with clinical outcomes in patients with peripheral artery disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 62:66-72. [PMID: 38176961 DOI: 10.1016/j.carrev.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/11/2023] [Accepted: 12/19/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND The beneficial role of dual anti-platelet therapy (DAPT) in coronary artery disease is well established. However, there is limited data describing the effects of DAPT in patients with atherosclerotic peripheral artery disease (PAD). The aim of this meta-analysis is to compare clinical outcomes associated with DAPT versus single anti-platelet therapy (SAPT) in patients with symptomatic PAD. METHODS We performed a literature search for studies assessing the risk of adverse cardiovascular and limb events in cohorts receiving either DAPT or SAPT. The primary endpoint was all cause mortality. The secondary endpoints included graft failure, amputation, total bleeding, severe bleeding and fatal bleeding. The search included the following databases: Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status. RESULTS A total of 11 studies with 54,331 participants (24,449 on SAPT and 29,882 on DAPT) were included. Patients with PAD treated with SAPT had higher all-cause mortality compared to patients treated with DAPT (OR 1.37, 95 % CI 1.09-1.74; p < 0.01). There was no difference in risk of graft failure or amputation between patients treated with SAPT or DAPT (OR 0.9, 95 % CI 0.77-1.06; p = 0.19; OR 1.11, 95 % CI 0.88-1.41; p = 0.37). Patients treated with SAPT had lower total bleeds compared to patients treated with DAPT (OR 0.53, 95 % CI 0.36-0.77; p < 0.01). However, For SAPT plus AC vs SAPT, a total of 8 studies with 17,100 participants (3447 with SAPT plus AC and 8619 with only SAPT) were included. Patients on SAPT plus AC did not have a statistically significant difference in risk for all-cause mortality, (OR 0.91, 95 % CI 0.67-1.24; p = 0.56). SAPT plus AC had significantly lower risk of MI (OR 0.82, 95 % CI 0.69-0.97; p = 0.02), amputation (OR 0.72, 95 % CI 0.53-0.97; p = 0.03), and graft failure (OR 0.66, 95 % CI 0.48-0.93; p = 0.02). There was no significant different in risk of fatal bleeding be-tween the two groups (OR 1.60, 95 % CI 0.76-3.35; p = 0.22). CONCLUSIONS In patients with symptomatic PAD, a strategy of DAPT may confer a mortality benefit when compared to SAPT without significantly increasing the risk of serious bleeding events.
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Affiliation(s)
- Mohammed Al-Sadawi
- Division of Cardiology, University of Michigan Hospital, Ann Arbor, MI, USA.
| | - Michael Tao
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Simrat Dhaliwal
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Ravi Masson
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Aditi A Bhagat
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Puja B Parikh
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - William E Lawson
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - John P Reilly
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
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Lu J, Bisset LM, Shaw K, Sharma P, Morris NR. Examining the role of mood in pain-limited treadmill walking duration in young healthy individuals. Eur J Pain 2024; 28:144-152. [PMID: 37584244 DOI: 10.1002/ejp.2170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 07/03/2023] [Accepted: 08/02/2023] [Indexed: 08/17/2023]
Abstract
PURPOSE The purpose of the study was to examine the effects of acute mood modulation on treadmill walking duration during experimental pain application. METHODS This was a repeated measure, within-subject study design. 30 healthy individuals (Males: Females 16:14; age 22.9 ± 2.5 years; height 170.9 ± 9.5 cm; body mass 68.4 ± 14.6 kg) attended a familiarization session and three experimental sessions, whereby they simultaneously viewed emotionally evoking stimulus from the International Affective Picture System (IAPS) and performed two treadmill walking tests (maximum 10 min duration) with a fixed nociceptive input applied to the thigh (pressure cuff). The primary outcome was treadmill walking duration during pain application to achieve a fixed pain score. During walking, mood (Self-Assessment Manikin: SAM 0-9) and pain (numerical rating scale: NRS 0-10) were measured. RESULTS Mood valence scores were significantly different in all conditions (p < 0.001), negative (2.4 ± 0.3), neutral (4.9 ± 0.6) and positive (6.6 ± 0.3). There was a significant difference (p = 0.04) in the treadmill walking duration for different mood states. For the primary outcome, post hoc analysis found differences between the negative and positive mood conditions for the treadmill walking durations to reach pain scores of 3 (negative: 224 ± 49 s; positive: 259 ± 60s, effect size [ES]: 0.80), 4 (negative: 262 ± 59 s; positive: 326 ± 90s, ES: 0.92), 5 (negative: 313 ± 86 s; positive: 385 ± 113 s, ES: 0.90), 6 (negative: 367 ± 106 s; positive: 447 ± 113 s, ES: 1.04) and 7 (negative: 423 ± 114 s; positive: 521 ± 110 s, ES: 1.02). There was no significant difference in the treadmill walking duration between the neutral vs negative mood and neutral vs positive mood conditions. CONCLUSION These results highlight the potential psychophysiological impacts on the pain experience in healthy individuals and encourages pursuit in strategies to minimize pain-limited exercise, a highly prevalent issue in the chronic pain population. SIGNIFICANCE Walking-based rehabilitation, designed to improve physical activity, has been shown to improve pain and disability. However active participation and adherence in walking-based rehabilitation has shown to be jeopardized by pain and pain-related cognitive and behavioural adaptations. This study examined the effect of a shift in mood on pain perception and treadmill walking tolerance. We found that with a worse mood, individuals were less tolerant of pain and walked on the treadmill for a shorter duration. These results suggest that factors which improve mood should be combined with walking-based training to improve tolerance.
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Affiliation(s)
- Jenny Lu
- Menzies Health Institute Queensland, School of Health Sciences and Social Work, Griffith University, Nathan, Australia
| | - Leanne M Bisset
- Menzies Health Institute Queensland, School of Health Sciences and Social Work, Griffith University, Nathan, Australia
| | - Kirstin Shaw
- Menzies Health Institute Queensland, School of Health Sciences and Social Work, Griffith University, Nathan, Australia
| | - Pramod Sharma
- Menzies Health Institute Queensland, School of Health Sciences and Social Work, Griffith University, Nathan, Australia
- Metro North Hospital and Health Service, The Prince Charles Hospital, Allied Health Research Collaborative, Chermside, Australia
| | - Norman R Morris
- Menzies Health Institute Queensland, School of Health Sciences and Social Work, Griffith University, Nathan, Australia
- Metro North Hospital and Health Service, The Prince Charles Hospital, Allied Health Research Collaborative, Chermside, Australia
- Heart Lung Institute. The Prince Charles Hospital, Chermside, Australia
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Hansen D, Beckers P, Neunhäuserer D, Bjarnason-Wehrens B, Piepoli MF, Rauch B, Völler H, Corrà U, Garcia-Porrero E, Schmid JP, Lamotte M, Doherty P, Reibis R, Niebauer J, Dendale P, Davos CH, Kouidi E, Spruit MA, Vanhees L, Cornelissen V, Edelmann F, Barna O, Stettler C, Tonoli C, Greco E, Pedretti R, Abreu A, Ambrosetti M, Braga SS, Bussotti M, Faggiano P, Takken T, Vigorito C, Schwaab B, Coninx K. Standardised Exercise Prescription for Patients with Chronic Coronary Syndrome and/or Heart Failure: A Consensus Statement from the EXPERT Working Group. Sports Med 2023; 53:2013-2037. [PMID: 37648876 DOI: 10.1007/s40279-023-01909-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/01/2023]
Abstract
Whereas exercise training, as part of multidisciplinary rehabilitation, is a key component in the management of patients with chronic coronary syndrome (CCS) and/or congestive heart failure (CHF), physicians and exercise professionals disagree among themselves on the type and characteristics of the exercise to be prescribed to these patients, and the exercise prescriptions are not consistent with the international guidelines. This impacts the efficacy and quality of the intervention of rehabilitation. To overcome these barriers, a digital training and decision support system [i.e. EXercise Prescription in Everyday practice & Rehabilitative Training (EXPERT) tool], i.e. a stepwise aid to exercise prescription in patients with CCS and/or CHF, affected by concomitant risk factors and comorbidities, in the setting of multidisciplinary rehabilitation, was developed. The EXPERT working group members reviewed the literature and formulated exercise recommendations (exercise training intensity, frequency, volume, type, session and programme duration) and safety precautions for CCS and/or CHF (including heart transplantation). Also, highly prevalent comorbidities (e.g. peripheral arterial disease) or cardiac devices (e.g. pacemaker, implanted cardioverter defibrillator, left-ventricular assist device) were considered, as well as indications for the in-hospital phase (e.g. after coronary revascularisation or hospitalisation for CHF). The contributions of physical fitness, medications and adverse events during exercise testing were also considered. The EXPERT tool was developed on the basis of this evidence. In this paper, the exercise prescriptions for patients with CCS and/or CHF formulated for the EXPERT tool are presented. Finally, to demonstrate how the EXPERT tool proposes exercise prescriptions in patients with CCS and/or CHF with different combinations of CVD risk factors, three patient cases with solutions are presented.
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Affiliation(s)
- Dominique Hansen
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium.
- UHasselt, BIOMED (Biomedical Research Institute) and REVAL (Rehabilitation Research Centre) (REVAL/BIOMED), Hasselt University, Agoralaan Building A, 3590, Diepenbeek, Belgium.
| | - Paul Beckers
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
- Translational Pathophysiological Research, Antwerp University, Antwerp, Belgium
| | - Daniel Neunhäuserer
- Sport and Exercise Medicine Division, Department of Medicine, University of Padova, Padua, Italy
| | - Birna Bjarnason-Wehrens
- Department of Preventive and Rehabilitative Sport and Exercise Medicine, Institute for Cardiology and Sports Medicine, German Sports University, Cologne, Germany
| | - Massimo F Piepoli
- Clinical Cardiology, IRCCS Policlinico San Donato, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Bernhard Rauch
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen am Rhein/Stiftung Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen am Rhein/Zentrum für Ambulante Rehabilitation, ZAR Trier, Trier, Germany
| | - Heinz Völler
- Department of Cardiology, Klinik am See, Rüdersdorf, Germany
- Center of Rehabilitation Research, University of Potsdam, Potsdam, Germany
| | - Ugo Corrà
- Cardiologic Rehabilitation Department, Istituti Clinici Scientifici Salvatore Maugeri, SPA, SB, Scientific Institute of di Veruno, IRCCS, Veruno, NO, Italy
| | | | - Jean-Paul Schmid
- Department of Cardiology, Clinic Barmelweid, Barmelweid, Switzerland
| | | | | | - Rona Reibis
- Cardiological Outpatient Clinics at the Park Sanssouci, Potsdam, Germany
| | - Josef Niebauer
- Institute of Sports Medicine, Prevention and Rehabilitation, Research Institute of Molecular Sports Medicine and Rehabilitation, Rehab-Center Salzburg, Ludwig Boltzmann Institute for Digital Health and Prevention, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Paul Dendale
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- UHasselt, BIOMED (Biomedical Research Institute) and REVAL (Rehabilitation Research Centre) (REVAL/BIOMED), Hasselt University, Agoralaan Building A, 3590, Diepenbeek, Belgium
| | - Constantinos H Davos
- Cardiovascular Research Laboratory, Biomedical Research Foundation, Academy of Athens, Athens, Greece
| | - Evangelia Kouidi
- Laboratory of Sports Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Martijn A Spruit
- UHasselt, BIOMED (Biomedical Research Institute) and REVAL (Rehabilitation Research Centre) (REVAL/BIOMED), Hasselt University, Agoralaan Building A, 3590, Diepenbeek, Belgium
- Department of Research & Education; CIRO+, Centre of Expertise for Chronic Organ Failure, Horn/Department of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Luc Vanhees
- Research Group of Cardiovascular Rehabilitation, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Department Rehabilitation Sciences, University Leuven, Leuven, Belgium
| | - Véronique Cornelissen
- Research Group of Cardiovascular Rehabilitation, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Department Rehabilitation Sciences, University Leuven, Leuven, Belgium
| | - Frank Edelmann
- Department of Cardiology, Angiology and Intensive Care, Deutsches Herzzentrum der Charité (DHZC), Charité-Universitaetsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Olga Barna
- Family Medicine Department, National O.O. Bogomolets Medical University, Kiev, Ukraine
| | - Christoph Stettler
- Division of Endocrinology, Diabetes and Clinical Nutrion, University Hospital/Inselspital, Bern, Switzerland
| | - Cajsa Tonoli
- Movement Control and Neuroplasticity Research Group, Department of Movement Sciences, Faculty of Movement and Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | | | | | - Ana Abreu
- Centre of Cardiovascular RehabilitationCardiology Department, Centro Universitário Hospitalar Lisboa Norte & Faculdade de Medicina da Universidade Lisboa/Instituto Saúde Ambiental & Instituto Medicina Preventiva, Faculdade Medicina da Universidade Lisboa/CCUL/CAML, Lisbon, Portugal
| | - Marco Ambrosetti
- Cardiovascular Rehabilitation Unit, Le Terrazze Clinic, Cunardo, Italy
| | | | - Maurizio Bussotti
- Unit of Cardiorespiratory Rehabilitation, Instituti Clinici Maugeri, IRCCS, Institute of Milan, Milan, Italy
| | | | - Tim Takken
- Division of Pediatrics, Child Development & Exercise Center, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht, The Netherlands
| | - Carlo Vigorito
- Department of Translational Medical Sciences, Internal Medicine and Cardiac Rehabilitation, University of Naples Federico II, Naples, Italy
| | - Bernhard Schwaab
- Curschmann Clinic, Rehabilitation Center for Cardiology, Vascular Diseases and Diabetes, Timmendorfer Strand/Medical Faculty, University of Lübeck, Lübeck, Germany
| | - Karin Coninx
- UHasselt, Faculty of Sciences, Human-Computer Interaction and eHealth, Hasselt University, Hasselt, Belgium
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4
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Lee M, Smolderen KG, Ionescu C, Hillegass WB, Romain G, Mena-Hurtado C. Lower extremity symptoms and ankle-brachial index screening as predictors of cardiovascular outcomes in Black adults. Vasc Med 2023; 28:197-204. [PMID: 37293738 DOI: 10.1177/1358863x231151729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2023]
Abstract
BACKGROUND The prevalence of peripheral artery disease (PAD) and leg symptoms are higher in Black than White adults. We studied the effects of self-reported lower extremity symptoms and ankle-brachial indices (ABI) groups on outcomes. METHODS Black participants in the Jackson Heart Study with baseline ABI and PAD symptom assessments (exertional leg pain by the San Diego Claudication questionnaire) were included. Abnormal ABI was < 0.90 or > 1.40. Participants were divided into (1) normal ABI, asymptomatic, (2) normal ABI, symptomatic, (3) abnormal ABI, asymptomatic, and (4) abnormal ABI, symptomatic to examine their associations with MACE (stroke, myocardial infarction, fatal coronary heart disease) and all-cause mortality, using Kaplan-Meier survival curves and stepwise Cox proportional hazard models adjusting for Framingham risk factors. RESULTS Of 4586 participants, mean age was 54.6 ± 12.6 years, with 63% women. Compared with participants with normal ABI who were asymptomatic, participants with abnormal ABI and leg symptoms had highest risk of MACE (adjusted HR 2.28; 95% CI 1.62, 3.22) and mortality (aHR 1.82; 95% CI 1.32, 2.56). Participants with abnormal ABI without leg symptoms had higher risk for MACE (aHR 1.49; 95% CI 1.06, 2.11) and mortality (aHR 1.44; 95% CI 1.12, 1.99). Participants with normal ABI and no leg symptoms did not have higher risks. CONCLUSION Among Black adults, the highest risk for adverse outcomes were in symptomatic participants with abnormal ABIs, followed by asymptomatic participants with abnormal ABIs. These findings underscore the need for further studies to screen for PAD and develop preventative approaches in Black adults with asymptomatic disease.
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Affiliation(s)
- Megan Lee
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kim G Smolderen
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Costin Ionescu
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - William B Hillegass
- Departments of Data Science and Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Gaelle Romain
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
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5
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Sieland J, Niederer D, Engeroff T, Vogt L, Troidl C, Schmitz-Rixen T, Banzer W, Troidl K. Changes in miRNA expression in patients with peripheral arterial vascular disease during moderate- and vigorous-intensity physical activity. Eur J Appl Physiol 2023; 123:645-654. [PMID: 36418750 PMCID: PMC9684818 DOI: 10.1007/s00421-022-05091-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Walking is the preferred therapy for peripheral arterial disease in early stage. An effect of walking exercise is the increase of blood flow and fluid shear stress, leading, triggered by arteriogenesis, to the formation of collateral blood vessels. Circulating micro-RNA may act as an important information transmitter in this process. We investigated the acute effects of a single bout of 1) aerobic walking with moderate intensity; and 2) anaerobic walking with vigorous intensity on miRNA parameters related to vascular collateral formation. METHODS Ten (10) patients with peripheral arterial disease with claudication (age 72 ± 7 years) participated in this two-armed, randomized-balanced cross-over study. The intervention arms were single bouts of supervised walking training at (1) vigorous intensity on a treadmill up to volitional exhaustion and (2) moderate intensity with individual selected speed for a duration of 20 min. One week of washout was maintained between the arms. During each intervention, heart rate was continuously monitored. Acute effects on circulating miRNAs and lactate concentration were determined using pre- and post-intervention measurement comparisons. RESULTS Vigorous-intensity walking resulted in a higher heart rate (125 ± 21 bpm) than the moderate-intensity intervention (88 ± 9 bpm) (p < 0.05). Lactate concentration was increased after vigorous-intensity walking (p = 0.005; 3.3 ± 1.2 mmol/l), but not after moderate exercising (p > 0.05; 1.7 ± 0.6 mmol/l). The circulating levels of miR-142-5p and miR-424-5p were up-regulated after moderate-intensity (p < 0.05), but not after vigorous-intensity training (p > 0.05). CONCLUSION Moderate-intensity walking seems to be more feasible than vigorous exercises to induce changes of blood flow and endurance training-related miRNAs in patients with peripheral arterial disease. Our data thus indicates that effect mechanisms might follow an optimal rather than a maximal dose response relation. Steady state walking without the necessity to reach exhaustion seems to be better suited as stimulus.
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Affiliation(s)
- Johanna Sieland
- Department of Sports Medicine, Institute of Sports Sciences, Goethe University, Ginnheimer Landstraße 39, 60487, Frankfurt, Germany.
| | - Daniel Niederer
- grid.7839.50000 0004 1936 9721Department of Sports Medicine, Institute of Sports Sciences, Goethe University, Ginnheimer Landstraße 39, 60487 Frankfurt, Germany ,grid.7839.50000 0004 1936 9721Division of Preventive and Sports Medicine, Institute for Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Tobias Engeroff
- grid.7839.50000 0004 1936 9721Institute for Occupational Medicine, Social Medicine and Environmental Medicine, Division Health and Performance, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Lutz Vogt
- grid.7839.50000 0004 1936 9721Department of Sports Medicine, Institute of Sports Sciences, Goethe University, Ginnheimer Landstraße 39, 60487 Frankfurt, Germany
| | - Christian Troidl
- grid.8664.c0000 0001 2165 8627Department of Experimental Cardiology, Medical Faculty, Justus-Liebig-University, 35392 Giessen, Germany ,grid.419757.90000 0004 0390 5331Department of Cardiology, Kerckhoff Heart and Thorax Center, 61231 Bad Nauheim, Germany ,grid.452396.f0000 0004 5937 5237German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Frankfurt Am Main, Germany
| | - Thomas Schmitz-Rixen
- grid.411088.40000 0004 0578 8220Department of Vascular and Endovascular Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Winfried Banzer
- grid.7839.50000 0004 1936 9721Division of Preventive and Sports Medicine, Institute for Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Kerstin Troidl
- grid.411088.40000 0004 0578 8220Department of Vascular and Endovascular Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany ,grid.449744.e0000 0000 9323 0139Department of Life Sciences and Engineering, TH Bingen, Berlinstrasse 109, 55411 Bingen Am Rhein, Germany
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6
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Makita S, Yasu T, Akashi YJ, Adachi H, Izawa H, Ishihara S, Iso Y, Ohuchi H, Omiya K, Ohya Y, Okita K, Kimura Y, Koike A, Kohzuki M, Koba S, Sata M, Shimada K, Shimokawa T, Shiraishi H, Sumitomo N, Takahashi T, Takura T, Tsutsui H, Nagayama M, Hasegawa E, Fukumoto Y, Furukawa Y, Miura SI, Yasuda S, Yamada S, Yamada Y, Yumino D, Yoshida T, Adachi T, Ikegame T, Izawa KP, Ishida T, Ozasa N, Osada N, Obata H, Kakutani N, Kasahara Y, Kato M, Kamiya K, Kinugawa S, Kono Y, Kobayashi Y, Koyama T, Sase K, Sato S, Shibata T, Suzuki N, Tamaki D, Yamaoka-Tojo M, Nakanishi M, Nakane E, Nishizaki M, Higo T, Fujimi K, Honda T, Matsumoto Y, Matsumoto N, Miyawaki I, Murata M, Yagi S, Yanase M, Yamada M, Yokoyama M, Watanabe N, Ito H, Kimura T, Kyo S, Goto Y, Nohara R, Hirata KI. JCS/JACR 2021 Guideline on Rehabilitation in Patients With Cardiovascular Disease. Circ J 2022; 87:155-235. [PMID: 36503954 DOI: 10.1253/circj.cj-22-0234] [Citation(s) in RCA: 74] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Shigeru Makita
- Department of Cardiac Rehabilitation, Saitama Medical University International Medical Center
| | - Takanori Yasu
- Department of Cardiovascular Medicine and Nephrology, Dokkyo Medical University Nikko Medical Center
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Hitoshi Adachi
- Department of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Hideo Izawa
- Department of Cardiology, Fujita Health University of Medicine
| | - Shunichi Ishihara
- Department of Psychology, Bunkyo University Faculty of Human Sciences
| | - Yoshitaka Iso
- Division of Cardiology, Showa University Fujigaoka Hospital
| | - Hideo Ohuchi
- Department of Pediatrics, National Cerebral and Cardiovascular Center
| | | | - Yusuke Ohya
- Department of Cardiovascular Medicine, Nephrology and Neurology, Graduate School of Medicine, University of the Ryukyus
| | - Koichi Okita
- Graduate School of Lifelong Sport, Hokusho University
| | - Yutaka Kimura
- Department of Health Sciences, Kansai Medical University Hospital
| | - Akira Koike
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Masahiro Kohzuki
- Department of Internal Medicine and Rehabilitation Science, Tohoku University Graduate School of Medicine
| | - Shinji Koba
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | - Kazunori Shimada
- Department of Cardiology, Juntendo University School of Medicine
| | | | - Hirokazu Shiraishi
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Tetsuya Takahashi
- Department of Physical Therapy, Faculty of Health Science, Juntendo University
| | - Tomoyuki Takura
- Department of Healthcare Economics and Health Policy, Graduate School of Medicine, The University of Tokyo
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | | | - Emiko Hasegawa
- Faculty of Psychology and Social Welfare, Seigakuin University
| | - Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Sumio Yamada
- Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine
| | - Yuichiro Yamada
- Center for Diabetes, Endocrinology and Metabolism, Kansai Electric Power Hospital
| | | | | | - Takuji Adachi
- Department of Physical Therapy, Nagoya University Graduate School of Medicine
| | | | | | | | - Neiko Ozasa
- Cardiovascular Medicine, Kyoto University Hospital
| | - Naohiko Osada
- Department of Physical Checking, St. Marianna University Toyoko Hospital
| | - Hiroaki Obata
- Division of Internal Medicine, Niigata Minami Hospital.,Division of Rehabilitation, Niigata Minami Hospital
| | | | - Yusuke Kasahara
- Department of Rehabilitation, St. Marianna University Yokohama Seibu Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kentaro Kamiya
- Department of Rehabilitation, School of Allied Health Sciences, Kitasato University
| | - Shintaro Kinugawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | - Yuji Kono
- Department of Rehabilitation, Fujita Health University Hospital
| | - Yasuyuki Kobayashi
- Department of Medical Technology, Gunma Prefectural Cardiovascular Center
| | | | - Kazuhiro Sase
- Clinical Pharmacology and Regulatory Science, Graduate School of Medicine, Juntendo University
| | - Shinji Sato
- Department of Physical Therapy, Teikyo Heisei University
| | - Tatsuhiro Shibata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine
| | - Norio Suzuki
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Daisuke Tamaki
- Department of Nutrition, Showa University Fujigaoka Hospital
| | - Minako Yamaoka-Tojo
- Department of Rehabilitation, School of Allied Health Sciences, Kitasato University
| | - Michio Nakanishi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Mari Nishizaki
- Department of Rehabilitation, National Hospital Organization Okayama Medical Center
| | - Taiki Higo
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | - Kanta Fujimi
- Department of Rehabilitation, Fukuoka University Hospital
| | - Tasuku Honda
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Center
| | - Yasuharu Matsumoto
- Department of Cardiovascular Medicine, Shioya Hospital, International University of Health and Welfare
| | | | - Ikuko Miyawaki
- Department of Nursing, Kobe University Graduate School of Health Sciences
| | - Makoto Murata
- Department of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Shusuke Yagi
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | - Masanobu Yanase
- Department of Transplantation, National Cerebral and Cardiovascular Center
| | | | - Miho Yokoyama
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | | | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Syunei Kyo
- Tokyo Metropolitan Geriatric Medical Center
| | | | | | - Ken-Ichi Hirata
- Department of Internal Medicine, Kobe University Graduate School of Medicine
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7
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Leslie R, May S, Scordis C, Isgar V, Poulton P, Garnham A. Outcomes following supervised exercise and home-based exercise for patients with intermittent claudication. JOURNAL OF VASCULAR NURSING 2022; 40:157-161. [PMID: 36435597 DOI: 10.1016/j.jvn.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Intermittent claudication (IC) is the most common symptom of peripheral arterial disease (PAD) which presents as a consequence of muscle ischaemia resulting from the atherosclerotic obstruction to arterial flow. High-quality evidence (Lane et al., 2017) shows that exercise programmes provide important benefits compared with usual care in improving pain-free and maximum walking distance in people with IC, but do not improve ankle-brachial pressure index (ABPI). METHODS Retrospective data were analysed to examine walking and ABPI outcomes for participants who completed a 12-week course of supervised or home-based exercise. All participants had a history of IC. RESULTS 46 participants (mean age 69±11 years; 76% male; 29% current smokers) referred for exercise were assessed, completed a 12-week course of exercise (home-based or supervised) and subsequently attended for re-assessment. Claudication onset distance (COD) increased by 363% (mean improvement 344.7 ± 265.1m; p < .001) and peak walking distance (PWD) by 324.4% in the supervised exercise group; COD increased by 30.6% (mean improvement 32.8 ± 57.2 m; p = 0.026) and PWD by 31.5% in the home-based exercise group. Resting ABPI for the total cohort significantly improved from 0.82 ± 0.25 at A1 to 0.88 ± 0.25 at A2 (p = 0.027). DISCUSSION A 12-week course of supervised exercise results in significantly greater walking distance outcomes (COD and PWD) than unmonitored home-based exercise. In contrast with previous findings (Lane et al. 2017), this retrospective study demonstrated a significant improvement in resting ABPI with both supervised exercise as well as home-based exercise. CONCLUSION A 12-week programme of exercise favourably influenced walking and ABPI outcomes for patients with IC. Both home-based exercise and supervised individualised exercise increased walking distances, but the magnitude of the improvement in walking outcomes was greater in individuals who attended supervised exercise therapy.
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Affiliation(s)
- R Leslie
- Chief Allied Health Professional, Royal Wolverhampton NHS Trust, New Cross Hospital, Wolverhampton WV10 0QP, United Kingdom.
| | - S May
- Exercise Physiologist Cardiac Rehabilitation, Royal Wolverhampton NHS Trust, United Kingdom
| | - C Scordis
- Specialist Exercise Physiologist Cardiac Rehabilitation, Royal Wolverhampton NHS Trust, United Kingdom
| | - V Isgar
- Clinical Nurse Specialist Vascular, Royal Wolverhampton NHS Trust, United Kingdom
| | - P Poulton
- Clinical Nurse Specialist Vascular, Royal Wolverhampton NHS Trust, United Kingdom
| | - A Garnham
- Vascular Surgeon, Royal Wolverhampton NHS Trust, United Kingdom
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8
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Kapusta J, Irzmański R. The Impact of Controlled Physical Training with Hydrotherapy on Changes in Swelling and Claudication Distance in Patients with Atherosclerotic Ischemia of the Lower Limbs. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15715. [PMID: 36497790 PMCID: PMC9738843 DOI: 10.3390/ijerph192315715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Patients with peripheral artery disease (PAD) often experience intermittent claudication. It is manifested by pain typically seen in the distal part of the legs during walking, which impairs the ability to walk, limits physical activity and results in lower health-related quality of life. It often leads to chronic ischemic pain, ulceration and even amputation. The aim of the study was to evaluate the effect of controlled physical training and whirlpool massage on changes in circuits, range of motion and distance of claudication in people with atherosclerotic ischemia of the lower limbs. MATERIAL AND METHODS The study included 100 patients, males and females aged 39 to 79 years, with peripheral circulation disorders of the lower limbs. The subjects were randomly divided into two groups. Group I (G) was treated with a series of 10 lower-limb whirling massages and took part in individually planned training, including breathing, relaxation and active free lower-limb exercises. Group II-control group (GC) took part only in individually planned training. Prior to the treatment procedures and after their completion, the ranges of movement of the ankle joint and the circumference of the lower limbs were measured and the corridor test (6MWT, six-minute walk test) was performed. RESULTS Statistically significant reduction in the circumference of the foot, ankle, calf and thigh in the G group was noticed. Both, in G and in GC group, a statistically significant increase in the range of dorsiflexion of the foot was found in comparison to the period before the procedures (p = 0.010; p = 0.006, respectively). There was also a statistically significant increase in the range of motion of the plantar flexion of the foot after the procedures in G (p = 0.007) and in GC (p = 0.048). Differences in the circumference of the lower limbs and the range of ankle joint movements between the study group and the control group before and after the therapy were not statistically significant. However, there was a statistically significant difference between these groups after the procedures in the 6-min walk test-significantly higher values of 6MWT were recorded in group G (p = 0.003). CONCLUSIONS Individually planned training, supplemented with hydrotherapy as thermal therapy, has a beneficial effect on reducing swelling of the lower limbs, increasing the range of foot movements and extending the distance in the 6-min walk test.
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Affiliation(s)
- Joanna Kapusta
- Department of Internal Diseases, Rehabilitation and Physical Medicine, Medical University of Lodz, 70-445 Lodz, Poland
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9
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Katorkin SE, Krivoshchekov EP, Elshin EB, Kushnarchuk MY. Modern possibilities and prospects of conservative treatment of patients with peripheral arterial diseases. AMBULATORNAYA KHIRURGIYA = AMBULATORY SURGERY (RUSSIA) 2022. [DOI: 10.21518/1995-1477-2022-19-2-50-60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The most common clinical manifestation of peripheral arterial disease is intermittent claudication due to insufficient blood supply to the affected limb. The article summarizes and systematizes the latest achievements in the field of conservative treatment of patients with intermittent claudication. In accordance with the requirements of evidence-based medicine, an overview of modern promising trends in conservative therapy presented in the latest Russian and foreign consensus documents, is given. The basis of the complex treatment of patients with peripheral arterial diseases is: non-drug and drug treatment to relieve the symptoms of chronic ischemia, pharmacotherapy for the secondary prevention of cardiovascular complications, open or endovascular revascularization to increase the distance of painfree walking. With the development of atherosclerosis, disturbances in the peptide composition of the endothelium occur, which reduce the ability of the vascular wall to resist inflammation and the associated triggering of pathological processes. It has been experimentally proven that the use of a complex of peptides obtained from the vessels of healthy and young animals in this situation restores the endothelial function of the arteries, affecting the main links of pathogenesis. Decrease in oxidative stress, decrease in atherogenic and lipidemic action, normalization of vascular tone and blood coagulation parameters, increase in the microvascular bed – these are the mechanisms that justify the indication of peptides to patients with atherosclerosis obliterans. Angioprotector based on a complex of polypeptides isolated from blood vessels can become an important part of the treatment of patients with obliterating diseases of the arteries of the lower extremities, providing a complex pathogenetic effect. It is necessary to further study in multicenter clinical trials the duration of the therapeutic effect of a drug in a longer period after a course of treatment, its effect on long-term outcomes of the disease, the possibility of using repeated courses, in chronic obliterating diseases of the arteries of the lower extremities III-IV stages according to the Fontaine classification, as well as the use drug for the treatment of systemic atherosclerosis of various arterial basins.
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10
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Englund EK, Langham MC, Wehrli FW, Fanning MJ, Khan Z, Schmitz KH, Ratcliffe SJ, Floyd TF, Mohler ER. Impact of supervised exercise on skeletal muscle blood flow and vascular function measured with MRI in patients with peripheral artery disease. Am J Physiol Heart Circ Physiol 2022; 323:H388-H396. [PMID: 35802515 PMCID: PMC9359664 DOI: 10.1152/ajpheart.00633.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 06/21/2022] [Accepted: 07/07/2022] [Indexed: 11/22/2022]
Abstract
Supervised exercise is a common therapeutic intervention for patients with peripheral artery disease (PAD), however, the mechanism underlying the improvement in claudication symptomatology is not completely understood. The hypothesis that exercise improves microvascular blood flow is herein tested via temporally resolved magnetic resonance imaging (MRI) measurement of blood flow and oxygenation dynamics during reactive hyperemia in the leg with the lower ankle-brachial index. One hundred and forty-eight subjects with PAD were prospectively assigned to standard medical care or 3 mo of supervised exercise therapy. Before and after the intervention period, subjects performed a graded treadmill walking test, and MRI data were collected with Perfusion, Intravascular Venous Oxygen saturation, and T2* (PIVOT), a method that simultaneously quantifies microvascular perfusion, as well as relative oxygenation changes in skeletal muscle and venous oxygen saturation in a large draining vein. The 3-mo exercise intervention was associated with an improvement in peak walking time (64% greater in those randomized to the exercise group at follow-up, P < 0.001). Significant differences were not observed in the MRI measures between the subjects randomized to exercise therapy versus standard medical care based on an intention-to-treat analysis. However, the peak postischemia perfusion averaged across the leg between baseline and follow-up visits increased by 10% (P = 0.021) in participants that were adherent to the exercise protocol (completed >80% of prescribed exercise visits). In this cohort of adherent exercisers, there was no difference in the time to peak perfusion or oxygenation metrics, suggesting that there was no improvement in microvascular function nor changes in tissue metabolism in response to the 3-mo exercise intervention.NEW & NOTEWORTHY Supervised exercise interventions can improve symptomatology in patients with peripheral artery disease, but the underlying mechanism remains unclear. Here, MRI was used to evaluate perfusion, relative tissue oxygenation, and venous oxygen saturation in response to cuff-induced ischemia. Reactive hyperemia responses were measured before and after 3 mo of randomized supervised exercise therapy or standard medical care. Those participants who were adherent to the exercise regimen had a significant improvement in peak perfusion.
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Affiliation(s)
- Erin K Englund
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Michael C Langham
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Felix W Wehrli
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Molly J Fanning
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zeeshan Khan
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathryn H Schmitz
- Department of Public Health Sciences, Penn State University, University Park, Pennsylvania
| | - Sarah J Ratcliffe
- Department of Biostatistics, University of Virginia, Charlottesville, Virginia
| | - Thomas F Floyd
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas
| | - Emile R Mohler
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Süss JD, Gawenda M. Primärtherapie der Claudicatio intermittens – Anspruch und Wirklichkeit. Zentralbl Chir 2022; 147:453-459. [DOI: 10.1055/a-1798-0602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungDie narrative Übersichtsarbeit fasst die Studienlage zum Thema Gehtraining bei Patienten mit Claudicatio intermittens (CI) zusammen. Eindringlich wird auf die evidenzbasierten
Leitlinienempfehlungen und die dahinterstehenden Studien eingegangen. Aspekte zum angiomorphologischen Befund, zu Patientenadhärenz, Langzeitwirkung, Studienqualität und ihre
Vergleichbarkeit werden diskutiert. Der Problematik in der Versorgungsrealität mit Abweichungen von den Leitlinien und der oftmals invasiven Erstlinientherapie des PAVK-IIb-Patienten werden
besondere Bedeutung geschenkt. Dabei wird die Rolle des Rehasports und die gesundheitspolititsche Bedeutung von Gehtraining in Deutschland erörtert. Gründe für die fehlende Leitlinientreue
und deren Umsetzung im Gesundheitssystem werden analysiert. Dementsprechend werden Handlungsempfehlungen, in Anlehnung an internationale Erfahrungen (Niederlande, Dänemark), zur Besserung
der Situation in Deutschland formuliert.
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Affiliation(s)
- Jan David Süss
- Gefäßchirurgie, St-Antonius-Hospital gGmbH, Eschweiler, Deutschland
| | - Michael Gawenda
- Gefäßchirurgie, St-Antonius-Hospital gGmbH, Eschweiler, Deutschland
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12
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Yasu T. Comprehensive cardiac rehabilitation program for peripheral arterial diseases. J Cardiol 2021; 80:303-305. [PMID: 34857431 DOI: 10.1016/j.jjcc.2021.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/16/2021] [Indexed: 10/19/2022]
Abstract
Peripheral arterial disease (PAD) is a phenotype of atherosclerotic disease often associated with cerebrovascular or coronary artery disease. The incidence of cardiovascular events in patients with PAD is 5.4% per year, which is higher than that of cerebrovascular or coronary artery disease. The most useful screening method for PAD is the ankle brachial pressure index (ABI). The ABI should be measured in (1) all patients with lower limb symptoms such as claudication, (2) all patients aged 65 years and over, and (3) those aged 50 to 65 years who have risk factors such as smoking and diabetes mellitus. PAD is diagnosed if the ABI is <0.9. A comprehensive cardiac rehabilitation program includes complete smoking cessation, blood pressure control with antihypertensive medications and salt reduction for hypertension, glycemic control for diabetes mellitus, and appropriate medications such as antiplatelet agents and statins. A multidisciplinary team approach is effective in comprehensive cardiac rehabilitation for patients with PAD, even those with critical limb ischemia (CLI). Exercise therapy is a crucial and essential treatment for PAD, except in CLI. Exercise therapy is contraindicated in patients with acute arterial occlusion and CLI with infection. PAD is often associated with other atherosclerotic diseases; the patient should be monitored for ischemic heart disease during the initial exercise stress test using the Gardner treadmill protocol. Supervised exercise therapy is highly recommended (Class I, Level of Evidence A). Alternatively, a home-based exercise program is feasible (Class IIa, Level of Evidence A). The exercise type (treadmill, track walking, ergometer), frequency (3 to 5 days per week), intensity (speed and incline), and duration (30 minutes) are determined based on the exercise stress test results for each patient. Exercise should be continued at least 3 times a week for at least 12 weeks. Cilostazol is highly recommended (Class I, Level of Evidence A).
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Affiliation(s)
- Takanori Yasu
- Department of Cardiovascular Medicine & Nephrology, Dokkyo Medical University.
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13
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Qu CJ, Teng LQ, Liu XN, Zhang YB, Fang J, Shen CY. Dose-Response Relationship Between Physical Activity and the Incidence of Peripheral Artery Disease in General Population: Insights From the National Health and Nutrition Examination Survey 1999-2004. Front Cardiovasc Med 2021; 8:730508. [PMID: 34722663 PMCID: PMC8553979 DOI: 10.3389/fcvm.2021.730508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/09/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: A low ABI, ≦0.9, indicates peripheral artery disease (PAD) and physical activity (PA) represents an important non-surgical treatment for patients with PAD. However, as for the general population, the associations between PA, PAD, and their mutual dependence are not well-defined. Here we aimed to determine whether there is a dose-response relationship between PA and incidence of PAD in the general population using restricted cubic spline (RCS). Patients and methods: This study analyzed 1,370 adults aged ≧40 years who had participated in the National Health and Nutrition Examination Survey (NHANES) during 1999-2004. The ABI of the participants were measured by trained technicians, and PAD was defined as ABI ≦0.9. PA was obtained with a standard questionnaire, and metabolic equivalents (MET) were used to quantify the PA level. Logistic regression was used to assess the association between PA and incidence of PAD, and the dose-response relationship was analyzed with RCS. Results: PAD was present in 6.2% of the participants: 5.6% of males and 6.9% of females. After adjusting for potential confounders, compared with the first quartile (Q1) of MET, the odds ratios (ORs) of PAD for those with Q2, Q3, and Q4 of MET were 0.688 [95% confidence interval (CI) = 0.684-0.692], 0.463 (95% CI = 0.460-0.466), 0.816 (95% CI = 0.812-0.821), respectively (all p < 0.0001). The RCS regression showed that physical activity was related to the incidence of PAD in a non-linear manner (p for non-linearity < 0.0001). For females, the prevalence of PAD decreased as physical activity increased, reaching the minimum for activity at ~5,800 MET-min month-1 (OR = 0.425, 95% CI = 0.424-0.426), and for males, no plateau was found in this study. Conclusion: The prevalence of PAD is inversely associated with PA, and vigorous activities might help decrease PAD risk for general population. The prevalence of PAD reaches the minimum at ~5,800 MET-min month-1, representing a recommended PA value.
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Affiliation(s)
- Cheng-Jia Qu
- Vascular Surgery Center, Chinese Academy of Medical Sciences, Peking Union Medical University Fuwai Hospital, Beijing, China
| | - Le-Qun Teng
- Vascular Surgery Center, Chinese Academy of Medical Sciences, Peking Union Medical University Fuwai Hospital, Beijing, China
| | - Xin-Nong Liu
- Vascular Surgery Department, Peking Union Medical College, Beijing, China
| | - Yong-Bao Zhang
- Vascular Surgery Center, Chinese Academy of Medical Sciences, Peking Union Medical University Fuwai Hospital, Beijing, China
| | - Jie Fang
- Vascular Surgery Center, Chinese Academy of Medical Sciences, Peking Union Medical University Fuwai Hospital, Beijing, China
| | - Chen-Yang Shen
- Vascular Surgery Center, Chinese Academy of Medical Sciences, Peking Union Medical University Fuwai Hospital, Beijing, China
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14
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Noumairi M, Bouallala A, EL Mir S, Allam A, EL Oumri A. Rehabilitation of patients with peripheral arterial disease. Ann Med Surg (Lond) 2021; 70:102864. [PMID: 34584689 PMCID: PMC8452755 DOI: 10.1016/j.amsu.2021.102864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/12/2021] [Accepted: 09/13/2021] [Indexed: 11/26/2022] Open
Abstract
Vascular rehabilitation is an essential and effective treatment of peripheral arterial obstructive disease (PAOD). It is recommended in the first line by the European and American scientific societies. The rehabilitation to the walk remains the basic treatment of the arteriopathy of the lower limbs. Different walking protocols can be proposed. For similar effectiveness, vascular rehabilitation consists of an outpatient or specialized institution management program based on a comprehensive approach involving all or many of the following techniques: relaxation, active analytical exercises, gait rehabilitation, exercise re-entry, physical activities adapted to the patient's daily life and illness, respiratory physiotherapy, therapeutic education of the patient, smoking cessation aid. Vascular rehabilitation of arteritis requires a variety of skills but still faces a clear lack of suitable structures; it remains poorly prescribed and poorly known by usual prescribers (general practitioner, vascular surgeon).
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Affiliation(s)
- M. Noumairi
- Department of Physical Medicine and Rehabilitation,university Hospital, MOHAMMED VI OUJDA, Morocco
| | - A. Bouallala
- Department of Vascular Surgery,university Hospital, MOHAMMED VI OUJDA Morocco
| | - S. EL Mir
- Department of Physical Medicine and Rehabilitation,university Hospital, MOHAMMED VI OUJDA, Morocco
| | - A. Allam
- Department of Physical Medicine Rheumatology and Rehabilitation Faculty of Medicine Tanta University, Egypt
| | - A.A. EL Oumri
- Department of Physical Medicine and Rehabilitation,university Hospital, MOHAMMED VI OUJDA, Morocco
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15
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Lorenz EC, Kennedy CC, Rule AD, LeBrasseur NK, Kirkland JL, Hickson LJ. Frailty in CKD and Transplantation. Kidney Int Rep 2021; 6:2270-2280. [PMID: 34514190 PMCID: PMC8418946 DOI: 10.1016/j.ekir.2021.05.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/18/2021] [Accepted: 05/24/2021] [Indexed: 12/20/2022] Open
Abstract
The population is aging. Although older adults have higher rates of comorbidities and adverse health events, they represent a heterogeneous group with different health trajectories. Frailty, a clinical syndrome of decreased physiological reserve and increased susceptibility to illness and death, has emerged as a potential risk stratification tool in older patients with chronic kidney disease (CKD). Frailty is commonly observed in patients with CKD and associated with numerous adverse outcomes, including falls, decreased quality of life, hospitalizations, and death. Multiple pathologic factors contribute to the development of frailty in patients with CKD, including biological mechanisms of aging and physiological dysregulation. Current interventions to reduce frailty are promising, but additional investigations are needed to determine whether optimizing frailty measures improves renal and overall health outcomes. This review of frailty in CKD examines frailty definitions, the impact of frailty on health outcomes across the CKD spectrum, mechanisms of frailty, and antifrailty interventions (e.g., exercise or senescent cell clearance) tested in CKD patients. In addition, existing knowledge gaps, limitations of current frailty definitions in CKD, and challenges surrounding effective antifrailty strategies in CKD are considered.
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Affiliation(s)
- Elizabeth C Lorenz
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA.,William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Cassie C Kennedy
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA.,Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Nathan K LeBrasseur
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, Minnesota, USA
| | - James L Kirkland
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, Minnesota, USA
| | - LaTonya J Hickson
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida, USA
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16
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Détriché G, Lanéelle D, Radureau C. Pharmacological management of obstructive peripheral arterial disease: two case reports. Hosp Pract (1995) 2021; 49:379-383. [PMID: 34278930 DOI: 10.1080/21548331.2021.1956805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Peripheral artery disease (PAD), also abbreviated as LEAD or lower extremity artery disease, is an important predictor of cardiovascular morbidity and mortality. Rivaroxaban, a selective direct factor Xa inhibitor, is proposed as an additional pharmacologic option for managing this disease. CASES Two patients presented with PAD and high-risk comorbidities. The first case showed how the evaluation of the cardiovascular risk guided the therapeutic management of the patient. The second case was about a patient diagnosed with LEAD who experienced worsening from exertional ischemia towards critical ischemia requiring amputation despite distal revascularization, and parenteral vasodilator therapy to relieve pain. This case suggested a comprehensive care management approach, adapted to PAD progression stages. CONCLUSION The PAD management consists nowadays of optimizing the management of cardiovascular risk factors and disease progression. Diagnosis, treatment, monitoring and patient education should be handled by a vascular specialist in a specialized care unit.
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Affiliation(s)
- Grégoire Détriché
- Department of Vascular Medicine, European Hospital Georges-Pompidou, APHP, Paris University, France
| | | | - Chloé Radureau
- Department of Vascular Medicine, CHU de Caen, Caen, France
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17
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Abstract
BACKGROUND Symptomatic peripheral arterial disease (PAD) has several treatment options, including angioplasty, stenting, exercise therapy, and bypass surgery. Atherectomy is an alternative procedure, in which atheroma is cut or ground away within the artery. This is the first update of a Cochrane Review published in 2014. OBJECTIVES To evaluate the effectiveness of atherectomy for peripheral arterial disease compared to other established treatments. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Allied and Complementary Medicine (AMED) databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 12 August 2019. SELECTION CRITERIA We included all randomised controlled trials that compared atherectomy with other established treatments. All participants had symptomatic PAD with either claudication or critical limb ischaemia and evidence of lower limb arterial disease. DATA COLLECTION AND ANALYSIS Two review authors screened studies for inclusion, extracted data, assessed risk of bias and used GRADE criteria to assess the certainty of the evidence. We resolved any disagreements through discussion. Outcomes of interest were: primary patency (at six and 12 months), all-cause mortality, fatal and non-fatal cardiovascular events, initial technical failure rates, target vessel revascularisation rates (TVR; at six and 12 months); and complications. MAIN RESULTS We included seven studies, with a total of 527 participants and 581 treated lesions. We found two comparisons: atherectomy versus balloon angioplasty (BA) and atherectomy versus BA with primary stenting. No studies compared atherectomy with bypass surgery. Overall, the evidence from this review was of very low certainty, due to a high risk of bias, imprecision and inconsistency. Six studies (372 participants, 427 treated lesions) compared atherectomy versus BA. We found no clear difference between atherectomy and BA for the primary outcomes: six-month primary patency rates (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.94 to 1.20; 3 studies, 186 participants; very low-certainty evidence); 12-month primary patency rates (RR 1.20, 95% CI 0.78 to 1.84; 2 studies, 149 participants; very low-certainty evidence) or mortality rates (RR 0.50, 95% CI 0.10 to 2.66, 3 studies, 210 participants, very low-certainty evidence). One study reported cardiac failure and acute coronary syndrome as causes of death at 24 months but it was unclear which arm the participants belonged to, and one study reported no cardiovascular events. There was no clear difference when examining: initial technical failure rates (RR 0.48, 95% CI 0.22 to 1.08; 6 studies, 425 treated vessels; very low-certainty evidence), six-month TVR (RR 0.51, 95% CI 0.06 to 4.42; 2 studies, 136 treated vessels; very low-certainty evidence) or 12-month TVR (RR 0.59, 95% CI 0.25 to 1.42; 3 studies, 176 treated vessels; very low-certainty evidence). All six studies reported complication rates (RR 0.69, 95% CI 0.28 to 1.68; 6 studies, 387 participants; very low-certainty evidence) and embolisation events (RR 2.51, 95% CI 0.64 to 9.80; 6 studies, 387 participants; very low-certainty evidence). Atherectomy may be less likely to cause dissection (RR 0.28, 95% CI 0.14 to 0.54; 4 studies, 290 participants; very low-certainty evidence) and may be associated with a reduction in bailout stenting (RR 0.26, 95% CI 0.09 to 0.74; 4 studies, 315 treated vessels; very low-certainty evidence). Four studies reported amputation rates, with only one amputation event recorded in a BA participant. We used subgroup analysis to compare the effect of plain balloons/stents and drug-eluting balloons/stents, but did not detect any differences between the subgroups. One study (155 participants, 155 treated lesions) compared atherectomy versus BA and primary stenting, so comparison was extremely limited and subject to imprecision. This study did not report primary patency. The study reported one death (RR 0.38, 95% CI 0.04 to 3.23; 155 participants; very low-certainty evidence) and three complication events (RR 7.04, 95% CI 0.80 to 62.23; 155 participants; very low-certainty evidence) in a very small data set, making conclusions unreliable. We found no clear difference between the treatment arms in cardiovascular events (RR 0.38, 95% CI 0.04 to 3.23; 155 participants; very low-certainty evidence). This study found no initial technical failure events, and TVR rates at six and 24 months showed little difference between treatment arms (RR 2.27, 95% CI 0.95 to 5.46; 155 participants; very low-certainty evidence and RR 2.05, 95% CI 0.96 to 4.37; 155 participants; very low-certainty evidence, respectively). AUTHORS' CONCLUSIONS This review update shows that the evidence is very uncertain about the effect of atherectomy on patency, mortality and cardiovascular event rates compared to plain balloon angioplasty, with or without stenting. We detected no clear differences in initial technical failure rates or TVR, but there may be reduced dissection and bailout stenting after atherectomy although this is uncertain. Included studies were small, heterogenous and at high risk of bias. Larger studies powered to detect clinically meaningful, patient-centred outcomes are required.
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Affiliation(s)
- Bethany G Wardle
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, UK
| | - Graeme K Ambler
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, UK
- Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Robert J Hinchliffe
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, UK
- Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Christopher P Twine
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, UK
- Centre for Surgical Research, University of Bristol, Bristol, UK
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18
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Rümenapf G, Morbach S, Schmidt A, Sigl M. Intermittent Claudication and Asymptomatic Peripheral Arterial Disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:188-193. [PMID: 32327031 DOI: 10.3238/arztebl.2020.0188] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 09/10/2019] [Accepted: 12/20/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The conservative treatment of peripheral arterial disease (PAD), as recommended in current guidelines, encompasses measures such as lifestyle modification and risk-factor management. In addition, in patients with vasogenic intermittent claudication (IC), it is recommended that patients first be given drugs to improve perfusion and undergo supervised gait training. Revascularization is not recommended for asymptomatic persons, but it is considered mandatory for patients with critical ischemia. In this article on conservative and revascularizing treatment strategies for IC, we address the following questions: whether all treatment options are available, how effective they are, and whether the reality of treatment for IC in Germany corresponds to what is recommended in the guidelines. METHODS In 2014, the German Society for Angiology carried out a comprehensive literature search in order to prepare a new version of the S3 guideline on PAD. This literature search was updated up to 2018, with identical methods, for the present review. RESULTS The benefit of lifestyle modification and risk factor treatment is supported by high-level evidence ( evidence level I, recommendation grade A ). The distance patients are able to walk without pain is increased by drug therapy as well (evidence level IIb), but the therapeutic effect is only moderate. Supervised exercise training (SET), though supported by high-level evidence (I, A), is of limited efficacy, availability, and applicability, and patient compliance with it is also limited. In patients with IC, revascularization leads to complete relief of symptoms more rapidly than gait training, and its long-term benefit is steadily improving owing to advances in medical technology. A combination of arterial revascularization and gait training yields the best results. In a clinical trial, patients with IC who underwent combined therapy increased the distance they could walk without pain by 954 m in six months, compared to 407 m in a group that underwent gait training alone. CONCLUSION In the treatment of vasogenic IC, SET and drugs to increase perfusion are now giving way to revascularization, which is more effective. As far as can be determined, SET is not currently implemented at all in the German health care system. It would be desirable for SET to be more available and more widely used, both to sustain the benefit of revascularization over the long term and to lower the general cardiovascular risk.
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Affiliation(s)
- Gerhard Rümenapf
- Department of Angiology, Center of Vascular Medicine "Oberrhein" Speyer, Diakonissen-Stiftungs-Krankenhaus, Speyer; Department of Diabetology and Angiology, Marienkrankenhaus, Soest; Department of Angiology, University Hospital Leipzig; Department of Angiology, Department of Medicine 1, University Hospital Mannheim
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19
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Lorenz EC, Hickson LJ, Weatherly RM, Thompson KL, Walker HA, Rasmussen JM, Stewart TL, Garrett JK, Amer H, Kennedy CC. Protocolized exercise improves frailty parameters and lower extremity impairment: A promising prehabilitation strategy for kidney transplant candidates. Clin Transplant 2020; 34:e14017. [PMID: 32573816 DOI: 10.1111/ctr.14017] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/28/2020] [Accepted: 06/13/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Frailty and decreased functional status are risk factors for adverse kidney transplant (KT) outcomes. Our objective was to examine the efficacy of an exercise intervention on frailty and decreased functional status in a cohort of patients with advanced chronic kidney disease (CKD). METHODS We conducted a prospective study involving 21 adults with ≥stage 4 CKD who were (a) frail or pre-frail by Fried phenotype and/or (b) had lower extremity impairment [short physical performance battery score ≤10]. The intervention consisted of two supervised outpatient exercise sessions per week for 8 weeks. RESULTS Among our cohort, median participant age was 62 years (interquartile range, 53-67) and 85.7% had been evaluated for KT. Following the study, participants reported satisfaction with the intervention and multiple frailty parameters improved significantly, including fatigue, physical activity, walking time, and grip strength. Lower extremity impairment also improved (90.5%-61.9%, P = .03). No study-related adverse events occurred. CONCLUSIONS Preliminary data from this study suggest that a supervised, outpatient exercise intervention is safe, acceptable, feasible, and associated with improved frailty parameters, and lower extremity function, in patients with advanced CKD. Further studies are needed to confirm these findings and determine whether this prehabilitation strategy improves KT outcomes.
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Affiliation(s)
- Elizabeth C Lorenz
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA.,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - LaTonya J Hickson
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Renee M Weatherly
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Karin L Thompson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Heidi A Walker
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Judy M Rasmussen
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tara L Stewart
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - James K Garrett
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hatem Amer
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Cassie C Kennedy
- William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA.,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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20
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Vascular Assessment of the Foot Surgery Patient. Orthop Nurs 2020; 39:114-118. [PMID: 32218007 DOI: 10.1097/nor.0000000000000642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Foot surgery is common. Orthopaedic nurses charged with evaluating and treating patients who have undergone foot surgery are required to evaluate the vascular status of the patient's foot (or feet). As a result, these nurses are often the first to identify vascular issues. This article provides orthopaedic nurses with the background to understand how the patient's history, the procedure(s) performed, and a thorough assessment of the foot's circulation will allow them to promptly identify circulatory problems and potentially save a patient from having a serious complication.
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21
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Krishna SM, Omer SM, Li J, Morton SK, Jose RJ, Golledge J. Development of a two-stage limb ischemia model to better simulate human peripheral artery disease. Sci Rep 2020; 10:3449. [PMID: 32103073 PMCID: PMC7044206 DOI: 10.1038/s41598-020-60352-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 01/29/2020] [Indexed: 12/24/2022] Open
Abstract
Peripheral arterial disease (PAD) develops due to the narrowing or blockage of arteries supplying blood to the lower limbs. Surgical and endovascular interventions are the main treatments for advanced PAD but alternative and adjunctive medical therapies are needed. Currently the main preclinical experimental model employed in PAD research is based on induction of acute hind limb ischemia (HLI) by a 1-stage procedure. Since there are concerns regarding the ability to translate findings from this animal model to patients, we aimed to develop a novel clinically relevant animal model of PAD. HLI was induced in male Apolipoprotein E (ApoE-/-) deficient mice by a 2-stage procedure of initial gradual femoral artery occlusion by ameroid constrictors for 14 days and subsequent excision of the femoral artery. This 2-stage HLI model was compared to the classical 1-stage HLI model and sham controls. Ischemia severity was assessed using Laser Doppler Perfusion Imaging (LDPI). Ambulatory ability was assessed using an open field test, a treadmill test and using established scoring scales. Molecular markers of angiogenesis and shear stress were assessed within gastrocnemius muscle tissue samples using quantitative polymerase chain reaction. HLI was more severe in mice receiving the 2-stage compared to the 1-stage ischemia induction procedure as assessed by LDPI (p = 0.014), and reflected in a higher ischemic score (p = 0.004) and lower average distance travelled on a treadmill test (p = 0.045). Mice undergoing the 2-stage HLI also had lower expression of angiogenesis markers (vascular endothelial growth factor, p = 0.004; vascular endothelial growth factor- receptor 2, p = 0.008) and shear stress response mechano-transducer transient receptor potential vanilloid 4 (p = 0.041) within gastrocnemius muscle samples, compared to animals having the 1-stage HLI procedure. Mice subjected to the 2-stage HLI receiving an exercise program showed significantly greater improvement in their ambulatory ability on a treadmill test than a sedentary control group. This study describes a novel model of HLI which leads to more severe and sustained ischemia than the conventionally used model. Exercise therapy, which has established efficacy in PAD patients, was also effective in this new model. This new model maybe useful in the evaluation of potential novel PAD therapies.
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Affiliation(s)
- Smriti M Krishna
- The Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, 4811, Australia
| | - Safraz Mohamed Omer
- The Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, 4811, Australia
| | - Jiaze Li
- The Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, 4811, Australia
| | - Susan K Morton
- The Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, 4811, Australia
| | - Roby J Jose
- The Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, 4811, Australia
| | - Jonathan Golledge
- The Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, 4811, Australia.
- Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, 4811, Australia.
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22
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Akerman AP, Thomas KN, van Rij AM, Body ED, Alfadhel M, Cotter JD. Heat therapy vs. supervised exercise therapy for peripheral arterial disease: a 12-wk randomized, controlled trial. Am J Physiol Heart Circ Physiol 2019; 316:H1495-H1506. [DOI: 10.1152/ajpheart.00151.2019] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Peripheral arterial disease (PAD) is characterized by lower limb atherosclerosis impairing blood supply and causing walking-induced leg pain or claudication. Adherence to traditional exercise training programs is poor due to these symptoms despite exercise being a mainstay of conservative treatment. Heat therapy improves many cardiovascular health outcomes, so this study tested if this was a viable alternative cardiovascular therapy for PAD patients. Volunteers with PAD were randomized to 12 wk of heat ( n = 11; mean age 76 ± 8 yr, BMI 28.7 ± 3.5 kg/m2, 4 females) or exercise ( n = 11; 74 ± 10 yr, 28.5 ± 6.8 kg/m2, 3 females). Heat involved spa bathing at ∼39°C, 3–5 days/wk for ≤30 min, followed by ≤30 min of callisthenics. Exercise involved ≤90 min of supervised walking and gym-based exercise, 1–2 days/wk. Following the interventions, total walking distance during a 6-min walk test increased (from ∼350 m) by 41 m (95% CI: [13, 69], P = 0.006) regardless of group, and pain-free walking distance increased (from ∼170 m) by 43 m ([22, 63], P < 0.001). Systolic blood pressure was reduced more following heat (−7 mmHg, [−4, −10], P < 0.001) than following exercise (−3 mmHg, [0, −6], P = 0.078), and diastolic and mean arterial pressure decreased by 4 mmHg in both groups ( P = 0.002). There were no significant changes in blood volume, ankle-brachial index, or measures of vascular health. There were no differences in the improvement in functional or blood pressure outcomes between heat and exercise in individuals with PAD. NEW & NOTEWORTHY Heat therapy via hot-water immersion and supervised exercise both improved walking distance and resting blood pressure in peripheral arterial disease (PAD) patients over 12 wk. Adherence to heat therapy was excellent, and the heat intervention was well tolerated. The results of the current study indicate that heat therapy can improve functional ability and has potential as an effective cardiovascular conditioning tool for individuals with PAD. Listen to this article's corresponding podcast at https://ajpheart.podbean.com/e/heat-therapy-vs-exercise-in-peripheral-arterial-disease/ .
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Affiliation(s)
- Ashley P. Akerman
- School of Physical Education, Sport, and Exercise Sciences, University of Otago, Dunedin, New Zealand
| | - Kate N. Thomas
- Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - Andre M. van Rij
- Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - E. Dianne Body
- Physiotherapy Department, Dunedin Public Hospital, Dunedin, New Zealand
| | - Mesfer Alfadhel
- Cardiology Department, Dunedin Public Hospital, Dunedin, New Zealand
| | - James D. Cotter
- School of Physical Education, Sport, and Exercise Sciences, University of Otago, Dunedin, New Zealand
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23
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Incorporating an exercise rehabilitation programme for people with intermittent claudication into an established cardiac rehabilitation service: A protocol for a pilot study. Contemp Clin Trials Commun 2019; 15:100389. [PMID: 31388598 PMCID: PMC6675947 DOI: 10.1016/j.conctc.2019.100389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 05/14/2019] [Accepted: 05/27/2019] [Indexed: 01/28/2023] Open
Abstract
Introduction Current UK guidance for the treatment of intermittent claudication (IC) states that supervised exercise programmes (SEPs) should be offered as first-line treatment [1], prior to surgical interventions. However, there is currently a national shortage of dedicated SEPs. It has been suggested that the established network of UK Cardiac Rehabilitation (CR) programmes could cater for IC patients. This study will investigate the feasibility of combining IC and CR patients into one SEP, and explore the patient perception's regarding the treatment programme, to establish whether CR could potentially fill the gap in service provision. Methods and analysis Patients diagnosed with IC will be incorporated into a CR programme where they will exercise alongside patients with coronary artery disease (CAD). Participants will attend a 2-h class, once a week for a total of 12 weeks. Another group of IC patients will attend an SEP consisting solely of other IC patients (control group). Outcome measures The study will evaluate the feasibility of recruitment, retention, and participant experience of the intervention as well as physiological outcomes (primary outcome: pain-free walking, and maximal walking distance; secondary outcomes: physical activity levels, perceived walking ability, and disease-specific quality of life). Outcomes will be assessed at baseline and on completion of the SEP. Ethics and dissemination Ethical approval for this study was obtained from North West- Greater Manchester West Research Ethics Committee on 13th June 2018 (IRAS ID: 230391). This study is registered with clinicaltrials. gov (NCT03564080) and conforms to the Declaration of Helsinki. Results will be disseminated via national conferences and published in peer-reviewed journals.
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24
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Kropielnicka K, Dziubek W, Bulińska K, Stefańska M, Wojcieszczyk-Latos J, Jasiński R, Pilch U, Dąbrowska G, Skórkowska-Telichowska K, Kałka D, Janus A, Zywar K, Paszkowski R, Rachwalik A, Woźniewski M, Szuba A. Influence of the Physical Training on Muscle Function and Walking Distance in Symptomatic Peripheral Arterial Disease in Elderly. BIOMED RESEARCH INTERNATIONAL 2018; 2018:1937527. [PMID: 30345295 PMCID: PMC6174806 DOI: 10.1155/2018/1937527] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 07/10/2018] [Accepted: 07/25/2018] [Indexed: 11/18/2022]
Abstract
INTRODUCTION A typical symptom of chronic lower-limb ischaemia is lower-limb pain, which occurs during walking forcing the patient to stop, intermittent claudication (IC). Exercise rehabilitation is the basic form of treatment for these patients. AIM The aim of this study was to compare the effectiveness of three types of physical training programmes conducted over a 12-week period in patients with chronic lower-limb arterial insufficiency. MATERIALS AND METHODS Ninety-five people qualified for the 3-month supervised motor rehabilitation programme, conducted three times a week. The respondents were assigned to three types of rehabilitation programmes using a pseudo-randomization method: Group I (TW), subjects undertaking treadmill walking training; Group II (NW), subjects undertaking Nordic walking training; Group III (RES+NW), subjects undertaking resistance and Nordic walking training. Treadmill test, 6 Minute Walk Test (6MWT), and isokinetic test were repeated after 3 months of rehabilitation, which 80 people completed. RESULTS Combined training (RES+NW) is more effective than Nordic walking alone and supervised treadmill training alone for improving ankle force-velocity parameters (p<0.05) in patients with intermittent claudication. Each of the proposed exercise rehabilitation programmes increased walking distance of patients with intermittent claudication (p<0.05), especially in 6MWT (p=0.001). Significant relationships of force-velocity parameters are observed in the maximum distance obtained in 6MWT, both in Group III (RES + NW) and in Group II (NW) at the level of moderate and strong correlation strength, which indicates that if the lower limbs are stronger the walking distance achieved in 6MWT is longer. CONCLUSIONS Given both the force-velocity parameters and the covered distance, the training RES + NW gives the most beneficial changes compared to training TW alone and NW alone. All types of training increased walking distance, which is an important aspect of the everyday functioning of people with IC.
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Affiliation(s)
- Katarzyna Kropielnicka
- Faculty of Physiotherapy, University School of Physical Education, al. I. J. Paderewskiego 35, 51-612 Wroclaw, Poland
| | - Wioletta Dziubek
- Faculty of Physiotherapy, University School of Physical Education, al. I. J. Paderewskiego 35, 51-612 Wroclaw, Poland
| | - Katarzyna Bulińska
- Faculty of Physiotherapy, University School of Physical Education, al. I. J. Paderewskiego 35, 51-612 Wroclaw, Poland
- WROVASC–an Integrated Cardiovascular Centre, Specialist District Hospital in Wroclaw, Centre for Research and Development, ul. H. Kamińskiego 73a, 51-124 Wroclaw, Poland
| | - Małgorzata Stefańska
- Faculty of Physiotherapy, University School of Physical Education, al. I. J. Paderewskiego 35, 51-612 Wroclaw, Poland
| | - Joanna Wojcieszczyk-Latos
- Faculty of Physiotherapy, University School of Physical Education, al. I. J. Paderewskiego 35, 51-612 Wroclaw, Poland
| | - Ryszard Jasiński
- Faculty of Physiotherapy, University School of Physical Education, al. I. J. Paderewskiego 35, 51-612 Wroclaw, Poland
| | - Urszula Pilch
- Faculty of Physiotherapy, University School of Physical Education, al. I. J. Paderewskiego 35, 51-612 Wroclaw, Poland
| | - Grażyna Dąbrowska
- Faculty of Physiotherapy, University School of Physical Education, al. I. J. Paderewskiego 35, 51-612 Wroclaw, Poland
| | - Katarzyna Skórkowska-Telichowska
- WROVASC–an Integrated Cardiovascular Centre, Specialist District Hospital in Wroclaw, Centre for Research and Development, ul. H. Kamińskiego 73a, 51-124 Wroclaw, Poland
| | - Dariusz Kałka
- Medical University of Wroclaw, Department of Pathophysiology, ul. Marcinkowskiego 1, 50-368 Wroclaw, Poland
| | - Agnieszka Janus
- Wrocław Medical University Department of Internal Medicine, Occupational Diseases and Hypertension, ul. Borowska 213, 50-556 Wroclaw, Poland
| | - Katarzyna Zywar
- WROVASC–an Integrated Cardiovascular Centre, Specialist District Hospital in Wroclaw, Centre for Research and Development, ul. H. Kamińskiego 73a, 51-124 Wroclaw, Poland
- Specialist District Hospital in Wroclaw, Department of Angiology, ul. Kamieńskiego 73a, 51-124 Wroclaw, Poland
| | - Rafał Paszkowski
- WROVASC–an Integrated Cardiovascular Centre, Specialist District Hospital in Wroclaw, Centre for Research and Development, ul. H. Kamińskiego 73a, 51-124 Wroclaw, Poland
- Specialist District Hospital in Wroclaw, Department of Angiology, ul. Kamieńskiego 73a, 51-124 Wroclaw, Poland
| | - Anna Rachwalik
- WROVASC–an Integrated Cardiovascular Centre, Specialist District Hospital in Wroclaw, Centre for Research and Development, ul. H. Kamińskiego 73a, 51-124 Wroclaw, Poland
- Specialist District Hospital in Wroclaw, Department of Angiology, ul. Kamieńskiego 73a, 51-124 Wroclaw, Poland
| | - Marek Woźniewski
- Faculty of Physiotherapy, University School of Physical Education, al. I. J. Paderewskiego 35, 51-612 Wroclaw, Poland
| | - Andrzej Szuba
- WROVASC–an Integrated Cardiovascular Centre, Specialist District Hospital in Wroclaw, Centre for Research and Development, ul. H. Kamińskiego 73a, 51-124 Wroclaw, Poland
- 4th Military Clinical Hospital with a Polyclinic in Wroclaw, Department of Internal Medicine, ul. Weigla 5, 50-981 Wroclaw, Poland
- Medical University of Wroclaw, Division of Angiology, Bartla 5 Str., 51-618 Wroclaw, Poland
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Addison O, Ryan AS, Prior SJ, Katzel LI, Kundi R, Lal BK, Gardner AW. Changes in Function After a 6-Month Walking Intervention in Patients With Intermittent Claudication Who Are Obese or Nonobese. J Geriatr Phys Ther 2018; 40:190-196. [PMID: 27341324 DOI: 10.1519/jpt.0000000000000096] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE Both obesity and peripheral artery disease (PAD) limit function and may work additively to reduce mobility. The purpose of this study was to compare the effects of a 6-month, center-based walking program on mobility function between adults who are weight-stable obese and nonobese with PAD. METHODS This is a secondary data analysis of 2 combined studies taken from previous work. Fifty-three adults with PAD and intermittent claudication participated in 6 months of treadmill training or standard of care. Patients were divided into 4 groups for analyses: exercise nonobese (Ex), exercise obese (ExO), standard-of-care nonobese (SC), and standard-of-care obese (SCO). Mobility was assessed by a standardized treadmill test to measure claudication onset time (COT) and peak walking time (PWT) as well as the distance walked during a 6-minute walk distance (6MWD) test. RESULTS There was a significant (P < .001) interaction (intervention × obesity) effect on 6MWD, wherein both exercise groups improved (Ex = 7%, ExO = 16%; P < .02), the SC group did not change (0.9%; P > .05), and the SCO group tended to decline (-18%; P = .06). Both exercise intervention groups significantly improved COT (Ex = 92%, ExO = 102%; P < .01) and PWT (Ex = 54%, ExO = 103%; P < .001). There was no change (P > .05) in either standard-of-care group. CONCLUSIONS Individuals who are obese and nonobese with PAD made similar improvements after a 6-month, center-based walking program. However, patients who are obese with PAD and do not exercise may be susceptible to greater declines in mobility. Exercise may be particularly important in patients who are obese with PAD to avoid declines in mobility.
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Affiliation(s)
- Odessa Addison
- 1Department of Medicine, Division of Gerontology, University of Maryland, Baltimore. 2Department of Veterans Affairs and Veterans Affairs Medical Center, Geriatric Research, Education and Clinical Centers, Baltimore, Maryland. 3Department of Surgery, Division of Vascular Surgery, University of Maryland, Baltimore. 4Reynolds Oklahoma Center on Aging, Donald W. Reynolds Department of Geriatric Medicine, University of Oklahoma Health Sciences Center, Oklahoma City
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26
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Farndon L, Stephenson J, Binns-Hall O, Knight K, Fowler-Davis S. The PodPAD project: a podiatry-led integrated pathway for people with peripheral arterial disease in the UK - a pilot study. J Foot Ankle Res 2018; 11:26. [PMID: 29991966 PMCID: PMC5987540 DOI: 10.1186/s13047-018-0269-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 05/23/2018] [Indexed: 11/10/2022] Open
Abstract
Background Peripheral arterial disease affects the lower limb and is associated with diabetes, high cholesterol, smoking and obesity. It increases the risk of cardiovascular morbidity and mortality. It can be symptomatic causing intermittent claudication, but often there are few clinical signs. Podiatrists are able to detect the presence of peripheral arterial disease as part of their lower limb assessment and are well placed to give advice on lifestyle changes to help reduce disease progression. This is important to improve health outcomes and is offered as a prevention/public health intervention. Method We describe the clinical and patient-centred outcomes of patients attending a podiatry-led integrated care pathway in a multi-use clinic situated in a venue supported by the National Centre for Sports and Exercise Medicine in the UK. At the baseline appointment, patients were given a full assessment where symptoms of intermittent claudication using the Edinburgh Intermittent Claudication Questionnaire, foot pulses, Doppler sounds, Ankle Brachial Pressure Indices, glycated haemoglobin (HbA1c) and cholesterol levels, and smoking status were recorded. A tailored treatment plan was devised, including referral to an exercise referral service, smoking cessation programmes (if applicable) and each participant was also seen by a dietician for nutritional advice. Participants were followed up at 3 and 6 months to assess any improvement in vascular status and with each completing the EQ-5D quality of life questionnaire and a simple satisfaction questionnaire at the end of the study. As this was a complex intervention a pilot study design was adopted to evaluate if the method and outcomes were suitable and acceptable to participants the results of which will then inform the design of a larger study. Results Data was collected on 21 individuals; 15 men (71.4%) and 6 women (28.6%) across the 6-month study period. Eleven participants were referred onto the exercise referral service; 16 participants saw the dietician for nutritional advice at baseline and had one-to-one or telephone follow-up at 3 months. Five out of 14 participants had reduced scores from baseline of intermittent claudication during the study period. No evidence for substantive changes in Doppler sounds or ABPI measurements was revealed. Quality of life scores with the EQ-5D improved in 15 participants; this was statistically significant (p = 0.007) with 14 participants who completed the simple satisfaction questionnaire expressing a positive view of the programme. Of the four people who were smokers, two stopped smoking cigarettes and moved to e-cigarettes as part of smoking cessation advice. Conclusion As this was a pilot study the sample size was low, but some statistically significant improvements with some measures were observed over the 6-month study. Podiatrists are able to provide a comprehensive vascular assessment of the lower limb and accompanying tailored advice on lifestyle changes including smoking cessation and exercise. Locating clinics in National Centres for Sports and Exercise Medicine enables easy access to exercise facilities to encourage the adoption of increased activity levels, though the long term sustainability of exercise programmes still requires evaluation.This study was reviewed and approved by London Brent Ethics Committee IRAS ID 204611 and received research governance approval from the sponsor, Sheffield Teaching Hospitals NHS Foundation Trust Research and Innovation Office STH19410.
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Affiliation(s)
- Lisa Farndon
- 1Sheffield Podiatry Services, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John Stephenson
- 2School of Human & Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Oliver Binns-Hall
- 1Sheffield Podiatry Services, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Kayleigh Knight
- 1Sheffield Podiatry Services, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Sally Fowler-Davis
- 3Sheffield Hallam University /Combined Community & Acute Care Group, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Kumar AM, Lyden AK, Carlozzi NE, Sen A, Richardson CR, Jackson EA. The Physical Activity Daily (PAD) Trial: The rationale and design of a randomized controlled trial evaluating an internet walking program to improve maximal walking distance among patients with peripheral arterial disease. Contemp Clin Trials 2018; 67:23-30. [PMID: 29274894 PMCID: PMC5944605 DOI: 10.1016/j.cct.2017.12.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 12/17/2017] [Accepted: 12/20/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Despite established guidelines for regular walking as a first line therapy for adults with peripheral arterial disease (PAD), most patients do not walk routinely. This paper presents the design specifications for a randomized clinical trial to examine the effectiveness of an internet-based walking program compared to a telephone intervention, or the combination (internet-based with telephone counseling) for promotion of regular walking in patients with PAD. METHODS Sedentary adults with documented lower extremity PAD are being recruited from the University of Michigan Health System and the surrounding area. Participants are randomized to one of four arms in a 2×2 factorial design: 1) telephone counseling to promote walking, 2) an internet-based walking program with tailored step-count goals, 3) the combination of telephone counseling with the internet-based walking program, or 4) waitlist control. Participants receive a 4-month intervention phase, after which all participants are followed for an additional 8months to assess long-term adherence to regular walking. Outcomes are assessed at baseline, 4 and 12months. The primary outcome is walking distance assessed through a standardized treadmill protocol. Additional outcomes include change in step-counts measured with a commercial activity tracker, pain-free walking distance, and changes in health-related quality of life from baseline to follow-up. CONCLUSION Finding effective and feasible programs to promote walking among PAD patients is warranted. This study will add to current evidence regarding use of internet based programs with and without telephone counseling to promote regular walking in this population.
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Affiliation(s)
- Anjana M Kumar
- Michigan State University, College of Human Medicine, 15 Michigan Street, Grand Rapids, MI 49503, USA
| | - Angela K Lyden
- Department of Internal Medicine, Division of Cardiology, University of Michigan School of Medicine, 1500 E Medical Center Drive, Ann Arbor, MI 48109-0708, USA
| | - Noelle E Carlozzi
- Department of Physical Medicine and Rehabilitation, Center for Clinical Outcomes, Development, and Application (CODA), University of Michigan School of Medicine, 2800 Plymouth Rd, Ann Arbor, MI 48109-2800, USA
| | - Ananda Sen
- Department of Family Medicine, University of Michigan School of Medicine, 1018 Fuller Street, Ann Arbor, MI 48109-0708, USA
| | - Caroline R Richardson
- Department of Family Medicine, University of Michigan School of Medicine, 1018 Fuller Street, Ann Arbor, MI 48109-0708, USA
| | - Elizabeth A Jackson
- Department of Internal Medicine, Division of Cardiology, University of Michigan School of Medicine, 1500 E Medical Center Drive, Ann Arbor, MI 48109-0708, USA.
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Srivaratharajah K, Abramson BL. Women and Peripheral Arterial Disease: A Review of Sex Differences in Epidemiology, Clinical Manifestations, and Outcomes. Can J Cardiol 2018; 34:356-361. [DOI: 10.1016/j.cjca.2018.01.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 11/17/2022] Open
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Thomas RJ, Balady G, Banka G, Beckie TM, Chiu J, Gokak S, Ho PM, Keteyian SJ, King M, Lui K, Pack Q, Sanderson BK, Wang TY. 2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol 2018; 71:1814-1837. [PMID: 29606402 DOI: 10.1016/j.jacc.2018.01.004] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Fakhry F, Fokkenrood HJP, Spronk S, Teijink JAW, Rouwet EV, Hunink MGM. Endovascular revascularisation versus conservative management for intermittent claudication. Cochrane Database Syst Rev 2018; 2018:CD010512. [PMID: 29518253 PMCID: PMC6494207 DOI: 10.1002/14651858.cd010512.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Intermittent claudication (IC) is the classic symptomatic form of peripheral arterial disease affecting an estimated 4.5% of the general population aged 40 years and older. Patients with IC experience limitations in their ambulatory function resulting in functional disability and impaired quality of life (QoL). Endovascular revascularisation has been proposed as an effective treatment for patients with IC and is increasingly performed. OBJECTIVES The main objective of this systematic review is to summarise the (added) effects of endovascular revascularisation on functional performance and QoL in the management of IC. SEARCH METHODS For this review the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (February 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1). The CIS also searched trials registries for details of ongoing and unpublished studies. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing endovascular revascularisation (± conservative therapy consisting of supervised exercise or pharmacotherapy) versus no therapy (except advice to exercise) or versus conservative therapy (i.e. supervised exercise or pharmacotherapy) for IC. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted data, and assessed the methodological quality of studies. Given large variation in the intensity of treadmill protocols to assess walking distances and use of different instruments to assess QoL, we used standardised mean difference (SMD) as treatment effect for continuous outcome measures to allow standardisation of results and calculated the pooled SMD as treatment effect size in meta-analyses. We interpreted pooled SMDs using rules of thumb (< 0.40 = small, 0.40 to 0.70 = moderate, > 0.70 = large effect) according to the Cochrane Handbook for Systematic Reviews of Interventions. We calculated the pooled treatment effect size for dichotomous outcome measures as odds ratio (OR). MAIN RESULTS We identified ten RCTs (1087 participants) assessing the value of endovascular revascularisation in the management of IC. These RCTs compared endovascular revascularisation versus no specific treatment for IC or conservative therapy or a combination therapy of endovascular revascularisation plus conservative therapy versus conservative therapy alone. In the included studies, conservative treatment consisted of supervised exercise or pharmacotherapy with cilostazol 100 mg twice daily. The quality of the evidence ranged from low to high and was downgraded mainly owing to substantial heterogeneity and small sample size.Comparing endovascular revascularisation versus no specific treatment for IC (except advice to exercise) showed a moderate effect on maximum walking distance (MWD) (SMD 0.70, 95% confidence interval (CI) 0.31 to 1.08; 3 studies; 125 participants; moderate-quality evidence) and a large effect on pain-free walking distance (PFWD) (SMD 1.29, 95% CI 0.90 to 1.68; 3 studies; 125 participants; moderate-quality evidence) in favour of endovascular revascularisation. Long-term follow-up in two studies (103 participants) showed no clear differences between groups for MWD (SMD 0.67, 95% CI -0.30 to 1.63; low-quality evidence) and PFWD (SMD 0.69, 95% CI -0.45 to 1.82; low-quality evidence). The number of secondary invasive interventions (OR 0.81, 95% CI 0.12 to 5.28; 2 studies; 118 participants; moderate-quality evidence) was also not different between groups. One study reported no differences in disease-specific QoL after two years.Data from five studies (n = 345) comparing endovascular revascularisation versus supervised exercise showed no clear differences between groups for MWD (SMD -0.42, 95% CI -0.87 to 0.04; moderate-quality evidence) and PFWD (SMD -0.05, 95% CI -0.38 to 0.29; moderate-quality evidence). Similarliy, long-term follow-up in three studies (184 participants) revealed no differences between groups for MWD (SMD -0.02, 95% CI -0.36 to 0.32; moderate-quality evidence) and PFWD (SMD 0.11, 95% CI -0.26 to 0.48; moderate-quality evidence). In addition, high-quality evidence showed no difference between groups in the number of secondary invasive interventions (OR 1.40, 95% CI 0.70 to 2.80; 4 studies; 395 participants) and in disease-specific QoL (SMD 0.18, 95% CI -0.04 to 0.41; 3 studies; 301 participants).Comparing endovascular revascularisation plus supervised exercise versus supervised exercise alone showed no clear differences between groups for MWD (SMD 0.26, 95% CI -0.13 to 0.64; 3 studies; 432 participants; moderate-quality evidence) and PFWD (SMD 0.33, 95% CI -0.26 to 0.93; 2 studies; 305 participants; moderate-quality evidence). Long-term follow-up in one study (106 participants) revealed a large effect on MWD (SMD 1.18, 95% CI 0.65 to 1.70; low-quality evidence) in favour of the combination therapy. Reports indicate that disease-specific QoL was comparable between groups (SMD 0.25, 95% CI -0.05 to 0.56; 2 studies; 330 participants; moderate-quality evidence) and that the number of secondary invasive interventions (OR 0.27, 95% CI 0.13 to 0.55; 3 studies; 457 participants; high-quality evidence) was lower following combination therapy.Two studies comparing endovascular revascularisation plus pharmacotherapy (cilostazol) versus pharmacotherapy alone provided data showing a small effect on MWD (SMD 0.38, 95% CI 0.08 to 0.68; 186 participants; high-quality evidence), a moderate effect on PFWD (SMD 0.63, 95% CI 0.33 to 0.94; 186 participants; high-quality evidence), and a moderate effect on disease-specific QoL (SMD 0.59, 95% CI 0.27 to 0.91; 170 participants; high-quality evidence) in favour of combination therapy. Long-term follow-up in one study (47 participants) revealed a moderate effect on MWD (SMD 0.72, 95% CI 0.09 to 1.36; P = 0.02) in favour of combination therapy and no clear differences in PFWD between groups (SMD 0.54, 95% CI -0.08 to 1.17; P = 0.09). The number of secondary invasive interventions was comparable between groups (OR 1.83, 95% CI 0.49 to 6.83; 199 participants; high-quality evidence). AUTHORS' CONCLUSIONS In the management of patients with IC, endovascular revascularisation does not provide significant benefits compared with supervised exercise alone in terms of improvement in functional performance or QoL. Although the number of studies is small and clinical heterogeneity underlines the need for more homogenous and larger studies, evidence suggests that a synergetic effect may occur when endovascular revascularisation is combined with a conservative therapy of supervised exercise or pharmacotherapy with cilostazol: the combination therapy seems to result in greater improvements in functional performance and in QoL scores than are seen with conservative therapy alone.
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Affiliation(s)
- Farzin Fakhry
- Erasmus MCDepartments of Epidemiology & RadiologyDr Molewaterplein 40PO Box 2040RotterdamNetherlands3015 GD
| | | | - Sandra Spronk
- Erasmus MCDepartments of Epidemiology & RadiologyDr Molewaterplein 40PO Box 2040RotterdamNetherlands3015 GD
- Dutch Health Care InspectorateDepartment of Research and InnovationUtrechtNetherlands
| | - Joep AW Teijink
- Catharina HospitalDepartment of Vascular Surgeryvisiting address: Michelangelolaan 2, 5623 EJ, Eindhovenpostal address: P.O. Box 1350EindhovenNetherlands5602 ZA
| | - Ellen V Rouwet
- Erasmus MCDepartment of Vascular SurgeryRotterdamNetherlands
| | - M G Myriam Hunink
- Erasmus MCDepartment of EpidemiologyPO Box 2040RotterdamNetherlands3000 CA
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Abstract
BACKGROUND Exercise programmes are a relatively inexpensive, low-risk option compared with other, more invasive therapies for treatment of leg pain on walking (intermittent claudication (IC)). This is the fourth update of a review first published in 1998. OBJECTIVES Our goal was to determine whether an exercise programme was effective in alleviating symptoms and increasing walking treadmill distances and walking times in people with intermittent claudication. Secondary objectives were to determine whether exercise was effective in preventing deterioration of underlying disease, reducing cardiovascular events, and improving quality of life. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Specialised Register (last searched 15 November 2016) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 10) via the Cochrane Register of Studies Online, along with trials registries. SELECTION CRITERIA Randomised controlled trials of an exercise regimen versus control or versus medical therapy for people with IC due to peripheral arterial disease (PAD). We included any exercise programme or regimen used for treatment of IC, such as walking, skipping, and running. Inclusion of trials was not affected by duration, frequency, or intensity of the exercise programme. Outcome measures collected included treadmill walking distance (time to onset of pain or pain-free walking distance and maximum walking time or maximum walking distance), ankle brachial index (ABI), quality of life, morbidity, or amputation; if none of these was reported, we did not include the trial in this review. DATA COLLECTION AND ANALYSIS For this update (2017), RAL and AH selected trials and extracted data independently. We assessed study quality by using the Cochrane 'Risk of bias' tool. We analysed continuous data by determining mean differences (MDs) and 95% confidence intervals (CIs), and dichotomous data by determining risk ratios (RRs) and 95% CIs. We pooled data using a fixed-effect model unless we identified significant heterogeneity, in which case we used a random-effects model. We used the GRADE approach to assess the overall quality of evidence supporting the outcomes assessed in this review. MAIN RESULTS We included two new studies in this update and identified additional publications for previously included studies, bringing the total number of studies meeting the inclusion criteria to 32, and involving a total of 1835 participants with stable leg pain. The follow-up period ranged from two weeks to two years. Types of exercise varied from strength training to polestriding and upper or lower limb exercises; supervised sessions were generally held at least twice a week. Most trials used a treadmill walking test for one of the primary outcome measures. The methodological quality of included trials was moderate, mainly owing to absence of relevant information. Most trials were small and included 20 to 49 participants. Twenty-seven trials compared exercise versus usual care or placebo, and the five remaining trials compared exercise versus medication (pentoxifylline, iloprost, antiplatelet agents, and vitamin E) or pneumatic calf compression; we generally excluded people with various medical conditions or other pre-existing limitations to their exercise capacity.Meta-analysis from nine studies with 391 participants showed overall improvement in pain-free walking distance in the exercise group compared with the no exercise group (MD 82.11 m, 95% CI 71.73 to 92.48, P < 0.00001, high-quality evidence). Data also showed benefit from exercise in improved maximum walking distance (MD 120.36 m, 95% CI 50.79 to 189.92, P < 0.0007, high-quality evidence), as revealed by pooling data from 10 studies with 500 participants. Improvements were seen for up to two years.Exercise did not improve the ABI (MD 0.04, 95% CI 0.00 to 0.08, 13 trials, 570 participants, moderate-quality evidence). Limited data were available for the outcomes of mortality and amputation; trials provided no evidence of an effect of exercise, when compared with placebo or usual care, on mortality (RR 0.92, 95% CI 0.39 to 2.17, 5 trials, 540 participants, moderate-quality evidence) or amputation (RR 0.20, 95% CI 0.01 to 4.15, 1 trial, 177 participants, low-quality evidence).Researchers measured quality of life using Short Form (SF)-36 at three and six months. At three months, the domains 'physical function', 'vitality', and 'role physical' improved with exercise; however this was a limited finding, as it was reported by only two trials. At six months, meta-analysis showed improvement in 'physical summary score' (MD 2.15, 95% CI 1.26 to 3.04, P = 0.02, 5 trials, 429 participants, moderate-quality evidence) and in 'mental summary score' (MD 3.76, 95% CI 2.70 to 4.82, P < 0.01, 4 trials, 343 participants, moderate-quality evidence) secondary to exercise. Two trials reported the remaining domains of the SF-36. Data showed improvements secondary to exercise in 'physical function' and 'general health'. The other domains - 'role physical', 'bodily pain', 'vitality', 'social', 'role emotional', and 'mental health' - did not show improvement at six months.Evidence was generally limited in trials comparing exercise versus antiplatelet therapy, pentoxifylline, iloprost, vitamin E, and pneumatic foot and calf compression owing to small numbers of trials and participants.Review authors used GRADE to assess the evidence presented in this review and determined that quality was moderate to high. Although results showed significant heterogeneity between trials, populations and outcomes were comparable overall, with findings relevant to the claudicant population. Results were pooled for large sample sizes - over 300 participants for most outcomes - using reproducible methods. AUTHORS' CONCLUSIONS High-quality evidence shows that exercise programmes provided important benefit compared with placebo or usual care in improving both pain-free and maximum walking distance in people with leg pain from IC who were considered to be fit for exercise intervention. Exercise did not improve ABI, and we found no evidence of an effect of exercise on amputation or mortality. Exercise may improve quality of life when compared with placebo or usual care. As time has progressed, the trials undertaken have begun to include exercise versus exercise or other modalities; therefore we can include fewer of the new trials in this update.
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Affiliation(s)
- Risha Lane
- Hull Royal InfirmaryVascular UnitAnlaby RoadHullUKHU3 2JZ
| | - Amy Harwood
- Hull Royal InfirmaryVascular UnitAnlaby RoadHullUKHU3 2JZ
| | - Lorna Watson
- NHS FifeCameron House, Cameron BridgeWindygatesLevenUKKY8 5RG
| | - Gillian C Leng
- National Institute for Health and Care Excellence10 Spring GardensLondonUKSW1A 2BU
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Woessner MN, VanBruggen MD, Pieper CF, O'Reilly EK, Kraus WE, Allen JD. Combined Dietary Nitrate and Exercise Intervention in Peripheral Artery Disease: Protocol Rationale and Design. JMIR Res Protoc 2017; 6:e139. [PMID: 28974486 PMCID: PMC5645641 DOI: 10.2196/resprot.7596] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 05/25/2017] [Accepted: 05/26/2017] [Indexed: 12/12/2022] Open
Abstract
Background Peripheral artery disease (PAD) is caused by atherosclerotic occlusions in the legs. It affects approximately 8-12 million people in the United States alone, one-third of whom suffer from intermittent claudication (IC), defined as ischemic leg pain that occurs with walking and improves with rest. Patients with IC suffer a markedly impaired quality of life and a high perception of disability. Improving pain-free walking time is a primary goal of rehabilitation in this population. Objective The nitric oxide (NO)-PAD trial is designed to compare the effects that 12 weeks of supervised exercise training, in combination with a high inorganic nitrate-content (beetroot [BR] juice) beverage or placebo (PL) beverage, has on clinical outcomes of exercise and functional capacity in two groups of PAD+IC patients: exercise training plus beetroot (EX+BR) and exercise training plus placebo (EX+PL). The primary aims of this randomized controlled, double-blind pilot study are to determine group differences following 12 weeks of EX+BR versus EX+PL in the changes for (1) exercise capacity: pain-free walking time (claudication onset time, COT), peak walk time (PWT), and maximal exercise capacity (peak oxygen uptake, VO2peak) during a maximal-graded cardiopulmonary exercise test (max CPX) and (2) functional capacity: 6-minute walk (6MW) distance. The secondary aims will provide mechanistic insights into the exercise outcome measures and will include (1) gastrocnemius muscle oxygenation during exercise via near-infrared spectroscopy (NIRS); (2) gastrocnemius muscle angiogenesis: capillaries per unit area and per muscle fiber, and relative fraction of type I, IIa, IIb, and IId/x fibers; and (3) vascular health/function via brachial artery flow-mediated dilation, lower-limb blood flow via plethysmography, and pulse wave velocity and reflection. Methods A total of 30 subjects between 40 and 80 years of age with PAD who are limited by IC will undergo exercise training 3 days per week for 12 weeks (ie, 36 sessions). They will be randomized to either the EX+BR or EX+PL group where participants will consume a beverage high in inorganic nitrate (4.2 mmol) or a low-nitrate placebo, respectively, 3 hours prior to each training session. Results Data collection from this study has been completed and is in the process of analysis and write-up. While the study is too underpowered—EX+BR, n=11; EX+PL, n=13—to determine between-group differences in the primary outcomes of COT, PWT, and 6MW, preliminary observations are promising with Cohen d effect sizes of medium to large. Conclusions Exercise training is currently the most effective therapy to increase functional capacity in PAD+IC. If the addition of inorganic nitrate to an exercise regimen elicits greater benefits, it may redefine the current standard of care for PAD+IC. Trial Registration ClinicalTrials.gov NCT01684930; https://clinicaltrials.gov/ct2/show/NCT01684930 (Archived by WebCite at http://www.webcitation.org/6raXFyEcP)
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Affiliation(s)
- Mary N Woessner
- Clinical Exercise Science Research Program, Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Australia.,Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, United States
| | - Mitch D VanBruggen
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, United States
| | - Carl F Pieper
- Duke University Medical Center, Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States
| | - Erin K O'Reilly
- Office of Regulatory Affairs and Quality, Duke University Medical Center, Durham, NC, United States
| | - William E Kraus
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, United States
| | - Jason D Allen
- Clinical Exercise Science Research Program, Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Australia.,Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, United States
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Monaro S, West S, Gullick J. An integrative review of health-related quality of life in patients with critical limb ischaemia. J Clin Nurs 2017; 26:2826-2844. [PMID: 27808440 DOI: 10.1111/jocn.13623] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2016] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To examine the domains and the domain-specific characteristics within a peripheral arterial disease health-related quality of life framework for their usefulness in defining critical limb ischaemia health-related quality of life. BACKGROUND Critical Limb Ischaemia presents a highly individualised set of personal and health circumstances. Treatment options include conservative management, revascularisation or amputation. However, the links between treatment decisions and quality of life require further investigation. DESIGN The framework for this integrative review was the peripheral arterial disease-specific health-related quality of life domains identified by Treat-Jacobson et al. RESULTS The literature expanded and refined Treat-Jacobson's framework by modifying the characteristics to better describe health-related quality of life in critical limb ischaemia. CONCLUSIONS Given that critical limb ischaemia is a highly individualised situation with powerful health-related quality of life implications, further research focusing on patient and family-centred decision-making relating to therapeutic options and advanced care planning is required. RELEVANCE TO CLINICAL PRACTICE A critical limb ischaemia-specific, health-related quality of life tool is required to capture both the unique characteristics of this disorder, and the outcomes for active or conservative care among this complex group of patients.
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Affiliation(s)
- Susan Monaro
- Concord Repatriation General Hospital, Concord, NSW, Australia.,Sydney Nursing School, University of Sydney, Sydney, NSW, Australia
| | - Sandra West
- Sydney Nursing School, University of Sydney, Sydney, NSW, Australia
| | - Janice Gullick
- Sydney Nursing School, University of Sydney, Sydney, NSW, Australia.,Sydney Local Health District, Sydney, NSW, Australia
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Wang AYM, Brimble KS, Brunier G, Holt SG, Jha V, Johnson DW, Kang SW, Kooman JP, Lambie M, McIntyre C, Mehrotra R, Pecoits-Filho R. ISPD Cardiovascular and Metabolic Guidelines in Adult Peritoneal Dialysis Patients Part II - Management of Various Cardiovascular Complications. Perit Dial Int 2016; 35:388-96. [PMID: 26228783 DOI: 10.3747/pdi.2014.00278] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Cardiovascular mortality has remained high in patients on peritoneal dialysis (PD) due to the high prevalence of various cardiovascular complications including coronary artery disease, left ventricular hypertrophy and dysfunction, heart failure, arrhythmia (especially atrial fibrillation), cerebrovascular disease, and peripheral arterial disease. In addition, nearly a quarter of PD patients develop sudden cardiac death as the terminal life event. Thus, it is essential to identify effective treatment that may lower cardiovascular mortality and improve survival of PD patients. The International Society for Peritoneal Dialysis (ISPD) commissioned a global workgroup in 2012 to formulate a series of recommendation statements regarding lifestyle modification, assessment and management of various cardiovascular risk factors, and management of the various cardiovascular complications to be published in 2 guideline documents. This publication forms the second part of the guideline documents and includes recommendation statements on the management of various cardiovascular complications in adult chronic PD patients. The documents are intended to serve as a global clinical practice guideline for clinicians who look after PD patients. We also define areas where evidence is clearly deficient and make suggestions for future research in each specific area.
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Affiliation(s)
| | - K Scott Brimble
- St. Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada
| | - Gillian Brunier
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Stephen G Holt
- Division of Nephrology, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Vivekanand Jha
- George Institute for Global Health India, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - David W Johnson
- University of Queensland at Princess Alexandra Hospital, Brisbane, Australia Centre for Kidney Disease Research, Translational Research Institute, Brisbane, Australia
| | - Shin-Wook Kang
- Department of Internal Medicine, College of Medicine, Severance Biomedical Science Institute, Yonsei University, Korea
| | - Jeroen P Kooman
- Division of Nephrology, University Hospital Maastricht, Maastricht, The Netherlands
| | - Mark Lambie
- Health Services Research Unit, Institute for Science and Technology in Medicine, Keele University, Keele, Staffordshire, United Kingdom
| | - Chris McIntyre
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, United Kingdom
| | - Rajnish Mehrotra
- Harborview Medical Center, Division of Nephrology/Department of Medicine, University of Washington, Washington, DC, United States
| | - Roberto Pecoits-Filho
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
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Lyu X, Li S, Peng S, Cai H, Liu G, Ran X. Intensive walking exercise for lower extremity peripheral arterial disease: A systematic review and meta-analysis. J Diabetes 2016; 8:363-77. [PMID: 25940390 DOI: 10.1111/1753-0407.12304] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 03/25/2015] [Accepted: 04/26/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Supervised treadmill exercise is the recommended therapy for peripheral arterial disease (PAD) patients with intermittent claudication (IC). However, most PAD patients do not exhibit typical symptoms of IC. The aim of the present study was to explore the efficacy and safety of intensive walking exercise in PAD patients with and without IC. METHODS The PubMed, Embase and Cochrane Library databases were systematically searched. Randomized controlled trials comparing the effects of intensive walking exercise with usual care in patients with PAD were included for systematic review and meta-analysis. RESULTS Eighteen trials with 1200 patients were eligible for the present analysis. Compared with usual care, intensive walking exercise significantly improved the maximal walking distance (MWD), pain-free walking distance, and the 6-min walking distance in patients with PAD (P < 0.00001 for all). Subgroup analyses indicated that a lesser improvement in MWD was observed in the subgroup with more diabetes patients, and that the subgroup with better baseline walking ability exhibited greater improvement in walking performance. In addition, similar improvements in walking performance were observed for exercise programs of different durations and modalities. No significant difference was found in adverse events between the intensive walking and usual care groups (relative risk 0.84; 95% confidence interval 0.51, 1.39; P = 0.50). CONCLUSIONS Regardless of exercise length and modality, regularly intensive walking exercise improves walking ability in PAD patients more than usual care. The presence of diabetes may attenuate the improvements in walking performance in patients with PAD following exercise.
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Affiliation(s)
- Xiafei Lyu
- Diabetic Foot Center, Chengdu, China
- Department of Endocrinology and Metabolism, West China Hospital, Chengdu, China
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, Chengdu, China
| | - Shifeng Peng
- Clinical Medicine of Eight-year Program, West China School of Medicine, Sichuan University, Chengdu, China
| | - Huimin Cai
- Clinical Medicine of Eight-year Program, West China School of Medicine, Sichuan University, Chengdu, China
| | - Guanjian Liu
- Chinese Cochrane Center, West China Hospital, Chengdu, China
| | - Xingwu Ran
- Diabetic Foot Center, Chengdu, China
- Department of Endocrinology and Metabolism, West China Hospital, Chengdu, China
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Abstract
BACKGROUND Intermittent claudication (IC) is pain caused by chronic occlusive arterial disease that develops in a limb during exercise and is relieved with rest. Most drug treatments of IC have a limited effect in improving walking distance. Padma 28, a Tibetan herbal preparation, has been used to treat IC, but there is debate as to whether Padma 28 produces a clinical benefit beyond the placebo effect. This is an update of a review first published in 2013. OBJECTIVES To determine whether Padma 28 is effective, compared with placebo or other medications, in increasing pain-free and maximum walking distance for patients with intermittent claudication. SEARCH METHODS For this update the Cochrane Vascular Trials Search Co-ordinator searched the Specialised Register (September 2015), the Cochrane Register of Studies ((CENTRAL) (2015, Issue 8)) and clinical trials databases. SELECTION CRITERIA Randomised controlled trials of Padma 28 compared with placebo or other pharmacological treatments in people suffering from IC. DATA COLLECTION AND ANALYSIS All review authors independently assessed the selected studies and extracted the data. Risk of bias was evaluated independently by two review authors. Depending on the data provided in the individual trials, we extracted mean or median walking distance at the end of the trial, or change in walking distance over the course of the trial, or both. Where not provided, and whenever possible, the statistical significance of differences in these parameters between treatment and placebo groups in individual trials was calculated. Where possible, data were combined by meta-analysis. MAIN RESULTS No new trials were identified in the search for this review update. In total five trials involving 365 participants were included in this review. All trials compared Padma 28 with placebo for at least 16 weeks of follow-up. Pain-free and maximum walking distances both increased significantly in the groups treated with Padma 28, with no significant change in the placebo group. In general, the studies presented results comparing the treatment arms before and after treatment but made no comparisons between the Padma 28 and placebo groups. Pooled data of maximum walking distance after treatment with Padma 28 and placebo from two studies (193 participants) indicated a higher maximum walking distance (mean difference (MD) 95.97 m, 95% confidence interval (CI) 79.07 m to 112.88 m, P < 0.00001, very low quality evidence) in the Padma 28 group compared with placebo. The clinical importance of these observed changes in walking distance is unclear as no quality of life data were reported. There was no effect on ankle brachial index (ABI): change in ABI values between baseline and six months follow up MD -0.01, 95% CI -0.07 to 0.05, 1 study, 56 participants, P = 0.72, very low quality evidence). Mild side effects, especially gastrointestinal discomfort, tiredness and skin eruption, were reported but this outcome was not different between the Padma 28 and placebo groups (odds ratio 1.09, 95% CI 0.42 to 2.83, four studies, 231 participants, P = 0.86, very low quality evidence). AUTHORS' CONCLUSIONS Some evidence exists from individual trials to suggest that Padma 28 may be effective in increasing walking distances, at least in the short term (four months), in people with IC. Side effects do not appear to be a problem. However, the longer term effects of treatment are unknown and the clinical significance of the improvements in walking distance are questionable. Moreover, the quality of the evidence is limited by the small sample size of the available trials, limited reporting of statistical analyses that compared treatment groups, and relatively high withdrawal rates that were linked to the outcome. That is, patients were withdrawn if they failed to improve walking distance. There was also evidence of publication bias. We therefore feel there is currently insufficient evidence to draw conclusions regards the effectiveness of Padma 28 in the routine management of IC. Further well-designed research would be required to determine the true effects of this herbal preparation.
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Affiliation(s)
- Marlene Stewart
- University of EdinburghUsher Institute of Population Health Sciences and InformaticsMedical School, Teviot PlaceEdinburghUKEH8 9AG
| | - Joanne R Morling
- University of NottinghamDivision of Epidemiology and Public HealthC120, Clinical Sciences Building ‐ Ph2City Hospital Campus, Hucknall RoadNottinghamUKNG5 1PB
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Myers SA, Huben NB, Yentes JM, McCamley JD, Lyden ER, Pipinos II, Johanning JM. Spatiotemporal Changes Posttreatment in Peripheral Arterial Disease. Rehabil Res Pract 2015; 2015:124023. [PMID: 26770826 PMCID: PMC4681815 DOI: 10.1155/2015/124023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 11/16/2015] [Indexed: 11/26/2022] Open
Abstract
Accumulating evidence suggests revascularization of peripheral arterial disease (PAD) limbs results in limited improvement in functional gait parameters, suggesting underlying locomotor system pathology. Spatial and temporal (ST) gait parameters are well studied in patients with PAD at baseline and are abnormal when compared to controls. The purpose of this study was to systematically review and critically analyze the available data on ST gait parameters before and after interventions. A full review of literature was conducted and articles were included which examined ST gait parameters before and after intervention (revascularization and exercise). Thirty-three intervention articles were identified based on 154 articles that evaluated ST gait parameters in PAD. Four articles fully assessed ST gait parameters before and after intervention and were included in our analysis. The systematic review of the literature revealed a limited number of studies assessing ST gait parameters. Of those found, results demonstrated the absence of improvement in gait parameters due to either exercise or surgical intervention. Our study demonstrates significant lack of research examining the effectiveness of treatments on ST gait parameters in patients with PAD. Based on the four published articles, ST gait parameters failed to significantly improve in patients with PAD following intervention.
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Affiliation(s)
- Sara A. Myers
- Center for Research in Human Movement Variability, School of Health, Physical Education, and Recreation, University of Nebraska Omaha, 6160 University Drive South, Omaha, NE 68182-0860, USA
| | - Neil B. Huben
- Center for Research in Human Movement Variability, School of Health, Physical Education, and Recreation, University of Nebraska Omaha, 6160 University Drive South, Omaha, NE 68182-0860, USA
| | - Jennifer M. Yentes
- Center for Research in Human Movement Variability, School of Health, Physical Education, and Recreation, University of Nebraska Omaha, 6160 University Drive South, Omaha, NE 68182-0860, USA
| | - John D. McCamley
- Center for Research in Human Movement Variability, School of Health, Physical Education, and Recreation, University of Nebraska Omaha, 6160 University Drive South, Omaha, NE 68182-0860, USA
| | - Elizabeth R. Lyden
- College of Public Health, Department of Biostatistics, University of Nebraska Medical Center, 984355 Nebraska Medical Center, Omaha, NE 68198, USA
| | - Iraklis I. Pipinos
- Department of Surgery, Omaha Veterans Affairs Medical Center, 4101 Woolworth Avenue (121), Omaha, NE 68105, USA
- College of Medicine, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198, USA
| | - Jason M. Johanning
- Department of Surgery, Omaha Veterans Affairs Medical Center, 4101 Woolworth Avenue (121), Omaha, NE 68105, USA
- College of Medicine, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198, USA
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Comparing Supervised Exercise Therapy to Invasive Measures in the Management of Symptomatic Peripheral Arterial Disease. Surg Res Pract 2015; 2015:960402. [PMID: 26601122 PMCID: PMC4639651 DOI: 10.1155/2015/960402] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 10/05/2015] [Accepted: 10/11/2015] [Indexed: 11/17/2022] Open
Abstract
Peripheral arterial disease (PAD) is associated with considerable morbidity and mortality. Consensus rightly demands the incorporation of supervised exercise training (SET) into PAD treatment protocols. However, the exact role of SET particularly its relationship with intervention requires further clarification. While supervised exercise is undoubtedly an excellent tool in the conservative management of mild PAD its use in more advanced disease as an adjunct to open or endovascular intervention is not clearly defined. Indeed its use in isolation in this cohort is incompletely reported. The aim of this review is to clarify the exact role of SET in the management of symptomatic PAD and in particular to assess its role in comparison with or as an adjunct to invasive intervention. A systematic literature search revealed a total 11 randomised studies inclusive of 969 patients. All studies compared SET and intervention with monotherapy. Study results suggest that exercise is a complication-free treatment. Furthermore, it appears to offer significant improvements in patients walk distances with a combination of both SET and intervention offering a superior walking outcome to monotherapy in those requiring invasive measures.
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[Update peripheral arterial occlusive disease]. Herz 2015; 40:1013-22; quiz 1023-4. [PMID: 26432712 DOI: 10.1007/s00059-015-4357-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Due to demographic changes, peripheral arterial occlusive disease (PAD) has become one of the most prevalent diseases in western industrial nations. In recent years the trend towards initial endovascular treatment approaches has further continued. Because of the high primary success and low complication rates, intervention-based revascularization strategies are the method of choice in the majority of cases. The treatment strategy should always be assessed in a multidisciplinary setting and if possible, within a designated vascular center. One of the main limitations of interventions is the occurrence of restenosis, in particular in infrapopliteal arterial lesions. A major progress arose from drug-eluting balloons, which dramatically reduced restenosis rates particular for femoropopliteal lesions. A potential alternative strategy could be the use of a combination therapy, such as plaque removal followed by insertion of drug-eluting balloons; however, economic issues have to be kept in mind for such approaches.
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Armijo-Olivo S, Saltaji H, da Costa BR, Fuentes J, Ha C, Cummings GG. What is the influence of randomisation sequence generation and allocation concealment on treatment effects of physical therapy trials? A meta-epidemiological study. BMJ Open 2015; 5:e008562. [PMID: 26338841 PMCID: PMC4563231 DOI: 10.1136/bmjopen-2015-008562] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To determine if adequacy of randomisation and allocation concealment is associated with changes in effect sizes (ES) when comparing physical therapy (PT) trials with and without these methodological characteristics. DESIGN Meta-epidemiological study. PARTICIPANTS A random sample of randomised controlled trials (RCTs) included in meta-analyses in the PT discipline were identified. INTERVENTION Data extraction including assessments of random sequence generation and allocation concealment was conducted independently by two reviewers. To determine the association between sequence generation, and allocation concealment and ES, a two-level analysis was conducted using a meta-meta-analytic approach. PRIMARY AND SECONDARY OUTCOME MEASURES association between random sequence generation and allocation concealment and ES in PT trials. RESULTS 393 trials included in 43 meta-analyses, analysing 44,622 patients contributed to this study. Adequate random sequence generation and appropriate allocation concealment were accomplished in only 39.7% and 11.5% of PT trials, respectively. Although trials with inappropriate allocation concealment tended to have an overestimate treatment effect when compared with trials with adequate concealment of allocation, the difference was non-statistically significant (ES=0.12; 95% CI -0.06 to 0.30). When pooling our results with those of Nuesch et al, we obtained a pooled statistically significant value (ES=0.14; 95% CI 0.02 to 0.26). There was no difference in ES in trials with appropriate or inappropriate random sequence generation (ES=0.02; 95% CI -0.12 to 0.15). CONCLUSIONS Our results suggest that when evaluating risk of bias of primary RCTs in PT area, systematic reviewers and clinicians implementing research into practice should pay attention to these biases since they could exaggerate treatment effects. Systematic reviewers should perform sensitivity analysis including trials with low risk of bias in these domains as primary analysis and/or in combination with less restrictive analyses. Authors and editors should make sure that allocation concealment and random sequence generation are properly reported in trial reports.
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Affiliation(s)
- Susan Armijo-Olivo
- CLEAR Outcomes (Connecting Leadership, Education and Research)Research Program, University of Alberta, Edmonton Clinic Health Academy (ECHA), Edmonton, Alberta, Canada
- Faculty of Rehabilitation Medicine, Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
- Faculty of Rehabilitation Medicine, Rehabilitation Research Center, University of Alberta, Edmonton, Alberta, Canada
| | - Humam Saltaji
- Orthodontic Graduate Clinic, School of Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Bruno R da Costa
- Universitat Bern, Institute of Primary Health Care, Bern, Switzerland
| | - Jorge Fuentes
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
- Department of Physical Therapy, Catholic University of Maule, Talca, Chile
| | - Christine Ha
- Faculty of Rehabilitation Medicine, Rehabilitation Research Center, University of Alberta, Edmonton, Alberta, Canada
| | - Greta G Cummings
- Faculty of Nursing, CLEAR Outcomes (Connecting Leadership Education & Research) Research Program, University of Alberta, Edmonton Clinic Health Academy|University of Alberta, Edmonton, Alberta, Canada
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Armijo-Olivo S, da Costa BR, Cummings GG, Ha C, Fuentes J, Saltaji H, Egger M. PEDro or Cochrane to Assess the Quality of Clinical Trials? A Meta-Epidemiological Study. PLoS One 2015; 10:e0132634. [PMID: 26161653 PMCID: PMC4498768 DOI: 10.1371/journal.pone.0132634] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 06/16/2015] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE There is debate on how the methodological quality of clinical trials should be assessed. We compared trials of physical therapy (PT) judged to be of adequate quality based on summary scores from the Physiotherapy Evidence Database (PEDro) scale with trials judged to be of adequate quality by Cochrane Risk of Bias criteria. DESIGN Meta-epidemiological study within Cochrane Database of Systematic Reviews. METHODS Meta-analyses of PT trials were identified in the Cochrane Database of Systematic Reviews. For each trial PeDro and Cochrane assessments were extracted from the PeDro and Cochrane databases. Adequate quality was defined as adequate generation of random sequence, concealment of allocation, and blinding of outcome assessors (Cochrane criteria) or as trials with a PEDro summary score ≥5 or ≥6 points. We combined trials of adequate quality using random-effects meta-analysis. RESULTS Forty-one Cochrane reviews and 353 PT trials were included. All meta-analyses included trials with PEDro scores ≥5, 37 (90.2%) included trials with PEDro scores ≥6 and only 22 (53.7%) meta-analyses included trials of adequate quality according to the Cochrane criteria. Agreement between PeDro and Cochrane was poor for PeDro scores of ≥5 points (kappa = 0.12; 95% CI 0.07 to 0.16) and slight for ≥6 points (kappa 0.24; 95% CI 0.16-0.32). When combining effect sizes of trials deemed to be of adequate quality according to PEDro or Cochrane criteria, we found that a substantial difference in the combined effect size (≥0.15) was evident in 9 (22%) out of the 41 meta-analyses for PEDro cutoff ≥5 and 10 (24%) for cutoff ≥6. CONCLUSIONS The PeDro and Cochrane approaches lead to different sets of trials of adequate quality, and different combined treatment estimates from meta-analyses of these trials. A consistent approach to assessing RoB in trials of physical therapy should be adopted.
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Affiliation(s)
- Susan Armijo-Olivo
- CLEAR (Connecting Leadership, Education, and Research) Outcomes Research Program, University of Alberta, Faculty of Nursing, University of Alberta, Edmonton, Canada
- Rehabilitation Research Center, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Bruno R. da Costa
- Universitat Bern, Institute of Primary Health Care, Gesellschaftstrasse 49, Bern, 3013, Switzerland
| | - Greta G. Cummings
- CLEAR (Connecting Leadership, Education, and Research) Outcomes Research Program, University of Alberta, Faculty of Nursing, University of Alberta, Edmonton, Canada
| | - Christine Ha
- Rehabilitation Research Center, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Jorge Fuentes
- Rehabilitation Research Center, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
- Catholic University of Maule, Department of Physical Therapy, Talca, Chile
| | - Humam Saltaji
- Orthodontic Graduate Program, School of Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Matthias Egger
- Institute of Social & Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
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Vemulapalli S, Dolor RJ, Hasselblad V, Subherwal S, Schmit KM, Heidenfelder BL, Patel MR, Schuyler Jones W. Comparative Effectiveness of Medical Therapy, Supervised Exercise, and Revascularization for Patients With Intermittent Claudication: A Network Meta-analysis. Clin Cardiol 2015; 38:378-86. [PMID: 25963038 DOI: 10.1002/clc.22406] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 02/19/2015] [Accepted: 02/20/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are limited data on the comparative effectiveness of medical therapy, supervised exercise, and revascularization to improve walking and quality of life in patients with intermittent claudication (IC). HYPOTHESIS Supervised exercise and revascularization was superior to medical therapy in IC. METHODS We studied the comparative effectiveness of exercise training, medications, endovascular intervention, and surgical revascularization on outcomes including functional capacity (walking distance and timing), quality of life, and mortality. We searched PubMed, EMBASE, and the Cochrane Database of Systematic Reviews from January 1995 to August 2012 for relevant English-language studies. Two investigators independently collected data. Meta-analyses with random-effects models of direct comparisons were supplemented by mixed-treatment analyses to incorporate data from placebo comparisons, head-to-head comparisons, and multiple treatment arms. RESULTS Thirty-five unique studies evaluated treatment modalities in 7475 patients with IC. Compared with usual care, only exercise training improved both maximal walking distance (150 meters; 95% confidence interval: 35-266 meters, P = 0.01) and initial claudication distance (39 meters; 95% confidence interval: 9-65 meters, P = 0.003). All modalities were associated with improved quality of life (Short Form-36 physical functioning score) compared with usual care, but there were no differences between treatments. There were insufficient safety data to assess treatment-related complications. All-cause mortality was not significantly different between modalities. CONCLUSIONS Evidence is insufficient to determine treatment superiority for improving quality of life and walking parameters in IC patients. Further studies with attention to study design, standardized efficacy and safety endpoints, and appropriate subgroup reporting are necessary to determine comparative effectiveness.
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Affiliation(s)
- Sreekanth Vemulapalli
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Rowena J Dolor
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.,Division of General Internal Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Evidence-based Practice Center, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Vic Hasselblad
- Duke Evidence-based Practice Center, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Sumeet Subherwal
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Kristine M Schmit
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Brooke L Heidenfelder
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Manesh R Patel
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - W Schuyler Jones
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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Tompra N, Foster C, Sanchis-Gomar F, de Koning JJ, Lucia A, Emanuele E. Upper versus lower limb exercise training in patients with intermittent claudication: A systematic review. Atherosclerosis 2015; 239:599-606. [DOI: 10.1016/j.atherosclerosis.2015.02.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 02/19/2015] [Accepted: 02/19/2015] [Indexed: 11/24/2022]
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Baltic A, Radjo I, Mahmutovic I, Mahmutovic I. Effects of programmed kinesiologic stimulus to hemodynamics at peripheral artery disease of lower limbs. Acta Inform Med 2015; 22:368-70. [PMID: 25684842 PMCID: PMC4315634 DOI: 10.5455/aim.2014.22.368-370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 05/22/2014] [Indexed: 11/23/2022] Open
Abstract
Goal: The goal of the article is to examine level of hemodynamic improvement in the peripheral artery diseases of lower limbs among patients on medication therapy and patients included in programmed physical activities simultaneously with the medication therapy. Material and methods: Prospective-retrospective study includes 100 patients of the Clinic for Vascular Disease, Clinical Center of Sarjevo University (CCUS). It has been found out that the majority of patients in both groups were males. Average age of patients in control group was 48.60±3.82. Average value of claudication distance for patients in control group was 277 m, while the value for patients in test group was 270 m. Results: At the end of research the analysis of average PSV values proved significant difference in relation to examined groups (p<0.05). Average PSV value statistically significantly decreased in both groups after the treatment. According to the obtained results it was determined that the claudication distance of control group was statistically considerably smaller in comparison to the average claudication distance in the test group. Conclusion: It was established that the chance for the patients to have claudication distance within reference values is 2.57 times higher in the test group in comparison with the patients in the control group after the treatment.
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Affiliation(s)
- Abel Baltic
- Clinic for Vascular Disease of the Clinic Center of the Sarajevo University, Sarajevo, Bosnia and Herzegovina
| | - Izet Radjo
- Faculty of Sport and Physical Education, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Ifet Mahmutovic
- Faculty of Sport and Physical Education, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Indira Mahmutovic
- Pedagogic Faculty, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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Jarek A, Wójtowicz M, Kwiatkowska D, Kita M, Turek-Lepa E, Chajewska K, Lewandowska-Pachecka S, Pokrywka A. The prevalence of trimetazidine use in athletes in Poland: excretion study after oral drug administration. Drug Test Anal 2014; 6:1191-6. [DOI: 10.1002/dta.1755] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/29/2014] [Accepted: 10/30/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Anna Jarek
- Institute of Sport; Department of Anti-Doping Research; Trylogii 2/16 Street 01-982 Warsaw Poland
| | - Marzena Wójtowicz
- Institute of Sport; Department of Anti-Doping Research; Trylogii 2/16 Street 01-982 Warsaw Poland
| | - Dorota Kwiatkowska
- Institute of Sport; Department of Anti-Doping Research; Trylogii 2/16 Street 01-982 Warsaw Poland
| | - Monika Kita
- Medical University of Warsaw, Faculty of Pharmacy; Department of Biochemistry and Clinical Chemistry; Banacha 1 Street 02-097 Warsaw Poland
| | - Ewa Turek-Lepa
- Institute of Sport; Department of Anti-Doping Research; Trylogii 2/16 Street 01-982 Warsaw Poland
| | - Katarzyna Chajewska
- Institute of Sport; Department of Anti-Doping Research; Trylogii 2/16 Street 01-982 Warsaw Poland
| | - Sylwia Lewandowska-Pachecka
- Medical University of Warsaw, Faculty of Pharmacy; Department of Biochemistry and Clinical Chemistry; Banacha 1 Street 02-097 Warsaw Poland
| | - Andrzej Pokrywka
- Institute of Sport; Department of Anti-Doping Research; Trylogii 2/16 Street 01-982 Warsaw Poland
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Subherwal S, Patel MR, Chiswell K, Tidemann-Miller BA, Jones WS, Conte MS, White CJ, Bhatt DL, Laird JR, Hiatt WR, Tasneem A, Califf RM. Clinical trials in peripheral vascular disease: pipeline and trial designs: an evaluation of the ClinicalTrials.gov database. Circulation 2014; 130:1812-9. [PMID: 25239436 PMCID: PMC4362518 DOI: 10.1161/circulationaha.114.011021] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 08/18/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tremendous advances have occurred in therapies for peripheral vascular disease (PVD); until recently, however, it has not been possible to examine the entire clinical trial portfolio of studies for the treatment of PVD (both arterial and venous disease). METHODS AND RESULTS We examined interventional trials registered in ClinicalTrials.gov from October 2007 through September 2010 (n=40,970) and identified 676 (1.7%) PVD trials (n=493 arterial only, n=170 venous only, n=13 both arterial and venous). Most arterial studies investigated lower-extremity peripheral artery disease and acute stroke (35% and 24%, respectively), whereas most venous studies examined deep vein thrombosis/pulmonary embolus prevention (42%) or venous ulceration (25%). A placebo-controlled trial design was used in 27% of the PVD trials, and 4% of the PVD trials excluded patients >65 years of age. Enrollment in at least 1 US site decreased from 51% of trials in 2007 to 41% in 2010. Compared with noncardiology disciplines, PVD trials were more likely to be double-blinded, to investigate the use of devices and procedures, and to have industry sponsorship and assumed funding source, and they were less likely to investigate drug and behavioral therapies. Geographic access to PVD clinical trials within the United States is limited to primarily large metropolitan areas. CONCLUSIONS PVD studies represent a small group of trials registered in ClinicalTrials.gov, despite the high prevalence of vascular disease in the general population. This low number, compounded by the decreasing number of PVD trials in the United States, is concerning and may limit the ability to inform current clinical practice of patients with PVD.
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Affiliation(s)
- Sumeet Subherwal
- From the Duke Clinical Research Institute, Duke University, Durham, NC (S.S., M.R.P., K.C., B.A.T.-M., W.S.J., A.T., R.M.C.); North Carolina State University, Raleigh (B.A.T.-M.); University of California, San Francisco, San Francisco (M.S.C.); Ochsner Heart & Vascular Institute, New Orleans, LA (C.J.W.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); University of California, Davis, Sacramento (J.R.L.); and University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
| | - Manesh R Patel
- From the Duke Clinical Research Institute, Duke University, Durham, NC (S.S., M.R.P., K.C., B.A.T.-M., W.S.J., A.T., R.M.C.); North Carolina State University, Raleigh (B.A.T.-M.); University of California, San Francisco, San Francisco (M.S.C.); Ochsner Heart & Vascular Institute, New Orleans, LA (C.J.W.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); University of California, Davis, Sacramento (J.R.L.); and University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.).
| | - Karen Chiswell
- From the Duke Clinical Research Institute, Duke University, Durham, NC (S.S., M.R.P., K.C., B.A.T.-M., W.S.J., A.T., R.M.C.); North Carolina State University, Raleigh (B.A.T.-M.); University of California, San Francisco, San Francisco (M.S.C.); Ochsner Heart & Vascular Institute, New Orleans, LA (C.J.W.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); University of California, Davis, Sacramento (J.R.L.); and University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
| | - Beth A Tidemann-Miller
- From the Duke Clinical Research Institute, Duke University, Durham, NC (S.S., M.R.P., K.C., B.A.T.-M., W.S.J., A.T., R.M.C.); North Carolina State University, Raleigh (B.A.T.-M.); University of California, San Francisco, San Francisco (M.S.C.); Ochsner Heart & Vascular Institute, New Orleans, LA (C.J.W.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); University of California, Davis, Sacramento (J.R.L.); and University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
| | - W Schuyler Jones
- From the Duke Clinical Research Institute, Duke University, Durham, NC (S.S., M.R.P., K.C., B.A.T.-M., W.S.J., A.T., R.M.C.); North Carolina State University, Raleigh (B.A.T.-M.); University of California, San Francisco, San Francisco (M.S.C.); Ochsner Heart & Vascular Institute, New Orleans, LA (C.J.W.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); University of California, Davis, Sacramento (J.R.L.); and University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
| | - Michael S Conte
- From the Duke Clinical Research Institute, Duke University, Durham, NC (S.S., M.R.P., K.C., B.A.T.-M., W.S.J., A.T., R.M.C.); North Carolina State University, Raleigh (B.A.T.-M.); University of California, San Francisco, San Francisco (M.S.C.); Ochsner Heart & Vascular Institute, New Orleans, LA (C.J.W.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); University of California, Davis, Sacramento (J.R.L.); and University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
| | - Christopher J White
- From the Duke Clinical Research Institute, Duke University, Durham, NC (S.S., M.R.P., K.C., B.A.T.-M., W.S.J., A.T., R.M.C.); North Carolina State University, Raleigh (B.A.T.-M.); University of California, San Francisco, San Francisco (M.S.C.); Ochsner Heart & Vascular Institute, New Orleans, LA (C.J.W.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); University of California, Davis, Sacramento (J.R.L.); and University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
| | - Deepak L Bhatt
- From the Duke Clinical Research Institute, Duke University, Durham, NC (S.S., M.R.P., K.C., B.A.T.-M., W.S.J., A.T., R.M.C.); North Carolina State University, Raleigh (B.A.T.-M.); University of California, San Francisco, San Francisco (M.S.C.); Ochsner Heart & Vascular Institute, New Orleans, LA (C.J.W.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); University of California, Davis, Sacramento (J.R.L.); and University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
| | - John R Laird
- From the Duke Clinical Research Institute, Duke University, Durham, NC (S.S., M.R.P., K.C., B.A.T.-M., W.S.J., A.T., R.M.C.); North Carolina State University, Raleigh (B.A.T.-M.); University of California, San Francisco, San Francisco (M.S.C.); Ochsner Heart & Vascular Institute, New Orleans, LA (C.J.W.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); University of California, Davis, Sacramento (J.R.L.); and University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
| | - William R Hiatt
- From the Duke Clinical Research Institute, Duke University, Durham, NC (S.S., M.R.P., K.C., B.A.T.-M., W.S.J., A.T., R.M.C.); North Carolina State University, Raleigh (B.A.T.-M.); University of California, San Francisco, San Francisco (M.S.C.); Ochsner Heart & Vascular Institute, New Orleans, LA (C.J.W.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); University of California, Davis, Sacramento (J.R.L.); and University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
| | - Asba Tasneem
- From the Duke Clinical Research Institute, Duke University, Durham, NC (S.S., M.R.P., K.C., B.A.T.-M., W.S.J., A.T., R.M.C.); North Carolina State University, Raleigh (B.A.T.-M.); University of California, San Francisco, San Francisco (M.S.C.); Ochsner Heart & Vascular Institute, New Orleans, LA (C.J.W.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); University of California, Davis, Sacramento (J.R.L.); and University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
| | - Robert M Califf
- From the Duke Clinical Research Institute, Duke University, Durham, NC (S.S., M.R.P., K.C., B.A.T.-M., W.S.J., A.T., R.M.C.); North Carolina State University, Raleigh (B.A.T.-M.); University of California, San Francisco, San Francisco (M.S.C.); Ochsner Heart & Vascular Institute, New Orleans, LA (C.J.W.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); University of California, Davis, Sacramento (J.R.L.); and University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
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Neurogenic claudication. PHLEBOLOGIE 2014. [DOI: 10.12687/phleb2223-6-2014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
SummaryNeurogenic claudication is a cardinal symptom of lumbar spinal stenosis and an important and frequent differential diagnosis in reported “leg pain”. Whereas findings are often relatively normal on clinical examination, a detailed anamnesis can frequently lead to the correct (suspected) diagnosis, which is subsequently confirmed by magnetic resonance imaging or CT myelography. In the absence of any relevant neurological deficits, conservative treatment with anal-gesia, peridural cortisone injections and physiotherapy can initially be attempted. If conservative treatment fails or neurological deficits occur, most patients benefit from surgical decompression of the spinal canal, with additional stabilisation if appropriate.
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Bedenis R, Stewart M, Cleanthis M, Robless P, Mikhailidis DP, Stansby G. Cilostazol for intermittent claudication. Cochrane Database Syst Rev 2014; 2014:CD003748. [PMID: 25358850 PMCID: PMC7173701 DOI: 10.1002/14651858.cd003748.pub4] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Peripheral arterial disease (PAD) affects between 4% and 12% of people aged 55 to 70 years, and 20% of people over 70 years. A common complaint is intermittent claudication, characterised by pain in the legs or buttocks that occurs with exercise and which subsides with rest. Compared with age-matched controls, people with intermittent claudication have a three- to six-fold increase in cardiovascular mortality. Symptoms of intermittent claudication, walking distance, and quality of life can be improved by risk factor modification, smoking cessation, and a structured exercise programme. Antiplatelet treatment is beneficial in patients with intermittent claudication for the reduction of vascular events but has not previously been shown to influence claudication distance. This is an update of a review first published in 2007. OBJECTIVES To determine the effect of cilostazol (an antiplatelet treatment) on improving initial and absolute claudication distances, and in reducing mortality and vascular events in patients with stable intermittent claudication. SEARCH METHODS For this update, the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched October 2013) and CENTRAL (2013, Issue 9). SELECTION CRITERIA Double-blind, randomised controlled trials (RCTs) of cilostazol versus placebo, or versus other antiplatelet agents in patients with stable intermittent claudication. DATA COLLECTION AND ANALYSIS Two authors independently assessed trials for selection and independently extracted data. Disagreements were resolved by discussion. We performed the meta-analysis as a fixed-effect model with weighted mean differences (WMDs) and 95% confidence intervals (CIs) for continuous data, and odds ratios (ORs) with 95% CIs for dichotomous data. MAIN RESULTS We included fifteen double-blind, RCTs comparing cilostazol with placebo, or medications currently known to increase walking distance e.g. pentoxifylline. There were a total of 3718 randomised participants with treatment durations ranging from six to 26 weeks. All participants had intermittent claudication secondary to PAD. Comparisons included cilostazol twice daily, with dosages of 50 mg, 100 mg and 150 mg compared with placebo, and cilostazol 100 mg, twice daily, compared with pentoxifylline 400 mg, three times daily. The methodological quality of the trials was generally low, with the majority being at an unclear risk for selection bias, performance bias, detection bias and other bias. Attrition bias was generally low, but reporting bias was high or unclear in the majority of the studies. For eight studies data were compatible for comparison by meta-analysis, but data for seven studies were too heterogenous to be pooled. For the studies included in the meta-analysis, for initial claudication distance (ICD - the distance walked on a treadmill before the onset of calf pain) there was an improvement in the cilostazol group for the 100 mg and 50 mg twice daily, compared with placebo (WMD 31.41 metres, 95% CI 22.38 to 40.45 metres; P < 0.00001) and WMD 19.89 metres, 95% CI 9.44 to 30.34 metres; P = 0.0002), respectively. ICD was improved in the cilostazol group for the comparison of cilostazol 150 mg versus placebo and cilostazol 100 mg versus pentoxifylline, but only single studies were used for these analyses. Absolute claudication distance (ACD - the maximum distance walked on a treadmill) was significantly increased in participants taking cilostazol 100 mg and 50 mg twice daily, compared with placebo (WMD 43.12 metres, 95% CI 18.28 to 67.96 metres; P = 0.0007) and WMD 32.00 metres, 95% CI 14.17 to 49.83 metres; P = 0.0004), respectively. As with ICD, ACD was increased in participants taking cilostazol 150 mg versus placebo, but with only one study an association cannot be clearly determined. Two studies comparing cilostazol to pentoxifylline had opposing findings, resulting in an imprecise CI (WMD 13.42 metres (95% CI -43.51 to 70.35 metres; P = 0.64). Ankle brachial index (ABI) was lowered in the cilostazol 100 mg group compared with placebo (WMD 0.06, 95% CI 0.04 to 0.08; P < 0.00001). The single study evaluating ABI for the comparison of cilostazol versus pentoxifylline found no change in ABI.There was no association between treatment type and all-cause mortality for any of the treatment comparisons, but there were very few events, and therefore larger, adequately powered studies will be needed to assess if there is a relationship. Only one study evaluated individual cardiovascular events, and from this study there is no clear evidence of a difference between any of the treatment groups and risk of myocardial infarction or stroke. We evaluated adverse side effects, and in general cilostazol was associated with a higher odds of headache, diarrhoea, abnormal stool, dizziness and palpitations. We only reported quality of life measures descriptively as there was insufficient statistical detail within the studies to combine the results, although there was a possible indication in improvement of quality of life in the cilostazol treatment groups. AUTHORS' CONCLUSIONS Cilostazol has been shown to be of benefit in improving walking distance in people with intermittent claudication secondary to PAD. Although there is an increase in adverse side effects, they are generally mild and treatable. There is currently insufficient data on whether taking cilostazol results in a reduction of all-cause mortality and cardiovascular events or an improvement in quality of life. Future research into the effect of cilostazol on intermittent claudication should carefully consider comparability, sample size and homogeneity when designing a study.
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Affiliation(s)
- Rachel Bedenis
- University of EdinburghCentre for Population Health SciencesEdinburghUKEH8 9AG
| | - Marlene Stewart
- University of EdinburghCentre for Population Health SciencesEdinburghUKEH8 9AG
| | | | - Peter Robless
- National University Health SystemDepartment of Cardiac, Thoracic and Vascular Surgery5 Lower Kent Ridge RoadSingaporeSingapore119074
| | - Dimitri P Mikhailidis
- Royal Free Hospital Campus, University College London Medical SchoolDepartment of Clinical BiochemistryUniversity College London (UCL)Pond StreetLondonUKNW3 2QG
| | - Gerard Stansby
- Freeman HospitalNorthern Vascular CentreNewcastle upon TyneUKNE7 7DN
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Change in dietary intake of adults with intermittent claudication undergoing a supervised exercise program and compared to matched controls. Nutr J 2014; 13:100. [PMID: 25316347 PMCID: PMC4210553 DOI: 10.1186/1475-2891-13-100] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 10/03/2014] [Indexed: 11/24/2022] Open
Abstract
Background Presence of numerous diet responsive comorbidities and high atherosclerotic burden among adults with intermittent claudication demands attention is given to diet in an effort to delay progression of peripheral artery disease. The aim of this study was to compare diet of adults with intermittent claudication: (a) against dietary recommendations; (b) following 12 weeks of supervised exercise training; and (c) against non-peripheral artery disease controls. Methods Diet was assessed using a food frequency questionnaire pre and post supervised exercise training. Pre-exercise diet was compared against Suggested Dietary Targets and against non-peripheral artery disease controls matched for gender, age and body weight. Pre-exercise diet was also compared against post-exercise diet. Results Pre-exercise 25/31 participants, 5/31 participants, 16/31 participants and 4/31 participants achieved recommendations for protein, carbohydrate, total fat and saturated fat respectively. Few achieved recommended intakes for fibre (3/31 participants), cholesterol (8/31 participants), folate (11/31 participants), potassium (1/31 participants), sodium (4/31 participants), retinol equivalents (1/31 participants) and vitamin C (3/31 participants). There were no differences observed between participants compared to controls in achievement of recommendations. Post-exercise, marginally more participants were able to achieve targets for cholesterol, sodium and vitamin C but not for any other nutrients. Conclusions Despite evidence to support benefits of dietary modification in risk reduction of peripheral artery disease, adults with intermittent claudication continue to consume poor diets. Research is required to determine whether dietary changes can be achieved with greater attention to nutrition counselling and the impact assessed in terms of delayed disease progression and long term health outcomes. Trial Registration ClinicalTrials.gov: NCT01871779.
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Bujak M, Gamberdella J, Mena C. Management of Atherosclerotic Aortoiliac Occlusive Disease. Interv Cardiol Clin 2014; 3:531-543. [PMID: 28582078 DOI: 10.1016/j.iccl.2014.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Development of aortoiliac occlusive disease (AIOD) is associated with classic risk factors for atherosclerotic disease such as hyperlipidemia, hypertension, diabetes, or smoking. Risk factor modification, smoking cessation, and prevention of cardiovascular events remain the cornerstones of AIOD management. Symptom improvement and limb loss prevention are considered secondary goals of therapy. Continuous technological advances, new devices, as well as new revascularization techniques are constantly changing the landscape of AIOD management. Surgical interventions, which were considered a gold standard therapy for nearly 50 years, currently give way to newer and less invasive endovascular techniques.
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Affiliation(s)
- Marcin Bujak
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, DANA3 Cardiology, New Haven, CT 06510, USA
| | - Jacqueline Gamberdella
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, DANA3 Cardiology, New Haven, CT 06510, USA
| | - Carlos Mena
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, DANA3 Cardiology, New Haven, CT 06510, USA.
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