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Lee S, Kalra K, Kashikar A, Redpath B, Bernheim A, Brewster L, Shaw L, Arya S. Evaluation of Lower Extremity Calcium Score as a Measure of Peripheral Arterial Disease Burden and Amputation Risk. Ann Vasc Surg 2023; 95:154-161. [PMID: 36889632 DOI: 10.1016/j.avsg.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/04/2023] [Accepted: 02/07/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND The ankle-brachial pressure index (ABI) and toe-brachial pressure index (TBI) are commonly used diagnostic tools for peripheral artery disease (PAD) that are unreliable in the presence of calcified vessels. In this study, we aimed to demonstrate the utility of the lower extremity calcium score (LECS) in addition to ABI and TBI in measuring disease burden and predicting the risk of amputation in patients with PAD. METHODS Patients who were evaluated in the vascular surgery clinic at Emory University for PAD and who underwent noncontrast computed tomography of the aorta and lower extremities were included in the study. Aortoiliac, femoral-popliteal, and tibial calcium scores were measured using the Agatston method. ABI and TBI that were obtained within 6 months of the computed tomography scan were noted and divided into categories of PAD severity. Associations between ABI, TBI, and LECS of each anatomic segment were evaluated. Univariate and multivariate ordinal regression analyses were performed to predict the outcome of amputation. Receiver operating characteristic analysis was performed to compare LECS with other variables in its ability to predict amputation. RESULTS Fifty patients included in the study cohort were divided into LECS quartiles, with 12-13 patients in each quartile. The highest quartile tended to be older (P = 0.016), had a higher percentage of diabetics (P = 0.034), and had a higher frequency of major amputations (P = 0.004) compared to the other quartiles. Patients in the highest quartile of tibial calcium score were more likely to have stage 3 chronic kidney disease (CKD) or greater (P = 0.011) and also had a higher frequency of amputation (P < 0.005) and mortality (P = 0.041). We found no significant association between each anatomic LECS and ABI/TBI categories. On univariate analysis, CKD (Odds Ratio [OR] 12.92 (95% CI 2.01 to 82.83), P = 0.007), diabetes mellitus (OR 5.47 (95% CI 1.27 to 23.64), P = 0.023), tibial calcium score (OR 6.62 (95% CI 1.79 to 24.54), P = 0.005), and total bilateral calcium score (OR 6.32 (95% CI 1.18 to 33.78), P = 0.031) were associated with increased risk of amputation. On multivariate stepwise ordinal regression, TBI and tibial calcium score were identified as important predictors of amputation, with hyperlipidemia and CKD increasing the overall prediction of the model. On Receiver operating characteristic analysis, the addition of the tibial calcium score (area under the curve 0.94, standard error 0.048) significantly improved the prediction of amputation compared to hyperlipidemia, CKD, and TBI alone (area under the curve 0.82, standard error 0.071, P = 0.022). CONCLUSIONS The addition of tibial calcium score to other known PAD risk factors may improve the prediction of amputation in patients with PAD.
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Affiliation(s)
- Sujin Lee
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA; Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Massachusetts General Hospital, Boston, MA; Surgical Service Line, Atlanta VA Medical Center, Decatur, GA; Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA.
| | - Kanika Kalra
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA; Surgical Service Line, Atlanta VA Medical Center, Decatur, GA; Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
| | - Aditi Kashikar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA; Surgical Service Line, Atlanta VA Medical Center, Decatur, GA; Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
| | - Benjamin Redpath
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA; Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA; Palo Alto VA Medical Center, Palo Alto, CA; Surgical Services, Palo Alto VA Medical Center, Palo Alto, CA
| | - Adam Bernheim
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA; Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA; Palo Alto VA Medical Center, Palo Alto, CA; Surgical Services, Palo Alto VA Medical Center, Palo Alto, CA
| | - Luke Brewster
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA; Surgical Service Line, Atlanta VA Medical Center, Decatur, GA
| | - Leslee Shaw
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
| | - Shipra Arya
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA; Palo Alto VA Medical Center, Palo Alto, CA; Surgical Services, Palo Alto VA Medical Center, Palo Alto, CA
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Gray G, Davenport ED, Bron D, Rienks R, d'Arcy J, Guettler N, Manen O, Syburra T, Nicol ED. The challenge of asymptomatic coronary artery disease in aircrew; detecting plaque before the accident. Heart 2019; 105:s17-s24. [PMID: 30425082 PMCID: PMC6256297 DOI: 10.1136/heartjnl-2018-313053] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 06/06/2018] [Accepted: 07/25/2018] [Indexed: 11/05/2022] Open
Abstract
Coronary events remain a major cause of sudden incapacitation, including death, in both the general population and among aviation personnel, and are an ongoing threat to flight safety and operations. The presentation is often unheralded, especially in younger adults, and is often due to rupture of a previously non-obstructive coronary atheromatous plaque. The challenge for aeromedical practitioners is to identify individuals at increased risk for such events. This paper presents the NATO Cardiology Working Group (HFM 251) consensus approach for screening and investigation of aircrew for asymptomatic coronary disease.A three-phased approach to coronary artery disease (CAD) risk assessment is recommended, beginning with initial risk-stratification using a population-appropriate risk calculator and resting ECG. For aircrew identified as being at increased risk, enhanced screening is recommended by means of Coronary Artery Calcium Score alone or combined with a CT coronary angiography investigation. Additional screening may include exercise testing, and vascular ultrasound imaging. Aircrew identified as being at high risk based on enhanced screening require secondary investigations, which may include functional ischaemia, and potentially invasive coronary angiography. Functional stress testing as a stand-alone investigation for significant CAD is not recommended in aircrew. Aircrew identified with coronary disease require further clinical and aeromedical evaluation before being reconsidered for flying status.
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Affiliation(s)
- Gary Gray
- Canadian Forces Environmental Medical Establishment, Toronto, Ontario, Canada
| | - Eddie D Davenport
- Aeromedical Consult Service, United States Air Force School of Aerospace Medicine, Wright-PAtterson AFB, Ohio, USA
| | - Dennis Bron
- Aeromedical Centre, Swiss Air Force, Duebendorf, Switzerland
| | - Rienk Rienks
- Department of Cardiology, University Medical Center Utrecht and Central Military Hospital, Utrecht, The Netherlands
| | - Joanna d'Arcy
- Royal Air Force Aviation Clinical Medicine Service, RAF Centre of Aviation Medicine, RAF Henlow, Bedfordshire, UK
| | - Norbert Guettler
- German Air Force Center for Aerospace Medicine, Fuerstenfeldbruck, Germany
| | - Olivier Manen
- Aviation Medicine Department, AeMC, Percy Military Hospital, Clamart, France
| | - Thomas Syburra
- Department of cardiothoracic surgery, Luzerner Kantonsspital, Luzern, Switzerland
| | - Edward D Nicol
- Royal Air Force Aviation Clinical Medicine Service, RAF Centre of Aviation Medicine, RAF Henlow, Bedfordshire, UK
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