Quality of life in patients with intermittent claudication

Role of noninvasive ocular imaging as a biomarker in peripheral artery disease (PAD): A systematic review

This study aimed to review the current literature exploring the utility of noninvasive ocular imaging for the diagnosis of peripheral artery disease (PAD). Our search was conducted in early April 2022 and included the databases Medline, Scopus, Embase, Cochrane, and others. Five articles were included in the final review. Of the five studies that used ocular imaging in PAD, two studies used retinal color fundus photography, one used optical coherence tomography (OCT), and two used optical coherence tomography angiography (OCTA) to assess the ocular changes in PAD. PAD was associated with both structural and functional changes in the retina. Structural alterations around the optic disc and temporal retinal vascular arcades were seen in color fundus photography of patients with PAD compared to healthy individuals. The presence of retinal hemorrhages, exudates, and microaneurysms in color fundus photography was associated with an increased future risk of PAD, especially the severe form of the disease. The retinal nerve fiber layer (RNFL) was significantly thinner in the nasal quadrant in patients with PAD compared to age-matched healthy individuals in OCT. Similarly, the choroidal thickness in the subfoveal region was significantly thinner in patients with PAD compared to controls. Patients with PAD also had a significant reduction in the retinal and choroidal circulation in OCTA compared to healthy controls. As PAD causes thinning and ischemic changes in retinal vessels, examination of the retinal vessels using retinal imaging techniques can provide useful information about early microvascular damage in PAD. Ocular imaging could potentially serve as a biomarker for PAD. PROSPERO ID: CRD42022310637.

A Delphi Consensus on Patient Reported Outcomes for Registries and Trials Including Patients with Intermittent Claudication: Recommendations and Reporting Standard

OBJECTIVE

This study aimed to develop a core set of patient reported outcome quality indicators (QIs) for the treatment of patients with intermittent claudication (IC), that allow a broad international implementation across different vascular registries and within trials.

METHODS

A rigorous modified two stage Delphi technique was used to promote consensus building on patient reported outcome QIs among an expert panel consisting of international vascular specialists, patient representatives, and registry members of the VASCUNET and the International Consortium of Vascular Registries. Potential QIs identified through an extensive literature search or additionally proposed by the panel were validated by the experts in a preliminary survey and included for evaluation. Consensus was reached if ≥ 80% of participants agreed that an item was both clinically relevant and practical.

RESULTS

Participation rates in two Delphi rounds were 66% (31 participants of 47 invited) and 90% (54 of 60), respectively. Initially, 145 patient reported outcome QIs were documented. Following the two Delphi rounds, 18 quality indicators remained, all of which reached consensus regarding clinical relevance. The VascuQoL questionnaire (VascuQoL-6), currently the most common patient reported outcome measurement (PROM) used within vascular registries, includes a total of six items. Five of these six items also matched with high rated indicators identified in the Delphi study. Consequently, the panel recommends the use of the VascuQoL-6 survey as a preferred core PROM QI set as well as an optional extension of 12 additional patient reported QIs that were also identified in this study.

CONCLUSION

The current recommendation based on the Delphi consensus building approach, strengthens the international harmonisation of registry data collection in relation to patient reported outcome quality. Continuous and standardised quality assurance will ensure that registry data may be used for future quality benchmarking studies and, ultimately, positively impact the overall quality of care provided to patients with peripheral arterial occlusive disease.

Effects of walking impairment on mental health burden, health risk behavior and quality of life in patients with intermittent claudication: A cross-sectional path analysis

Introduction

Intermittent claudication is the leading symptom of peripheral artery disease (leg pain when walking). The present study investigates the extent to which walking impairment is associated with health-related quality of life, mental health and health risk behavior.

Methods

A theory-based, cross-sectional path model was empirically examined using pre-intervention baseline data from a multicenter, randomized-controlled trial of patients with intermittent claudication (PAD-TeGeCoach). Data were available from 1 696 patients who completed a battery of questionnaires between April 14, 2018 and March 12, 2019, including measures of walking impairment (Walking Impairment Questionnaire), health-related quality of life (SF-12), mental burden (GAD-7, PHQ-9), nicotine- and alcohol-related risk behavior (Fagerström-Test, AUDIT-C). Sociodemographic characteristics and comorbid conditions were included in the postulated model a priori to minimize confounding effects.

Results

Walking impairment was associated with an increase in depressive (β = -.36, p < .001) and anxiety symptoms (β = -.24, p < .001). The prevalence of depressive and anxiety symptoms was 48.3% and 35.5%, respectively, with female patients and those of younger age being at greater risk. Depressive symptoms were predictive of an increased tobacco use (β = .21; p < .001). Walking impairment had adverse effects on physical quality of life, both directly (β = .60, p < .001) and indirectly mediated through depressive symptoms (β = -.16, p < .001); and indirectly on mental quality of life mediated through depressive (β = -.43, p < .001) and anxiety symptoms (β = -.35, p < .001).

Discussion

The findings underscore the need for a comprehensive treatment strategy in patients with intermittent claudication. Measures to improve walking impairment (e.g. exercise training) are key to enhance quality of life and should be the primary treatment. As a key mediator of mental quality of life, depressive and anxiety symptoms should be addressed by rigorously including mental health treatment. Risky health behaviors should be approached by promoting behavior change (e.g. smoking cessation) as a secondary prevention of peripheral artery disease.

Assessing health-related quality of life among patients with peripheral artery disease: A review of the literature and focus on patient-reported outcome measures

Peripheral artery disease (PAD) is a progressive atherosclerotic disease associated with high rates of morbidity and mortality. Symptomatic PAD typically presents with claudication, and symptom severity strongly associates with reduced health-related quality of life (HRQoL). Existing treatment strategies for PAD are aimed at reducing symptom severity and improving functional outcomes. However, there is a need to incorporate patient-reported outcome measures (PROMs) into PAD treatment and research in order to provide more patient-centered care. This review will discuss the impact of PAD on HRQoL, existing PROMs available to assess PAD-related HRQoL, utilization of PROMs in research studies and registries, and challenges and solutions related to the integration of PROMs into research and clinical settings.

Biomarker Utility for Peripheral Artery Disease Diagnosis in Real Clinical Practice: A Prospective Study

Peripheral arterial disease (PAD) is a common manifestation of generalized atherosclerosis, which affects more than 200 million patients worldwide. Currently, there is no ideal biomarker for PAD risk stratification and diagnosis. The goal of this research was to investigate the levels of inflammation biomarkers and cystatin C and to explore their utility for the diagnosis of PAD. The study included 296 participants, distributed in two groups: 216 patients diagnosed with PAD and 80 patients without PAD as controls. All studied biomarker levels (C-reactive protein, CRP; fibrinogen; erythrocyte sedimentation rate, ESR; neopterin; beta 2-microglobulin, B2-MG; and cystatin C) were significantly higher in the PAD group and indirectly correlated with the ankle-brachial index (ABI). The final logistic regression model included an association of neopterin, fibrinogen, and cystatin C as the most efficient markers for the prediction of PAD diagnosis. When comparing the area under the curve (AUC) for all biomarkers, the value for neopterin was significantly higher than those of all the other analyzed biomarkers. In agreement with previous studies, this research shows that markers such as fibrinogen, CRP, ESR, B2-MG, and cystatin C have significant value for the diagnosis of PAD, and also clearly underlines the accuracy of neopterin as a leading biomarker in PAD prediction.

Assessment of all-cause and cardiovascular death risk in Russian men with leg pain

Aim. To study the prevalence of intermittent claudication (IC) and assess the risk of cardiovascular and all-cause death In Russian men with IC according to 30-year follow-up.

Material and methods. The study used data obtained from representative samples of men examined inMoscow andSt. Petersburg (formerly known  as Leningrad) from 1975 to 1986. Response rate was 75%. The examination of men (n=10953) aged 35-70 years (mean age 48,8±6,6 years) was carried out according to a single protocol, which included a standard survey, biochemical profile test, measurement of blood pressure (BP) and heart rate, anthropometry and 12-lead electrocardiography. To determine IC, the original Rose questionnaire was used, according to which four categories of pain were identified. The first is the absence of pain (P0); the second — mixed pain, including not associated with exercise (P1); the third — atypical pain in calf muscles lasting >10 minutes of rest (P2); the fourth — typical IC (P3). The median follow-up was 21,9 years. In total, 7,893 people died, including 4220 people due to cardiovascular diseases (CVD). The KaplanMeier curves was used to assess the associations between IC categories and survival. The risk of death, including due to CVD, was assessed using Cox proportional hazard models.

Results. There were 38,8% of men with leg pain. The prevalence of IC in the studied sample was 1,0%, increasing with age from 0,4 to 2,3% in the older age group. As expected, individuals without leg pain live the longest. The years of life lost in persons with IC was 12. This parameter for cardiovascular deaths was 22,4 years. The contribution to survival not only of IC (P3), but also of atypical pain (P2) remains significant regardless of age. Moreover, the results of multivariate analysis showed that the contribution to mortality of P3 and P2 does not depend on increased blood pressure, smoking, ischemic and other electrocardiographic abnormalities, a history of myocardial infarction, which indicates the common etiology of lower limb and heart artery diseases. Similar data were obtained regarding cardiovascular mortality, however, the contribution of CI is more significant.

Conclusion. IC In Russian men aged 35-70 years is an independent predictor of all-cause and cardiovascular death.

Quality Indicators in Peripheral Arterial Occlusive Disease Treatment: A Systematic Review

OBJECTIVES

This systematic review aimed to identify evidence based quality indicators for invasive revascularisation of symptomatic peripheral arterial occlusive disease (PAOD).

METHODS

A systematic search of clinical practice guidelines, consensus statements, systematic reviews, and meta-analyses reporting quality indicators in patients undergoing invasive open and percutaneous revascularisations for symptomatic PAOD (PROSPERO registration number: CRD42019116317) was performed. Furthermore, a grey literature search was conducted involving databases of professional vascular medical organisations. The identified publications were screened independently by two reviewers for possible inclusion and full texts of potentially relevant records were independently evaluated for eligibility. Disagreement was resolved by discussion involving a third reviewer.

RESULTS

From 685 articles initially identified, one systematic review and one consensus statement focusing on quality indicators were selected for inclusion in the review. From these sources, a total of three process quality indicators matched the search criteria: one on pharmacological intervention, another on smoking cessation, and a third on surveillance of lower extremity vein bypass grafts. The grey literature search revealed an additional 31 structure, process, and outcome quality indicators.

CONCLUSIONS

This study revealed a lack of published evidence based quality indicators concerning invasive treatment for PAOD in the literature. An additional 31 indicators from the databases of professional societies and organisations have not been incorporated in prior guidelines. Interestingly, no indicator related to patient reported outcomes could be identified from either high quality sources or grey literature. Further research and harmonisation of different quality indicators is needed to enhance their evidence and subsequently improve patient centred decision making on invasive treatment.

A Novel, Individualized Exercise Program for Patients with Peripheral Arterial Disease Recovering from Bypass Surgery

The effectiveness of an individual six-month-long physical exercise program in improving health-related quality of life (HRQOL) is unclear. There is some evidence that an individual exercise program can be effective for this aim. The goal of this study was to compare an individual six-month-long physical exercise program for patients with PAD (Peripheral Arterial Disease) with a traditional exercise program and find the effect of these programs on HRQOL and PAD risk factors. The study included patients who underwent femoral–popliteal artery bypass grafting surgery. Patients were divided into three groups: patients participating in an individual six-month-long physical exercise program (group I), in the standard physical activity program (group II), and in a control group (group III), with no subjects participating in rehabilitation II. Results: group I patients had a significantly (p < 0.001) higher HRQOL at 6 months after their surgery compared with groups II and III. The HRQOL scores were significantly (p < 0.05) lower after surgery among older (≥ 65), overweight participants, as well as among patients with diabetes mellitus and cardiovascular diseases when comparing study results with patients without these risk factors.

Rationale and methods of the IDOMENEO health outcomes of the peripheral arterial disease revascularisation study in the GermanVasc registry

Abstract. Background: Atherosclerotic disease of the lower extremity arteries (PAD) remains a significant burden on global healthcare systems with increasing prevalence. Various guidelines on the diagnosis and treatment of patients with PAD are available but they often lack a sufficient evidence base for high-grade recommendations since randomized and controlled trials (RCT) remain rare or are frequently subject to conflicts of interest. This registry trial aims to evaluate the outcomes of catheter-based endovascular revascularisations vs. open-surgical endarterectomy vs. bypass surgery for symptomatic PAD on medical and patient-reported outcomes. Methods and design: The study is a prospective non-randomized multicentre registry trial including invasive revascularisations performed in 10 000 patients treated for symptomatic PAD at 30 to 40 German vascular centres. All patients matching the inclusion criteria are consecutively included for a recruitment period of six months (between May and December 2018) or until 10 000 patients have been included in the study registry. There are three follow-up measures at three, six, and 12 months. Automated completeness and plausibility checks as well as independent site visit monitoring will be performed to assure high internal and external validity of the study data. Study endpoints include relevant major cardiovascular and limb events and patient-reported outcomes from two Delphi studies with experts in vascular medicine and registry-based research. Discussion: It remains unclear if results from RCT can reflect daily treatment practice. Furthermore, great costs and complexity make it challenging to accomplish high quality randomized trials in PAD treatment. Prospective registry-based studies to collect real-world evidence can help to overcome these limitations.