Lower extremity peripheral arterial disease in individuals with coronary artery disease: prognostic importance, care gaps, and impact of therapy

Peripheral atherosclerosis evaluation through ultrasound: A promising diagnostic tool for coronary artery disease

Effective treatment, but also proper diagnosis of cardiovascular diseases, remains a major challenge in everyday practice. A quick, safe, and economically acceptable non-invasive procedure should play a leading role in cardiovascular risk assessment before invasive diagnostics is performed. The staging of subclinical atherosclerosis may help in further clinical decisions. Safe, widely available, and relatively inexpensive, ultrasonography is a promising examination that should find wider application in clinical practice. The latest ESC guidelines emphasize the usefulness of carotid ultrasound in the diagnosis of coronary artery disease (CAD) and subclinical assessment of atherosclerosis, which help to determine the level of cardiovascular risk. Ultrasound examination of peripheral arteries, especially superficial vessels such as the femoral arteries, is quite easy, quick, and accurate. Other vascular beds, such as iliac and renal, are more demanding to examine, but can also provide valuable information. This review summarizes important studies comparing the severity of atherosclerosis in ultrasound-visible vascular beds in patients with established CAD. We especially emphasize the benefits of the combined assessment of atherosclerosis features, which were characterized by high sensitivity and specificity in the diagnosis of CAD and other serious cardiovascular diseases.

Peripheral artery disease, abnormal ankle-brachial index, and prognosis in patients with acute coronary syndrome

Objectives

Ankle-brachial index (ABI) is an independent prognostic marker of cardiovascular events among patients with coronary artery disease (CAD). We aimed to investigate the outcome of patients hospitalized with acute coronary syndrome (ACS) and abnormal ABI.

Approach and results

ABI was prospectively measured in 1,047 patients hospitalized due to ACS, who were stratified into three groups, namely, those with clinical peripheral artery disease (PAD) (N = 132), those without clinical PAD but with abnormal (< 0.9) ABI (subclinical PAD; N = 148), and those without clinical PAD with normal ABI (no PAD; N = 767). Patients were prospectively followed for 30-day major adverse cardiovascular event (MACE) and 1-year all-cause mortality. The mean age was 64 years. There was a significant gradual increase throughout the three groups in age, i.e., the incidence of prior stroke, diabetes mellitus, and hypertension (p for trend = 0.001 for all). The in-hospital course showed a gradual rise in the incidence of complications with an increase in heart failure [2.5, 6.1, and 9.2%, (p for trend = 0.001)] and acute kidney injury [2, 4.1, and 11.5%, (p for trend = 0.001)]. At day 30, there was a stepwise increase in MACE, such that patients without PAD had the lowest rate, followed by subclinical and clinical PADs (3.5, 6.8, and 8.1%, respectively, p for trend = 0.009). Similarly, there was a significant increase in 1-year mortality from 3.4% in patients without PAD, through 6.8% in those with subclinical PAD, to 15.2% in those with clinical PAD (p for trend = 0.001).

Conclusion

Subclinical PAD is associated with poor outcomes in patients with ACS, suggesting that routine ABI screening could carry important prognostic significance in these patients regardless of PAD symptoms.

Peripheral Arterial Disease in Patients With Acute Coronary Syndrome: Results From a Large Real-World Registry

BACKGROUND

Limited data exist regarding the significance of peripheral arterial disease (PAD) in patients with acute coronary syndrome (ACS).

METHODS

We evaluated 16,922 consecutive ACS patients who were prospectively included in a national ACS registry. The co-primary endpoint included 30 days major adverse cardiovascular event (MACE) (re-infarction, stroke, and/or cardiovascular death) and 1-year mortality.

RESULTS

PAD patients were older (70±11 vs 63±13; p<0.01), male predominance (80% vs 77%; p=0.01), and more likely to sustain prior cardiovascular events. PAD patients were less likely to undergo coronary angiography (69% vs 83%; p<0.001) and revascularisation (80% vs 86%; p<0.001). Patients with PAD were more likely to sustain 30-day MACE (22% vs 14%; p<0.001) and mortality (10% vs 4.4%; p<0.001), as well as re-hospitalisation (23% vs 19%; p=0.001). After adjusting for potential confounders, PAD remained an independent predictor of 30-day MACE (odds ratio [OR], 1.6 [95% confidence interval (CI), 1.24-2.06]). Patients with compared to those without PAD had 2.5 times higher 1-year mortality rate (22% vs 9%; p<0.001). Co-existence of PAD remained an independent predictor of 1-year mortality after adjustment for potential confounders by multivariable regression analysis (OR, 1.62; 95% CI, 1.4-1.9). PAD was associated with a significant higher 1-year mortality rate across numerous sub-groups of patients including type of myocardial infarction (ST-elevation myocardial infarction vs non-ST-elevation myocardial infarction), and whether the patient underwent revascularisation.

CONCLUSIONS

Acute coronary syndrome with concomitant PAD represents a high-risk subgroup that warrants special attention and a more tailored approach.

How to perform a percutaneous coronary intervention, when no conventional arterial access site is available: A case report

Coronary artery disease is one of the leading causes of mortality in the world. The presence of concomitant peripheral artery disease increases the risks of cardiovascular events along with limiting the arterial access for coronary intervention. Invasive management of such cases includes either alternate site access or combined peripheral and coronary revascularization. We hereby report a patient of the infrarenal abdominal aorta and bilateral subclavian arterial occlusion, who presented with acute coronary syndrome. To perform the percutaneous coronary intervention, we first performed the endovascular stenting of occluded aortoiliac disease, followed by stenting of the right coronary artery. We had discussed the limitation of arterial access to perform PCI in such a situation.

Detecting Peripheral Arterial Disease in Primary Care: A Population Based Study

BACKGROUND

Peripheral arterial disease (PAD) can progress silently without any clinical symptoms. Ankle-brachial index (ABI) is the recommended method used in primary care. We aimed to determine the prevalence of PAD and its related risk factors in primary care.

METHODS

In this cross-sectional study, 250 participants aged ≥45 years were recruited randomly from the registered patients of family health center in a district of Izmir, Turkey. Patients' demographic data, PAD symptoms, and PAD risk factors were obtained. The PAD group consisted of patients with ABI levels <0.9; the non-compressible artery (NCA) group consisted of patients with ABI levels >1.3.

RESULTS

The prevalence of PAD was 17.6% (22.5% in women and 11.1% in men), while that of NCA was 15.2% (12.7% in women and 25.0% in men). About 27.3% and 54.5% of patients with PAD did not have claudication and problems with walking distance, respectively. Of the NCA patients, 15.8% had problems with walking distance and 39.5% had claudication. Regression analysis revealed two predictors of PAD (age ≥65 years: odds ratio [OR], 3.51; 95% confidence interval [CI], 1.65-7.47; claudication: OR, 3.41; 95% CI, 1.58-7.39) and three predictors of NCA (age <65 years: OR, 2.55; 95% CI, 1.01-6.45; male sex: OR, 2.40; 95% CI, 1.10-5.25; triglyceride [TG] >200 mg/dL: OR, 4.11; 95% CI, 1.58-10.67).

CONCLUSION

PAD had a prevalence of 17.6% and was associated with age ≥65 years and claudication. NCA had a prevalence of 15.2% and was associated with age <65 years, TG >200 mg/dL, and male sex.

The intrinsic prognostic value of the ankle-brachial index is independent from its mode of calculation

The object of this study was to compare the prognostic value of different methods of ankle-brachial index (ABI) calculation. From April 1998 to September 2008, we calculated the ABI in 1223 patients before coronary artery bypass grafting. The ABI was calculated according to five different calculation modes of the numerator. The patients were classified into three groups: clinical peripheral artery disease (PAD), subclinical PAD if no clinical history but abnormal ABI (< 0.90 or > 1.40), and no PAD. The primary outcome was total mortality. During a follow-up of 7.6 years (0.1-15.9), 406 patients (33%) died. The prevalence of the subclinical PAD varied from 22% to 29% according to the different modes of ABI calculation. Areas under the ROC curve to predict mortality according to different calculation modes varied from 0.608 ± 0.020 to 0.625 ± 0.020 without significant differences. The optimal ABI threshold to predict mortality varied for every method, ranging from 0.87 to 0.95. In multivariate models, ABI was significantly and independently associated with total mortality (hazard ratio (HR) = 1.46, 95% CI: 1.15-1.85, p = 0.002); however, this association was not significantly different between the various methods (HRs varying from 1.46 to 1.67). The use of the optimal ABI threshold for each calculation mode (rather than standard 0.90) allowed a slight improvement of the model. In conclusion, the ABI prognostic value to predict mortality is independent from its method of calculation. The use of different optimal thresholds for each method enables a comparable prognosis value.

Correlation of ankle-brachial index and peripheral artery disease with the status of body fat deposition and metabolic syndrome in asymptomatic premenopausal women

INTRODUCTION

Asymptomatic peripheral artery disease (PAD) in symptom-free subjects, and people with the metabolic syndrome (MetS) is a significant correlate of cardiovascular morbidity and mortality. However, little is known about their relationship and whether this is mediated through central obesity as one of the defining components of the MetS.

MATERIALS AND METHODS

In a cross-sectional setting, 150 asymptomatic healthy premenopausal women without previously diagnosed hypertension, diabetes or known history cardiovascular diseases were consecutively enrolled. Ankle-brachial index (ABI), various parameters of general and central body fat distribution, and MetS were assessed.

RESULTS

The prevalence rates for asymptomatic PAD and MetS within the study population were calculated at 6% and 44%, respectively. Following the rigorous adjustment made by the components of MetS and clincial variables of age and serum low-density lipoprotein cholesterols (LDL-C), several indicators of general and central body fat distribution, including total, truncal and visceral body fats were found to have significantly positive correlations with log-ABI values. Moreover, log-ABI was significantly and negatively associated with the presence of MetS in both crude and multivariate models of logistic regression analysis, as adjusted by age, LDL-C and several indices of general and central fat deposition (OR [95% CI]: 0.016 [0.001 to 0.424], P value=0.013 in the multivariate adjusted model).

CONCLUSION

ABI had positive and negative associations with central obesity and MetS, respectively. Our findings strongly suggest the inverse correlation between ABI and the MetS is likely not mediated through central obesity as one the key components of MetS.

Correlations between geriatric nutritional risk index and peripheral artery disease in elderly coronary artery disease patients

AIM

Malnutrition is associated with the development of atherosclerosis and an increased risk of cardiovascular mortality in elderly patients. The present study aimed to investigate the association between the Geriatric Nutritional Risk Index (GNRI), a simple nutritional assessment tool, and the prevalence of peripheral artery disease (PAD) in elderly coronary artery disease patients.

METHODS

We evaluated 228 elderly coronary artery disease patients (mean age 74.0 ± 5.7 years). Ankle-brachial index (ABI) measurements were routinely carried out to investigate the prevalence of lower extremity PAD. Patients showing ABI <0.9 were defined as having PAD.

RESULTS

Based on our findings, 20.6% of the study patients had PAD. The median GNRI values were significantly lower in patients with PAD than those in patients without PAD (93.8 vs 100.0, P < 0.001). Even after multivariate adjustment, GNRI values were independently associated with PAD (odds ratio 0.94; 95% confidence interval 0.89-0.99; P = 0.024). Furthermore, patients with low GNRI and high C-reactive protein levels had a 5.5-fold higher risk of having PAD than those with high GNRI and low C-reactive protein levels.

CONCLUSIONS

GNRI values showed a strong relationship with PAD in elderly coronary artery disease patients. These data reinforce the utility of GNRI as a screening tool in clinical practice. Geriatr Gerontol Int 2017; 17: 1057-1062.

The Prognostic Value of Peripheral Artery Disease in Heart Failure: Insights from a Meta-analysis

BACKGROUND

Peripheral artery disease (PAD) is prevalent in individuals with heart failure (HF). We therefore performed a meta-analysis to assess the prognostic impact of PAD in HF patients.

METHODS

A systematic search of PubMed and The Cochrane Library was conducted to identify publications from inception to May 2015. We also manually assessed the reference lists of relevant literature for more eligible citations. Only studies reporting the risk of PAD for prognostic endpoints in HF were included in our meta-analysis.

RESULTS

The search strategy yielded eight studies comprising a total of 20,968 subjects, of whom 19.4% had a concurrent PAD. All-cause mortality in HF patients with PAD was profoundly higher than in those without this comorbidity (hazard ratio [HR] 1.36, 95% confidence interval [CI] 1.25 to 1.49). Peripheral artery disease was also associated with significant increases in HF hospitalisation and cardiovascular mortality in individuals with HF (HR 1.15, 95% CI 1.01 to 1.32; HR 1.31, 95% CI 1.13 to 1.52, respectively). Subgroup and sensitivity analyses supported the positive relationship between PAD and HF.

CONCLUSIONS

Peripheral artery disease is associated with a worse overall prognosis in HF patients, which highlights the need to increase focus on PAD as an important comorbidity in patients with HF.

Distribution of Ankle-Brachial Index among Inpatients with Cardiovascular Disease: Analysis Using the Kumamoto University Hospital Medical Database

OBJECTIVE

To describe the distribution of ankle-brachial index (ABI) among Japanese cardiovascular inpatients and to explore risk factors of peripheral arterial disease (PAD) associated with ABI ≤0.9.

MATERIALS AND METHODS

This study was a retrospective analysis using clinical record databases of patients with cardiovascular disease admitted to the Department of Cardiovascular Medicine, Kumamoto University Hospital between 2007 and 2014.

RESULTS

Of 3639 patients included in the analysis, male patients accounted for 62.1% and the mean age of patients was 66.1 years. Ischemic heart disease (IHD) was observed in 49.1%. ABI ≤0.9 was observed in 11.3% of all patients, 14.1% in the IHD group and 8.5% in the non-IHD group. Age of ≥65 years (odds ratio [OR]: 2.93, 95% confidence interval [CI]: 2.22-3.86), current smoking (OR: 2.28, 95%CI:1.71-3.04), diabetes (OR: 2.15, 95%CI:1.71-2.71), hypertension (OR: 1.42, 95%CI:1.12-1.81) and chronic kidney disease (OR: 2.52, 95%CI:1.82-3.48) were significantly associated factors with ABI ≤0.9.

CONCLUSIONS

This study suggests that PAD is prevalent even in patients without IHD. Active management of risk factors, early detection of PAD based on ABI, and therapeutic intervention could be effective in preventing future cardiovascular events or death.

Comparative Efficacy and Safety of Different Antiplatelet Agents for Prevention of Major Cardiovascular Events and Leg Amputations in Patients with Peripheral Arterial Disease: A Systematic Review and Network Meta-Analysis

There is a lack of consensus regarding which type of antiplatelet agent should be used in patients with peripheral arterial disease (PAD) and little is known on the advantages and disadvantages of dual antiplatelet therapy. We conducted a systematic review and network meta-analysis of available randomized controlled trials (RCT) comparing different antiplatelet drugs (Aspirin, Ticlopidine, Clopidogrel, Ticagrelor, Cilostazol, Picotamide and Vorapaxar as monotherapies or in combination with aspirin) in PAD patients (PROSPERO public database; CRD42014010299).We collated evidence from previous relevant meta-analyses and searched online databases. Primary efficacy endpoints were: (1) the composite rate of major adverse cardiovascular events (MACE; including vascular deaths, non-fatal myocardial infarction and non-fatal stroke), and (2) the rate of major leg amputations. The primary safety endpoint was the rate of severe bleeding events. Bayesian models were employed for multiple treatment comparisons and risk-stratified hierarchies of comparative efficacy were produced to aid medical decision making. Number-Needed-to-Treat (NNT) and Number-Needed-to-Harm (NNH) are reported in case of significant results. We analyzed 49 RCTs comprising 34,518 patients with 88,358 person-years of follow-up with placebo as reference treatment. Aspirin, Cilostazol, Vorapaxar and Picotamide were ineffective in reducing MACE. A significant MACE reduction was noted with Ticagrelor plus aspirin (RR: 0.67; 95%CrI: 0.46-0.96, NNT = 66), Clopidogrel (RR: 0.72; 95%CrI: 0.58-0.91, NNT = 80), Ticlopidine (RR: 0.75; 95%CrI: 0.58-0.96, NNT = 87), and Clopidogrel plus aspirin (RR: 0.78; 95%CrI: 0.61-0.99, NNT = 98). Dual antiplatelet therapy with Clopidogrel plus aspirin significantly reduced major amputations following leg revascularization (RR: 0.68; 95%CrI: 0.46-0.99 compared to aspirin, NNT = 94). The risk of severe bleeding was significantly higher with Ticlopidine (RR: 5.03; 95%CrI: 1.23-39.6, NNH = 25), Vorapaxar (RR: 1.80; 95%CrI: 1.22-2.69, NNH = 130), and Clopidogrel plus aspirin (RR: 1.48; 95%CrI: 1.05-2.10, NNH = 215). Clopidogrel monotherapy showed the most favourable benefit-harm profile (79% cumulative rank probability best and 77% cumulative rank probability safest). In conclusion, Clopidogrel should be the indicated antiplatelet agent in PAD patients. Dual antiplatelet therapy with aspirin and Clopidogrel can reduce the rate of major leg amputations following revascularization, but carries a slightly higher risk of severe bleeding.

Co-existence of carotid artery disease, renal artery stenosis, and lower extremity peripheral arterial disease in patients with coronary artery disease

In atherosclerosis, carotid artery stenosis (CAS), renal artery stenosis (RAS), lower extremity peripheral arterial disease (PAD), and coronary artery disease (CAD) are common pathologic lesions; their interrelationship is, however, unclear. We studied concomitant multiple atherosclerotic lesions in patients with CAD to understand their prevalence and relations. A cross-sectional analysis was performed on data from consecutive patients who underwent nonemergent coronary angiography. Simultaneous carotid and renal artery Doppler studies and ankle-brachial systolic pressure measurements were reviewed to diagnose concomitant lesions and their severity. The study included 1,734 patients (aged 71 ± 9 years; 70% men), with prevalences of CAS, RAS, lower extremity PAD, and CAD of 6%, 7%, 13%, and 72%, respectively. In patients with CAD (n = 1,253), the prevalences of CAS, RAS, and lower extremity PAD were 7%, 9%, and 16%, respectively; 24% CAD patients had ≥1 additional atherosclerotic lesion. Significant interactions among the prevalences of these lesions were found. In addition, the extent of CAD and the prevalences of CAS, RAS, and lower extremity PAD were significantly correlated. Multivariate analysis supported these relationships. In conclusion, the prevalences of CAS, RAS, lower extremity PAD, and CAD were strongly interrelated in the study population; CAD severity was related to that of other atherosclerotic lesions. Additional systematic screening of other concomitant atherosclerotic lesions is recommended, especially in CAD patients having multivessel disease, left main disease, and/or already diagnosed with other concomitant atherosclerotic lesions.

The impact of polyvascular disease on long-term outcome in percutaneous coronary intervention patients

BACKGROUND

Previous studies demonstrated the prognostic importance of concomitant polyvascular disease in patients with coronary artery disease (CAD). However, the significance of the number of diseased vascular territories and subclinical disease is unknown.

MATERIALS AND METHODS

The number of diseased vascular territories was evaluated in 2299 percutaneous coronary intervention (PCI) patients. Vascular disease was defined by documented atherosclerotic disease, either diagnosed in the medical history (clinical) or at the standardized cardiovascular screening (subclinical). The following territories were evaluated: cerebrovascular disease, peripheral arterial disease, abdominal aortic aneurysm and vascular renal disease. The outcome measures were all-cause mortality, cardiovascular mortality and a composite cardiovascular endpoint (myocardial infarction, stroke, cardiovascular mortality). Patients with monovascular disease (CAD) served as the reference category. Hazard ratios (HRs) were adjusted for baseline characteristics.

RESULTS

Mean follow-up was 7.3 years. The HRs (95% confidence interval) for patients with two diseased territories compared to monovascular disease were for all-cause mortality 1.60 (1.14-2.25), cardiovascular mortality 2.13 (1.29-3.50) and the combined cardiovascular endpoint 1.66 (1.20-2.31). Moreover, the HRs (95% confidence intervals) for patients with more than two diseased territories compared to monovascular disease were for all-cause mortality 3.81 (2.45-5.92), cardiovascular mortality 4.40 (2.32-8.35) and the combined cardiovascular endpoint 2.75 (1.69-4.47). The HRs of patients with subclinical disease were comparable to the HRs of patients with clinical disease.

CONCLUSIONS

In patients undergoing PCI, the presence of subclinical and clinical polyvascular disease is associated with an increased long-term mortality and morbidity. Moreover, the outcome is highly influenced by the number of diseased territories.

The value of routine screening for peripheral arterial disease in stable outpatients with a history of coronary artery or cerebrovascular disease

BACKGROUND

Frequently unrecognised, PAD is associated with reduced quality of life and an increased mortality rate because of a greater propensity for fatal ischaemic events. PAD commonly coexists with coronary and cerebrovascular disease and is associated with poorer outcomes in such patients. The Edinburgh Claudication Questionnaire (ECQ) and the ankle-brachial index (ABI) are screening methods to identify the presence of PAD. This study used these methods to estimate the rate of previously undiagnosed PAD and to validate the ECQ against ABI in a Canadian outpatient population with manifest cerebrovascular or coronary disease.

METHODS

At a regular office visit, patients completed the ECQ and were categorised as ECQ(+) or ECQ(-). All ECQ(+) and a randomly selected 25% of ECQ(-) patients were referred for ABI measurement. An ABI < 0.9 was considered positive. The prevalence of PAD in the patient population and the sensitivity and specificity of the ECQ score against the ABI were assessed.

RESULTS

Of 2235 patients enrolled, 815 were selected for an ABI [ECQ(-), n = 478; ECQ(+), n = 337]. Extrapolated PAD prevalence in the total population was 12.3% (highest arterial pressure [HAP] method) and 20.8% (lowest arterial pressure [LAP] method), with a significantly higher prevalence found in diabetic patients than non-diabetic patients (p < 0.0001). Because ECQ is only a measure of symptomatic disease, it had poor sensitivity (35.3% and 25.8%), but high specificity (88.2% and 88.3%) using the HAP and LAP methods of ABI measurement, respectively.

CONCLUSIONS

Undiagnosed PAD is common in stable outpatients with a prior history of manifest cardiovascular disease, particularly in those with diabetes. The ECQ does not possess the diagnostic value of the ABI in detecting PAD in this high-risk population, but may be useful to raise suspicion of PAD to be confirmed by ABI assessment.

Gastrointestinal complications after open heart surgery: incidence and determinants of risk factors

Acute mesenteric ischemia is a rare but serious complication of open heart surgery. Between January 2009 and January 2012, 1360 adult patients underwent open heart surgery with cardiopulmonary bypass at our institution; 29 patients presented gastrointestinal complications. Eight patients developed acute mesenteric ischemia and all of them died. Significant predictors of the complication were New York Heart Association functional class III/IV, history of extensive atherosclerosis and chronic renal failure, acute renal failure following surgery, low cardiac output, use of 2 or more vasoconstrictor drugs, prolonged mechanical ventilation, and multiorgan failure. Atherosclerosis is a multisystemic disease that affects several organs. Radiologic evaluation of mesenteric arterial system should be performed in high-risk patient populations. Perioperative percutaneous and open vascular procedures will reduce the risk of acute mesenteric ischemia that may develop after cardiac surgery and consequent morbidity and mortality rates.

A validated biomarker panel to identify peripheral artery disease

Current guidelines recommend obtaining an ankle-brachial index (ABI) to screen for peripheral artery disease (PAD) in subjects at risk. Previous work demonstrated that a combination of β(2)-microglobulin, cystatin C, high-sensitivity C-reactive protein and glucose was associated with PAD. This study evaluated the ability of these biomarkers combined with clinical parameters to predict PAD in at-risk subjects. This study enrolled 1025 subjects from 99 primary care clinics who were smokers and/or diabetics ≥ 50 years or any individual ≥ 70 years. Consented subjects underwent a clinical assessment, fasting blood draw, and an ABI measurement with PAD defined as an ABI < 0.90 in either leg. The biomarkers and their interactions were evaluated using logistic regression and performance was evaluated at a cut point of the biomarker panel selected to maximize sensitivity while minimizing the false positive rate of the test. Of the 1025 subjects enrolled, 46 did not meet the ABI or other criteria for inclusion in the analysis. Among the evaluable subjects (n = 979), PAD was detected in 83 (8.5%). The model had a C-statistic of 0.73 (95% CI 0.67-0.79). There were 20 patients with PAD who were judged to be at low to moderate risk for cardiovascular events by clinical assessment; the model correctly identified 17 of these 20 patients. The model also performed well in subjects with no prior history of PAD. Thus, a biomarker panel may have a role for identifying PAD.

Percutaneous panvascular intervention in an unusual case of extensive atherosclerotic disease

It is common to see patients with atherosclerotic coronary disease and peripheral arterial disease in routine clinical practice. One needs to have a comprehensive and integrated multi-speciality approach and panvascular revascularization in such patients. We report a 54-year-old diabetic hypertensive male with extensive atherosclerotic coronary and peripheral arterial disease, who presented with congestive heart failure, claudication of both lower limbs and mesenteric ischemia. He underwent successful percutaneous panvascular revascularization of coronary, renal, mesenteric, aorto-iliac and superficial femoral arteries. Long-term patency of all the stents was also documented.

Internal Medicine Interns Have a Poor Knowledge of Peripheral Artery Disease

Peripheral arterial disease (PAD) is common and carries an increased risk of morbidity and mortality. The level of knowledge among incoming medical trainees about PAD is unknown. During orientation to a single internal medicine residency program, incoming medical interns were given a 19-question multiple-choice questionnaire. The questions fell into 1 of 4 categories about PAD: (1) prevalence, (2) screening, (3) treatment, and (4) outcome. Sixty-two incoming interns were queried. The percentage of questions answered correctly overall was 41.7% (10.5%-73.7%). The percentage of questions answered correctly in the prevalence, screening, treatment, and outcome groups were 48.9% (0 to 100%), 33.8% (0 to 80%), 45.0% (0 to 87.5%), and 42.5% (0 to 100%), respectively. Internal medicine interns have poor knowledge about PAD including its prevalence, screening, treatment, and outcomes. Increased education during medical school is encouraged.

The relationship of peripheral arterial disease and metabolic syndrome prevalence in asymptomatic US adults 40 years and older: results from the National Health and Nutrition Examination Survey (1999-2004)

Peripheral arterial disease (PAD) is a subclinical marker of coronary artery disease and identifies asymptomatic individuals at high risk for cardiovascular disease (CVD) events. The metabolic syndrome (MetS) is a constellation of clinical factors that increases the risk of developing diabetes and CVD. The authors' objectives were to estimate the prevalence of MetS in patients with PAD and to determine the prevalence of PAD in the population of asymptomatic US adults 40 years and older with MetS. The authors analyzed data from 3 National Health and Nutrition Examination Surveys (NHANES, 1999-2004). Prevalence of MetS as defined by the Third Report of the Adult Treatment Panel criteria and prevalence of associated cardiac risk factors were determined in 5376 asymptomatic participants 40 years and older. Presence of PAD was defined as ankle-brachial index <0.9. Estimates were weighted with the sample weights accounting for the unequal selection probability of complex NHANES sampling and over sampling of selected population subgroups. Prevalence of PAD in asymptomatic US adults 40 years and older was 4.2%. PAD prevalence in persons with MetS was 7.0% compared with 3.3% in persons without MetS. A total of 38% of the population with PAD also had MetS. High rates of abdominal obesity, hypertension, hyperglycemia, and low high-density lipoprotein cholesterol are significant contributors to both MetS and PAD. Persons with MetS have twice the risk of having PAD. Of persons with PAD, almost 40% have MetS. The presence of either PAD or MetS should warrant screening for both conditions so that risk stratification and management of risk factors may be performed.

Echocardiographic evaluation of aorto-iliac occlusive disease

Several studies demonstrated feasibility of visual assessment of the common femoral artery Doppler waveform, in an indirect evaluation of aorto-iliac segment stenosis. Patients with cardiac diseases referred for echocardiography often have coexistent arterial pathology. Since many of them are potential candidates for endovascular procedures, we decided to study, whether echocardiography can be useful for detection of aorto-iliac occlusive disease. We evaluated 92 patients with abdominal aortic aneurysm or peripheral artery occlusive disease, referred from the vascular surgery department for cardiac evaluation before surgery. At the end of an echocardiographic examination, evaluation of flow in the distal external iliac arteries with an echocardiographic probe was performed. The Doppler waveform was classified into normal—with early diastolic flow reversal or abnormal—without early diastolic flow reversal. Echocardiographic results were compared in a blinded fashion with reports from computed tomography angiography. Overall there were 58 iliac segments with significant (≥70%) area stenosis or occlusion and 126 iliac segments without significant disease on computed tomography angiography. Abnormal Doppler waveform was found in 56 out of 58 abnormal iliac segments—sensitivity 97%, and normal waveform was found in 106 out of 126 normal iliac segments—specificity 84%. Positive predictive value of abnormal Doppler waveform for significant iliac disease was 74%, and negative predicting value was 98%. Detection of significant stenoses in aorto-iliac segments is feasible with echocardiography. Further studies are necessary to evaluate its potential utility in a population of patients with cardiac disease referred for echocardiographic study.

Sex differences in the prevalence of peripheral artery disease in patients undergoing coronary catheterization

To determine whether there are sex differences in the prevalence of peripheral artery disease, we performed an observational study of 1014 men and 547 women, aged ≥ 40 years, referred for elective coronary angiography. Women were slightly older, more obese, had higher low-density lipoprotein cholesterol (LDL-C) levels and systolic blood pressure (BP), and were more likely to be African American. Women had higher high-density lipoprotein cholesterol (HDL-C) levels, lower diastolic BP, and were less likely to smoke or to have a history of cardiovascular disease. Women had less prevalent (62% vs 81%) and less severe coronary artery disease (CAD) (p < 0.001 for both) by coronary angiography, but more prevalent peripheral artery disease (PAD) as determined by the ankle-brachial index (ABI) than men (23.6% versus 17.2%). Independent predictors of lower ABI were female sex, black race, older age, tobacco use, CAD, diabetes, and triglyceride level. In a full multivariable logistic regression model, women had a risk-adjusted odds ratio for PAD of 1.78 (95% CI 1.25-2.54) relative to men. Among patients referred for coronary angiography, women have less prevalent and less severe CAD, but more prevalent PAD, a sex difference that is not explained by traditional cardiovascular disease risk factors or CAD severity. Clinical Trial Registration-URL: http://clinicaltrials.gov. Unique identifier: NCT00380185.

Prognosis and management of patients with acute coronary syndrome and polyvascular disease

INTRODUCTION AND OBJECTIVES

To assess prognosis and patterns of care in patients with acute coronary syndrome and peripheral arterial disease (PAD), cerebrovascular disease or both (i.e., polyvascular disease) in everyday clinical practice.

METHODS

We used data from the MASCARA acute coronary syndrome registry for 2004 and 2005. Patients were stratified according to the presence of PAD, cerebrovascular disease, neither, or both. In-hospital management, treatment at discharge and outcomes at 6 months were recorded.

RESULTS

Of 6745 patients, 597 (8.85%) had PAD, 392 (5.8%) had cerebrovascular disease, 131 (1.94%) had both and 5625 (83.4%) had neither. Patients with polyvascular disease had more extensive coronary disease, but less often received regularly recommended treatment (e.g., 75% with PAD received aspirin at discharge versus 84% of those without). In-hospital and 6-month mortality were significantly higher (P< .001) in patients with PAD (9.1% and 24.5%, respectively) or cerebrovascular disease (9.2% and 22.4%, respectively) or, especially, both (16.0% and 29.8%, respectively) than in those free from these conditions (4.8% and 10.8%, respectively). Cerebrovascular disease, PAD and their combination were all independently associated with in-hospital and 6-month mortality: for cerebrovascular disease, the odds ratio (OR) for mortality at 6 months was 1.45 (95% confidence interval [CI], 1.10-2.02); for PAD, it was 1.88 (95% CI, 1.45-2.40); and for both combined, 1.88 (95% CI, 1.17-3.00).

CONCLUSIONS

Patients with acute coronary syndrome and concomitant arterial disease had more extensive coronary artery disease and poorer outcomes, both inhospital and at 6 months, but frequently did not receive regularly recommended treatment.

Three-dimensional T2-weighted MRI of the human femoral arterial vessel wall at 3.0 Tesla

OBJECTIVES

To evaluate the potential use of a novel 3D turbo spin-echo (TSE) T2-weighted (T2w) technique for assessing the vessel wall in the superficial femoral artery at 3.0 T.

BACKGROUND

Magnetic resonance imaging can be used for the noninvasive assessment of atherosclerotic plaque burden in the peripheral circulation. Although black-blood 2D TSE techniques have been used for femoral arterial wall imaging, these techniques require prolonged imaging time to cover a large field of view required to cover the leg. Recently, variable-flip-angle 3D TSE T2w (SPACE) has been introduced as a fast vessel wall imaging technique with submillimeter spatial resolution. A systematic investigation of the application of this technique to femoral arterial wall imaging has yet to be performed.

METHODS

Fifteen healthy volunteers and 3 patients with peripheral arterial disease (PAD) underwent 3D SPACE imaging of the superficial femoral artery at 3.0 T, with the conventional 2D TSE T2w imaging as a reference. Muscle-lumen contrast to noise ratio (CNR) and wall/lumen volumes (WV, LV) were measured at the matched locations on the 3D and 2D image sets. Statistical comparison on a per-subject basis was conducted to determine the difference and agreement between 3D SPACE and the 2D TSE techniques.

RESULTS

The 3D SPACE data sets enabled vessel visualization from arbitrary orientation through multiplanar reformation technique. Muscle-lumen CNR was significantly higher with 3D SPACE than with the 2D TSE (3.12 +/- 0.84 vs. 2.17 +/- 0.34, P < 0.01). This trend was confirmed when CNR efficiency (CNR(eff)) values were further compared. A similar trend was observed in PAD patients (SPACE vs. 2D TSE T2w: CNR 2.35 +/- 0.13 vs. 1.77 +/- 0.25; CNR(eff) 15.35 +/- 0.61 vs. 3.59 +/- 2.62. all P < 0.05). Measurements of WV and LV from the 3D and 2D techniques were highly correlated in volunteers and PAD patients (volunteers, WV: linear regression r2 = 0.98, LV: r2 = 0.98, P < 0.001 for both; patients, WV: linear regression r2 = 0.96, LV: r2 = 0.94, P < 0.001 for both).

CONCLUSION

We established the feasibility of using the 3D SPACE technique for vessel wall imaging in the superficial femoral artery at 3.0T. High, isotropic-resolution SPACE images, with the aid of multiplanar reformation, enable superior vessel wall visualization. Superior blood signal suppression comparable to vessel wall morphologic measurements, and superior time efficiency compared to conventional 2D TSE imaging indicate the great potential of the SPACE method as a noninvasive imaging technique for the assessment of atherosclerotic plaque burden in PAD patients.

Relationship of age and exercise performance in patients with heart failure: the HF-ACTION study

BACKGROUND

More than three fourths of patients with heart failure (HF) are 65 years and older, and older age is associated with worse symptoms and prognoses than is younger age. Reduced exercise capacity is a chief HF complaint and indicates poorer prognosis, especially among elderly persons, but the mechanisms underlying functional decline in older patients with HF are largely unknown.

METHODS

Baseline cardiopulmonary exercise testing data from the HF-ACTION trial were assessed to clarify age effects on peak oxygen consumption (VO(2)) and ventilation-carbon dioxide production (VE/VCO(2)) slope.

RESULTS

Among 2,331 New York Heart Association class II-IV patients with HF, increased age corresponded to decreased peak VO(2) (-0.14 mL kg(-1) min(-1) per year >40 years; P < .0001) and increased VE/VCO(2) slope (0.30 U/y >70 years; P < .0001). In a multivariable model with 34 other potential determinants, age was the strongest independent predictor of peak VO(2) (partial R(2) 0.130, total R(2) 0.392; P < .001) and a significant but relatively weaker predictor of VE/VCO(2) slope (partial R(2) 0.037, total R(2) 0.199; P < .001). Blunted peak heart rate was also a strong predictor of peak VO(2). Although peak heart rate and age were strongly correlated, both were significant independent predictors of peak VO(2) when analyzed simultaneously in a model. Aggregate comorbidity increased significantly with age but did not account for age effects on peak VO(2).

CONCLUSIONS

Age is the strongest predictor of peak VO(2) and a significant predictor of VE/VCO(2) slope in the HF-ACTION population. Age-dependent comorbidities do not explain changes in peak VO(2). Age-related changes in cardiovascular physiology, potentially magnified by the HF disease state, should be considered a contributor to the pathophysiology and a target for more effective therapy in older patients with HF.

The 9p21 myocardial infarction risk allele increases risk of peripheral artery disease in older people

BACKGROUND

A common variant at chromosome 9p21 (tagged by the rs1333049 or rs10757278 single-nucleotide polymorphism) is strongly associated with myocardial infarction and major arterial aneurysms. An association with peripheral arterial disease (PAD) was also reported in a sample younger than 75 years, but this disappeared on removal of respondents with a myocardial infarction history, resulting in an odds ratio of 1.09 for PAD (P=0.075). We aimed at estimating the association of this variant with an Ankle-Brachial Index (ABI) and PAD in 3 older populations.

METHODS AND RESULTS

We used data from the InCHIANTI, Baltimore Longitudinal Study of Aging, and Health, Aging, and Body Composition studies. In 2630 white individuals (mean age, 76.4 years), the C allele at rs1333049 was associated with lower mean ABI measures and with an increased prevalence of PAD. These associations remained after removal of baseline and incident myocardial infarction cases over a 6-year follow-up for both ABI (-0.017 ABI units; 95% CI, -0.03 to -0.01; P = 1.3 x 10(-4)) and PAD (per allele odds ratio, 1.29; 95% CI, 1.06 to 1.56; P = 0.012). These associations also remained after adjustment for known atherosclerosis risk factors, including diabetes mellitus, smoking, hypercholesterolemia, and hypertension.

CONCLUSIONS

The C allele at rs1333049 is associated with an increased prevalence of PAD and lower mean ABI. This association was independent of the presence of diagnosed myocardial infarction and atherosclerotic risk factors in 3 older white populations.