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Lower Extremity Artery Disease and Cognitive Impairment. Artery Res 2022. [DOI: 10.1007/s44200-021-00010-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract
Background
The association between cerebrovascular disease and cognitive impairment is well known, but the impact of lower extremity arterial disease (LEAD) on neuropsychological performance is less established.
Objectives
The aim of this study was to investigate the influence of LEAD on cognitive impairment.
Materials and Methods
A total of 20 patients with LEAD, classified by Fountain’s stage IIB, qualified for revascularization surgery has been included in this prospective study. Neuropsychological assessments have been done using MoCA and CANTAB test. Fifteen patients qualified for hernia surgery, without peripheral artery disease served as a control group. Linear regression model has been applied to assess the connection between LEAD and cognitive impairment.
Results
Differences between the study groups reach significance in both MoCA and CANTAB test. In MoCA test, patients with LEAD had lower levels of performance in attention (p = 0.0254), visuospatial/executive (p = 0.0343) and delayed recall (p = 0.0032). The mean MoCA score was below 26 points. In CANTAB test, patients with LEAD performed worse in visual memory and learning. After adjusted for common cerebrovascular risk factors, LEAD was significantly correlated with cognitive impairment defined as MoCA score < 26 points.
Conclusions
Lower extremity artery disease is associated with cognitive impairment independently of cerebrovascular risk factors.
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Leardini-Tristao M, Charles AL, Lejay A, Pizzimenti M, Meyer A, Estato V, Tibiriçá E, Andres E, Geny B. Beneficial Effect of Exercise on Cognitive Function during Peripheral Arterial Disease: Potential Involvement of Myokines and Microglial Anti-Inflammatory Phenotype Enhancement. J Clin Med 2019; 8:jcm8050653. [PMID: 31083472 PMCID: PMC6571759 DOI: 10.3390/jcm8050653] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/05/2019] [Accepted: 05/07/2019] [Indexed: 12/25/2022] Open
Abstract
Peripheral arterial disease (PAD), leading to intermittent claudication, critical ischemia with rest pain, and/or tissue damage, is a public health issue associated with significant morbidity and mortality. Little is known about the link between PAD, cognitive function, and whether exercise might reduce cognitive dysfunction in PAD patients, as previously observed concerning both quality of life and prognosis. This review highlights the fact that patients suffering from PAD often demonstrate cognitive dysfunction characterized by reduced performance in nonverbal reasoning, reduced verbal fluency, and decreased information processing speed and a greater risk for progression toward dementia. Further, the data presented support that physical exercise, likely through myokine secretion and microglial anti-inflammatory phenotype enhancement, might participate in the cognition protection in common clinical settings.
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Affiliation(s)
- Marina Leardini-Tristao
- Laboratório de Imunofarmacologia, Instituto Oswaldo Cruz, FIOCRUZ, Avenida Brasil 4365, 21040-360, Rio de Janeiro, Brazil.
| | - Anne-Laure Charles
- Université de Strasbourg, Fédération de médecine translationnelle de Strasbourg (FMTS), Faculté de Médecine, Equipe d'accueil 3072, 11 Rue Humann, 67000 Strasbourg, France.
| | - Anne Lejay
- Université de Strasbourg, Fédération de médecine translationnelle de Strasbourg (FMTS), Faculté de Médecine, Equipe d'accueil 3072, 11 Rue Humann, 67000 Strasbourg, France.
- Service de Chirurgie Cardiovasculaire, Pôle de Pathologie Cardiaque, Hôpitaux Universitaires, CHRU Strasbourg, 67000 CEDEX, France.
| | - Mégane Pizzimenti
- Université de Strasbourg, Fédération de médecine translationnelle de Strasbourg (FMTS), Faculté de Médecine, Equipe d'accueil 3072, 11 Rue Humann, 67000 Strasbourg, France.
| | - Alain Meyer
- Université de Strasbourg, Fédération de médecine translationnelle de Strasbourg (FMTS), Faculté de Médecine, Equipe d'accueil 3072, 11 Rue Humann, 67000 Strasbourg, France.
- Service de Physiologie et d'explorations Fonctionnelles, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, 1 place de l'Hôpital, 67091 Strasbourg CEDEX, France.
| | - Vanessa Estato
- Laboratório de Imunofarmacologia, Instituto Oswaldo Cruz, FIOCRUZ, Avenida Brasil 4365, 21040-360, Rio de Janeiro, Brazil.
| | - Eduardo Tibiriçá
- Instituto Nacional de Cardiologia, Ministério da Saúde, Rua das lanjeiras 374, 22240-006, Rio de Janeiro 22240-006, Brazil.
| | - Emmanuel Andres
- Service de Médecine Interne, Diabète et Maladies Métaboliques, Pôle M.I.R.N.E.D., Hôpitaux Universitaires, CHRU Strasbourg, 67000 CEDEX, France.
| | - Bernard Geny
- Université de Strasbourg, Fédération de médecine translationnelle de Strasbourg (FMTS), Faculté de Médecine, Equipe d'accueil 3072, 11 Rue Humann, 67000 Strasbourg, France.
- Service de Physiologie et d'explorations Fonctionnelles, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, 1 place de l'Hôpital, 67091 Strasbourg CEDEX, France.
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Kuzawa CW, Barrett TM, Borja JB, Lee NR, Aquino CT, Adair LS, McDade TW. Ankle brachial index (ABI) in a cohort of older women in the Philippines: Prevalence of peripheral artery disease and predictors of ABI. Am J Hum Biol 2019; 31:e23237. [PMID: 30950564 DOI: 10.1002/ajhb.23237] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/17/2019] [Accepted: 03/02/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Cardiovascular disease (CVD) is rising in low and middle-income countries, but studies of CVD epidemiology in such settings often focus on risk factors rather than measures of disease progression. Here we use the ankle brachial index (ABI) to assess the prevalence of peripheral artery disease (PAD) among older women living in Metropolitan Cebu, Philippines, and relationships between ABI and CVD risk factors and body composition. METHODS ABI was measured using the Doppler technique in 538 female participants in the 2015 Cebu Longitudinal Health and Nutrition Survey (mean age 58 years, range 47-78 years). ABI was related to a panel of CVD risk factors measured in 2005 and 2012, and to 2012 body composition measures. RESULTS The prevalence of PAD (1.8%) was among the lowest reported in any comparably-aged sample, and only 9.9% of participants had an ABI indicating borderline PAD risk. Smoking (P < 0.011) and use of CVD medications (P < 0.0001) predicted lower ABI (indicating higher PAD risk), which was also lower in relation to 2012 systolic blood pressure (P < 0.054). ABI was unrelated to other CVD risk factors. An apparent protective relationship between body mass index (BMI) and ABI, noted in previous studies, was found to be confounded by protective relationships between ABI and fat free mass, height, and grip strength (all P < 0.05). CONCLUSIONS The prevalence of PAD is low in Cebu Longitudinal Health and Nutrition Survey participants, and ABI was related to few CVD risk factors. Past reports of lower PAD risk in relation to BMI may reflect confounding by lean mass, which has protective relationships with ABI.
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Affiliation(s)
- Christopher W Kuzawa
- Department of Anthropology, Northwestern University, Evanston, Illinois.,Institute for Policy Research, Northwestern University, Evanston, Illinois
| | - Tyler M Barrett
- Department of Anthropology, Northwestern University, Evanston, Illinois
| | - Judith B Borja
- USC-Office of Population Studies Foundation, Inc., University of San Carlos, Cebu City, Philippines.,Department of Nutrition and Dietetics, University of San Carlos, Cebu City, Philippines
| | - Nanette R Lee
- USC-Office of Population Studies Foundation, Inc., University of San Carlos, Cebu City, Philippines.,Department of Anthropology, Sociology and History, University of San Carlos, Cebu City, Philippines
| | - Celine T Aquino
- Department of Medicine, Cebu Institute of Medicine, Cebu City, Philippines
| | - Linda S Adair
- Carolina Population Center and Department of Nutrition, University of North Carolina, Chapel Hill, North Carolina
| | - Thomas W McDade
- Department of Anthropology, Northwestern University, Evanston, Illinois.,Institute for Policy Research, Northwestern University, Evanston, Illinois
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A national study of the prevalence and risk factors associated with peripheral arterial disease from China: The China Hypertension Survey, 2012–2015. Int J Cardiol 2019; 275:165-170. [DOI: 10.1016/j.ijcard.2018.10.047] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/07/2018] [Accepted: 10/12/2018] [Indexed: 11/21/2022]
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Woo J, Yu BWM, Chan RSM, Leung J. Influence of Dietary Patterns and Inflammatory Markers on Atherosclerosis Using Ankle Brachial Index as a Surrogate. J Nutr Health Aging 2018; 22:619-626. [PMID: 29717763 DOI: 10.1007/s12603-018-1031-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To examine the influence of various dietary patterns on ankle-brachial index (ABI) as a surrogate of atherosclerosis, taking into account serum levels of C-reactive protein (CRP) and factors that predispose to inflammation and/or endothelial damage (homocysteine) or may be protective (tryptophan, vitamin D), as well as age, gender, and lifestyle risk factors. DESIGN Cross sectional analysis. SETTING Cohort of 4000 men and women aged 65 years living in the community in Hong Kong SAR China. MEASUREMENTS Interviewer administered questionnaire that includes dietary intake estimation by the food frequency records (from which various dietary patterns can be characterized), socioeconomic status, smoking habit, alcohol consumption, physical activity. Clinical measurements include body weight and height, and ankle-brachial index using hand-held Doppler machine. Laboratory measurements include assays of serum 25 hydroxyvitamin D, CRP, homocysteine, and tryptophan using LC/MC methods. RESULT Compared with the lowest quintile of vitamin D level, higher quintile was associated with lower prevalence of ABI <0.9 in women only after multiple adjustments of covariates. In men the low score group of the vegetables-fruits dietary pattern was associated with increased odds of having ABI<0.9 after adjusting for all covariates (OR=16.51 (95% CI: 2.21, 123.26)). Similar findings apply to the low score group in the MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay Diet) pattern (OR=2.6 (95% CI: 1.24, 5.42)). In women, ABI<0.9 was associated with low Dietary Quality Index (DQI) score (OR=2.05 (95% CI: 1.22, 3.43)), and low score group of snacks-drinks-milk products dietary pattern (OR=3.07 (95% CI: 1.05, 9.04)). No association was observed for the Mediterranean Dietary Pattern (MDS), Dietary Approaches to Stop Hypertension (DASH), Okinawan and "meat-fish" dietary patterns in either men or women. CONCLUSION We conclude that any dietary patterns emphasizing fruit and vegetable intake are associated with better vascular health using ABI as an indicator.
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Affiliation(s)
- J Woo
- Prof Jean Woo, Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, N.T., Hong Kong, Tel: 852-3505-3493, Fax: 852-2637-3852
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Desormais I, Aboyans V, Guerchet M, Ndamba-Bandzouzi B, Mbelesso P, Mohty D, Marin B, Dartigues JF, Preux PM, Lacroix P. Ankle-Brachial Index: An Ubiquitous Marker of Cognitive Impairment-The EPIDEMCA Study. Angiology 2017; 69:497-506. [PMID: 29096531 DOI: 10.1177/0003319717736608] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Epidemiological research on the implication of atherosclerosis in the development of cognitive impairment is lacking in low- and middle-income countries, where two-thirds of the individuals affected by dementia live. Individuals aged ≥65 years living in urban and rural areas of 2 countries in Central Africa were invited. Demographic, clinical, and biological data were collected, and the ankle-brachial index (ABI) was measured. Cognitive impairment was defined according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria. Among 1662 participants (age 72.9 years, 59.3% females), the prevalence of cognitive impairment was 13.6%, which is higher in individuals with ABI ≤ 0.90 and ABI ≥ 1.40 than those with 0.90 < ABI < 1.40 (20.1% and 17% vs 12%, P = .0024). Cognitive impairment was significantly associated with the factors such as age (odds ratio [OR]: 1.09; 95% confidence interval [CI]: 1.07-1.12, P < .0001), female gender (OR: 2.36, 95% CI: 1.59-3.49, P < .0001), smoking (OR: 1.54, 95% CI: 1.06-2.23, P = .0026), and low ABI (≤0.90; OR: 1.52, 95% CI: 1.03-2.25, P = .0359). The ABI, a ubiquitous marker of atherosclerosis, provides independent and incremental information on susceptibility to present with cognitive disorders.
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Affiliation(s)
- Ileana Desormais
- 1 INSERM UMR 1094, Tropical Neuroepidemiology, Limoges, France.,2 Department of Thoracic and Cardiovascular Surgery and Angiology, Dupuytren University Hospital, Limoges, France
| | - Victor Aboyans
- 1 INSERM UMR 1094, Tropical Neuroepidemiology, Limoges, France.,3 Department of Cardiology, Dupuytren University Hospital, Limoges, France
| | - Maëlenn Guerchet
- 1 INSERM UMR 1094, Tropical Neuroepidemiology, Limoges, France.,4 Department of Health Service and Population Research, Centre for Global Mental Health, Institute of Psychiatry, King's College London, London, United Kingdom
| | | | - Pascal Mbelesso
- 6 Department of Neurology, Amitié Hospital, Bangui, Central African Republic
| | - Dania Mohty
- 1 INSERM UMR 1094, Tropical Neuroepidemiology, Limoges, France.,3 Department of Cardiology, Dupuytren University Hospital, Limoges, France
| | - Benoît Marin
- 1 INSERM UMR 1094, Tropical Neuroepidemiology, Limoges, France.,7 Department of Medical Information and Evaluation, Clinical Research and Biostatistic Unit, Dupuytren University Hospital, Limoges, France
| | | | - Pierre-Marie Preux
- 1 INSERM UMR 1094, Tropical Neuroepidemiology, Limoges, France.,7 Department of Medical Information and Evaluation, Clinical Research and Biostatistic Unit, Dupuytren University Hospital, Limoges, France
| | - Philippe Lacroix
- 1 INSERM UMR 1094, Tropical Neuroepidemiology, Limoges, France.,2 Department of Thoracic and Cardiovascular Surgery and Angiology, Dupuytren University Hospital, Limoges, France
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Fowkes FGR, Aboyans V, Fowkes FJI, McDermott MM, Sampson UKA, Criqui MH. Peripheral artery disease: epidemiology and global perspectives. Nat Rev Cardiol 2016; 14:156-170. [PMID: 27853158 DOI: 10.1038/nrcardio.2016.179] [Citation(s) in RCA: 411] [Impact Index Per Article: 51.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Global populations are undergoing a major epidemiological transition in which the burden of atherosclerotic cardiovascular diseases is shifting rapidly from high-income to low-income and middle-income countries (LMICs). Peripheral artery disease (PAD) is no exception, so that greater focus is now required on the prevention and management of this disease in less-advantaged countries. In this Review, we examine the epidemiology of PAD and, where feasible, take a global perspective. However, the dearth of publications in LMICs means an unavoidable over-reliance on studies in high-income countries. Research to date suggests that PAD might affect a greater proportion of women than men in LMICs. Although factors such as poverty, industrialization, and infection might conceivably influence the development of PAD in such settings, the ageing of the population and increase in traditional cardiovascular risk factors, such as smoking, diabetes mellitus, and hypertension, are likely to be the main driving forces.
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Affiliation(s)
- F Gerry R Fowkes
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, 2 Avenue Martin Luther King, 87000 Limoges, France
| | - Freya J I Fowkes
- Centre for Population Health, Burnet Institute, 85 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Mary M McDermott
- Department of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine, 675 North Saint Clair, Chicago, Illinois 60611, USA
| | - Uchechukwu K A Sampson
- Center for Translational Research and Implementation Science, National Heart, Lung and Blood Institute, National Institutes of Health, 6705 Rockledge Drive, Bethesda, Maryland 20824, USA
| | - Michael H Criqui
- Department of Family Medicine and Public Health, University of California San Diego, 9500 Gilman Drive, La Jolla, California 92093, USA
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Woo J, Zheng Z, Leung J, Chan P. Prevalence of frailty and contributory factors in three Chinese populations with different socioeconomic and healthcare characteristics. BMC Geriatr 2015; 15:163. [PMID: 26652647 PMCID: PMC4675032 DOI: 10.1186/s12877-015-0160-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 11/27/2015] [Indexed: 11/13/2022] Open
Abstract
Background Frailty predicts dependence and mortality, and is an important health indicator for aging populations. Comparing frailty prevalence between populations of the same ethnicity but different socioeconomic, lifestyle, health and social care systems, and environmental characteristics would address the role of these factors in contributing to frailty. Methods We compare frailty prevalence and contributory factors across three Chinese populations: Beijing rural, Beijing urban, and Hong Kong (urban). Older people aged 65 years and above living in the community were invited to respond to a general health questionnaire covering demographic, socioeconomic, medical and drug histories, geriatric syndromes, assessment of physical and cognitive functioning, psychological wellbeing and nutritional status. Frailty is defined as an index calculated from multiple deficits > = 0.25 (FI). The ratio of FI/life expectancy at birth was used as an indicator of compression of morbidity. Risk factors and attributable fraction for frailty were compared across the three cohorts. Results The prevalence of frailty increases with age in all three cohorts, and was lower among rural compared with urban (Beijing and Hong Kong) populations. The highest FI/LE ratio was observed in the Beijing urban population, followed by Hong Kong, with the Beijing rural population having the lowest ratio. Risk factors for frailty were similar in all three populations. Those having the highest ORs were multi-morbidity (number of diseases > = 3), polypharmacy (number of drugs > = 4), age 85+, female gender, followed by low education level, and physical inactivity. For all three cohorts, age and multi-morbidity constitute the highest attributable fraction, and were highest in the Beijing rural cohort. A major difference between the Beijing and Hong Kong cohorts is the high AF from polypharmacy in Beijing and the ‘protective’ contribution of being married; and the effect of being a teetotaler in the Hong Kong cohort. Conclusions This comparison draws attention to the importance of frailty prevention for ageing populations.
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Affiliation(s)
- Jean Woo
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, 9/F, Lui Che Woo Clinical Sciences Building, Prince of Wales Hospital, Shatin, N. T, Hong Kong.
| | - Zheng Zheng
- Beijing Institute of Geriatrics, Beijing, China
| | - Jason Leung
- The Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Piu Chan
- Beijing Institute of Geriatrics, Beijing, China
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Hilal S, Saini M, Tan CS, Catindig JA, Dong YH, Leon LBS, Niessen WJ, Vrooman H, Wong TY, Chen C, Venketasubramanian N, Ikram MK. Ankle-brachial index, cognitive impairment and cerebrovascular disease in a Chinese population. Neuroepidemiology 2014; 42:131-8. [PMID: 24481144 DOI: 10.1159/000357372] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 11/14/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Previous studies have assessed the association between ankle-brachial index (ABI) and cognition, mainly using brief cognitive tests. We investigated whether ABI was associated with cognition independent of neuroimaging markers of cerebrovascular disease. METHODS Chinese subjects (n = 278, aged ≥60 years) were recruited from the ongoing Epidemiology of Dementia in Singapore (EDIS) Study. Ankle and brachial blood pressures were measured, and low ABI was defined as ≤0.9. A neuropsychological battery was utilized to determine cognition. Cognitive impairment no dementia (CIND) and dementia were diagnosed according to standard diagnostic criteria. Magnetic resonance imaging (MRI) was used to obtain semiquantitative and quantitative markers of cerebrovascular disease and atrophy. RESULTS A low ABI was related to the presence of intracranial stenosis (odds ratio, OR = 1.71; 95% confidence interval, CI: 1.13-2.59), but not with the presence of infarcts, microbleeds or grey matter, white matter and white matter lesion volumes. Furthermore, a low ABI was associated with poorer overall cognitive function and CIND-moderate/dementia (OR = 2.26; 95% CI: 1.11-4.59), independent of cardiovascular risk factors, and the MRI markers related to cerebrovascular disease and atrophy. CONCLUSION We found an association between a low ABI and cognitive impairment, independent of any MRI marker of cerebral small vessel disease or large artery atherosclerotic disease.
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Affiliation(s)
- Saima Hilal
- Department of Pharmacology, National University of Singapore, Singapore, Singapore
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Fowkes FGR, Rudan D, Rudan I, Aboyans V, Denenberg JO, McDermott MM, Norman PE, Sampson UKA, Williams LJ, Mensah GA, Criqui MH. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet 2013; 382:1329-40. [PMID: 23915883 DOI: 10.1016/s0140-6736(13)61249-0] [Citation(s) in RCA: 2257] [Impact Index Per Article: 205.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Lower extremity peripheral artery disease is the third leading cause of atherosclerotic cardiovascular morbidity, following coronary artery disease and stroke. This study provides the first comparison of the prevalence of peripheral artery disease between high-income countries (HIC) and low-income or middle-income countries (LMIC), establishes the primary risk factors for peripheral artery disease in these settings, and estimates the number of people living with peripheral artery disease regionally and globally. METHODS We did a systematic review of the literature on the prevalence of peripheral artery disease in which we searched for community-based studies since 1997 that defined peripheral artery disease as an ankle brachial index (ABI) lower than or equal to 0·90. We used epidemiological modelling to define age-specific and sex-specific prevalence rates in HIC and in LMIC and combined them with UN population numbers for 2000 and 2010 to estimate the global prevalence of peripheral artery disease. Within a subset of studies, we did meta-analyses of odds ratios (ORs) associated with 15 putative risk factors for peripheral artery disease to estimate their effect size in HIC and LMIC. We then used the risk factors to predict peripheral artery disease numbers in eight WHO regions (three HIC and five LMIC). FINDINGS 34 studies satisfied the inclusion criteria, 22 from HIC and 12 from LMIC, including 112,027 participants, of which 9347 had peripheral artery disease. Sex-specific prevalence rates increased with age and were broadly similar in HIC and LMIC and in men and women. The prevalence in HIC at age 45-49 years was 5·28% (95% CI 3·38-8·17%) in women and 5·41% (3·41-8·49%) in men, and at age 85-89 years, it was 18·38% (11·16-28·76%) in women and 18·83% (12·03-28·25%) in men. Prevalence in men was lower in LMIC than in HIC (2·89% [2·04-4·07%] at 45-49 years and 14·94% [9·58-22·56%] at 85-89 years). In LMIC, rates were higher in women than in men, especially at younger ages (6·31% [4·86-8·15%] of women aged 45-49 years). Smoking was an important risk factor in both HIC and LMIC, with meta-OR for current smoking of 2·72 (95% CI 2·39-3·09) in HIC and 1·42 (1·25-1·62) in LMIC, followed by diabetes (1·88 [1·66-2·14] vs 1·47 [1·29-1·68]), hypertension (1·55 [1·42-1·71] vs 1·36 [1·24-1·50]), and hypercholesterolaemia (1·19 [1·07-1·33] vs 1·14 [1·03-1·25]). Globally, 202 million people were living with peripheral artery disease in 2010, 69·7% of them in LMIC, including 54·8 million in southeast Asia and 45·9 million in the western Pacific Region. During the preceding decade the number of individuals with peripheral artery disease increased by 28·7% in LMIC and 13·1% in HIC. INTERPRETATION In the 21st century, peripheral artery disease has become a global problem. Governments, non-governmental organisations, and the private sector in LMIC need to address the social and economic consequences, and assess the best strategies for optimum treatment and prevention of this disease. FUNDING Peripheral Arterial Disease Research Coalition (Europe).
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Affiliation(s)
- F Gerald R Fowkes
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK.
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Sheng CS, Liu M, Zeng WF, Huang QF, Li Y, Wang JG. Four-Limb Blood Pressure as Predictors of Mortality in Elderly Chinese. Hypertension 2013; 61:1155-60. [PMID: 23569084 DOI: 10.1161/hypertensionaha.111.00969] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Chang-Sheng Sheng
- From the Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ming Liu
- From the Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wei-Fang Zeng
- From the Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Qi-Fang Huang
- From the Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yan Li
- From the Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ji-Guang Wang
- From the Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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13
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Kwok T, Leung J, Zhang YF, Bauer D, Ensrud KE, Barrett-Connor E, Leung PC. Does the use of ACE inhibitors or angiotensin receptor blockers affect bone loss in older men? Osteoporos Int 2012; 23:2159-67. [PMID: 22080379 PMCID: PMC3772278 DOI: 10.1007/s00198-011-1831-7] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 10/17/2011] [Indexed: 01/13/2023]
Abstract
UNLABELLED In a prospective cohort study of 5,995 older American men (MrOS), users of angiotensin-converting enzyme (ACE) inhibitors had a small but significant increase in bone loss at the hip over 4 years after adjustment for confounders. Use of angiotensin II AT1 receptor blockers (ARB) was not significantly associated with bone loss. INTRODUCTION Experimental evidence suggests that angiotensin II promotes bone loss by its effects on osteoblasts. It is therefore plausible that ACE inhibitor and ARB may reduce rates of bone loss. The objective of this study is to examine the independent effects of ACE inhibitor and ARB on bone loss in older men. METHODS Out of 5,995 American men (87.2%) aged ≥65 years, 5,229 were followed up for an average of 4.6 years in a prospective six-center cohort study-The Osteoporotic Fractures in Men Study (MrOS). Bone mineral densities (BMD) at total hip, femoral neck, and trochanter were measured by Hologic densitometer (QDR 4500) at baseline and year 4. RESULTS Out of 3,494 eligible subjects with complete data, 1,166 and 433 subjects reported use of ACE inhibitors and ARBs, respectively. When compared with nonusers, continuous use of ACE inhibitors was associated with a small (0.004 g/cm(2)) but significant increase in the average rate of BMD loss at total hip and trochanter over 4 years after adjustment for confounders. Use of ARB was not significantly associated with bone loss. CONCLUSION Use of ACE inhibitors but not ARB may marginally increase bone loss in older men.
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Affiliation(s)
- T. Kwok
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - J. Leung
- Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Y. F. Zhang
- The Affiliated Hospital of Nantong University, Nantong, China
| | | | | | | | - P. C. Leung
- Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, Hong Kong, Hong Kong
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Woo J, Tang NLS, Leung J, Kwok T. The Alu polymorphism of angiotensin I converting enzyme (ACE) and atherosclerosis, incident chronic diseases and mortality in an elderly Chinese population. J Nutr Health Aging 2012; 16:262-8. [PMID: 22456784 DOI: 10.1007/s12603-011-0123-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE We examined the contribution of ACE I/D polymorphism in a large Chinese population to four year change in ankle-brachial index (ABI), development of cardiovascular diseases and mortality in a prospective study adjusting for many confounding factors. METHOD Data are drawn from a longitudinal study of 4000 community-living men and women aged 65 years and over, for which detailed information regarding lifestyle, chronic diseases, body mass index (BMI), ABI measurements and ACE polymorphisms were documented at baseline. During the fifth year of follow up, incident cardiovascular diseases, ABI, and mortality were documented, and related to ACE genotype adjusting for age, smoking, alcohol, dietary intake, physical activity, body mass index, and use of ACE inhibitors. RESULTS Women with the D/D genotype had the greatest reduction in mean ABI after adjusting for confounding factors. D/D genotype was also more common among women who developed hypertension or myocardial infarction. However D/D genotype was associated with mortality only in men. CONCLUSION In a Chinese elderly population, ACE polymorphism may be considered "deleterious" to longevity, the D/D genotype being associated with mortality, the atherosclerotic process, hypertension and myocardial infarction. There are gender differences in the relationship between D/D genotype and cardiovascular diseases and mortality may not be mediated by the atherosclerotic process alone.
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Affiliation(s)
- J Woo
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong.
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15
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Zimmermann LJ, Ferrucci L, Kiang Liu, Lu Tian, Guralnik JM, Criqui MH, Yihua Liao, McDermott MM. Poorer clock draw test scores are associated with greater functional impairment in peripheral artery disease: the Walking and Leg Circulation Study II. Vasc Med 2011; 16:173-81. [PMID: 21636676 DOI: 10.1177/1358863x11407109] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We hypothesized that, in the absence of clinically recognized dementia, cognitive dysfunction measured by the clock draw test (CDT) is associated with greater functional impairment in men and women with peripheral artery disease (PAD). Participants were men and women aged 60 years and older with Mini-Mental Status Examination scores ≥ 24 with PAD (n = 335) and without PAD (n = 234). We evaluated the 6-minute walk test, 4-meter walking velocity at usual and fastest pace, the Short Physical Performance Battery (SPPB), and accelerometer-measured physical activity. CDTs were scored using the Shulman system as follows: Category 1 (worst): CDT score 0-2; Category 2: CDT score 3; Category 3 (best): CDT score 4-5. Results were adjusted for age, sex, race, education, ankle-brachial index (ABI), and comorbidities. In individuals with PAD, lower CDT scores were associated with slower 4-meter usual-paced walking velocity (Category 1: 0.78 meters/second; Category 2: 0.83 meters/second; Category 3: 0.86 meters/second; p-trend = 0.025) and lower physical activity (Category 1: 420 activity units; Category 2: 677 activity units; Category 3: 701 activity units; p-trend = 0.045). Poorer CDT scores were also associated with worse functional performance in individuals without PAD (usual and fast-paced walking velocity and SPPB, p-trend = 0.022, 0.043, and 0.031, respectively). In conclusion, cognitive impairment identified with CDT is independently associated with greater functional impairment in older, dementia-free individuals with and without PAD. Longitudinal studies are necessary to explore whether baseline CDT scores and changes in CDT scores over time can predict long-term decline in functional performance in individuals with and without PAD.
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Guerchet M, Aboyans V, Nubukpo P, Lacroix P, Clément JP, Preux PM. Ankle-brachial index as a marker of cognitive impairment and dementia in general population. A systematic review. Atherosclerosis 2011; 216:251-7. [DOI: 10.1016/j.atherosclerosis.2011.03.024] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 03/02/2011] [Accepted: 03/14/2011] [Indexed: 11/16/2022]
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Abstract
With increasing life expectancy in developed and developing countries, maintaining health and function in old age has become an important goal, including avoidance or optimal control of chronic diseases; maintenance or retarding the decline of physical and cognitive function; optimizing psychological health; and maintaining independent functioning in tasks related to self-care and societal interaction. This article discusses all of those, as well as other components of successful aging such as social network and socioeconomic status.
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Affiliation(s)
- Jean Woo
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
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Woo J, Tang NLS, Suen E, Leung J. Shorter Telomere Length is Associated With Greater Decrease in Ankle-Brachial Index in Elderly Chinese Women but not Men. Angiology 2010; 62:87-91. [DOI: 10.1177/0003319710371618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jean Woo
- Department of Medicine and Therapeutics, the Chinese
University of Hong Kong, Shatin, Hong Kong,
| | - Nelson L. S. Tang
- Department of Chemical Pathology, the Chinese University
of Hong Kong, Shatin, Hong Kong
| | - Eddie Suen
- Department of Medicine and Therapeutics, the Chinese
University of Hong Kong, Shatin, Hong Kong
| | - Jason Leung
- Jockey Club Centre for Osteoporosis Care and Control,
the Chinese University of Hong Kong, Shatin, Hong Kong
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Johnson W, Price JF, Rafnsson SB, Deary IJ, Fowkes FGR. Ankle--brachial index predicts level of, but not change in, cognitive function: the Edinburgh Artery Study at the 15-year follow-up. Vasc Med 2010; 15:91-7. [PMID: 20147579 DOI: 10.1177/1358863x09356321] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The ankle-brachial index (ABI), a marker of generalized atherosclerosis, is related to cognitive impairment in older adults. We investigated whether ABI is associated specifically with age-related cognitive decline. We measured ABI at recruitment and 5 and 12 years later in a sample of individuals aged 55-74 years. Cognition was measured in 717 of these participants 10 years after recruitment and 5 years later. It was found that ABI was associated with the level of cognitive function, even after adjustment for estimated premorbid function and concurrently measured anxiety and depression (standardized coefficient of 0.07), but this was attenuated by anxiety and depression. ABI was not associated with change in cognitive function. In conclusion, over long time periods, low ABI may be associated with reduced cognitive function in older adults, at least partly because the associated poor health creates anxiety and depression.
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Affiliation(s)
- Wendy Johnson
- Centre for Cognitive Ageing and Cognitive Epidemiology, Department of Psychology, University of Edinburgh, Edinburgh, UK.
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Woo J, Leung J, Sham A, Kwok T. Defining Sarcopenia in Terms of Risk of Physical Limitations: A 5-Year Follow-Up Study of 3,153 Chinese Men and Women. J Am Geriatr Soc 2009; 57:2224-31. [DOI: 10.1111/j.1532-5415.2009.02566.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Abstract
As a marker of generalized atherosclerosis, peripheral arterial disease (PAD) has implications not only for the affected lower extremity but also to overall cardiovascular health. It confers an increased risk of non-fatal and fatal vascular events which increases with the severity of the disease. Patient-based studies have shown that individuals with advanced PAD tend to perform poorly on cognitive tests compared to controls. In population studies, PAD is associated with an increased cognitive decline independently of previous cerebrovascular disease and cardiovascular risk factors. A low ankle-brachial index (ABI) may be an early predictor of cognitive decline and of potential value in identifying individuals at increased risk of cognitive impairment. In patients with PAD, secondary preventive measures directed at decreasing the long-term systemic vascular complications may also be important to the preservation of cognitive health. However, evidence suggests that PAD patients may be undertreated with regard to atherosclerotic risk factors, as demonstrated by an undue emphasis on symptom relief rather than essential risk factor reduction. More research needs to be carried out to determine the predictors of cognitive function in PAD patients, whether subtle cognitive disturbances are related to activities of daily living, including medical treatment compliance, and whether neuroprotective strategies and atherosclerotic risk factor control positively influence cognitive function in these high-risk patients.
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Affiliation(s)
- Snorri B Rafnsson
- Public Health Sciences Section, School of Clinical Sciences and Community Health, University of Edinburgh, Edinburgh, Scotland, UK.
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Woo J, Leung J, Wong S, Kwok T, Lee J, Lynn H. Development of a simple scoring tool in the primary care setting for prediction of recurrent falls in men and women aged 65 years and over living in the community. J Clin Nurs 2009; 18:1038-48. [DOI: 10.1111/j.1365-2702.2008.02591.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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De Haro J, Acin F, Medina FJ, Lopez-Quintana A, March JR. Relationship between the plasma concentration of C-reactive protein and severity of peripheral arterial disease. Clin Med Cardiol 2008; 3:1-7. [PMID: 20508761 PMCID: PMC2872580 DOI: 10.4137/cmc.s1062] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To determine whether the increase in plasma levels of C-Reactive Protein (CRP), a non-specific reactant in the acute-phase of systemic inflammation, is associated with clinical severity of peripheral arterial disease (PAD). METHODS AND RESULTS This is a cross-sectional study at a referral hospital center of institutional practice in Madrid, Spain. A stratified random sampling was done over a population of 3370 patients with symptomatic PAD from the outpatient vascular laboratory database in 2007 in the order of their clinical severity: the first group of patients with mild chronological clinical severity who did not require surgical revascularization, the second group consisted of patients with moderate clinical severity who had only undergone only one surgical revascularization procedure and the third group consisted of patients who were severely affected and had undergone two or more surgical revascularization procedures of the lower extremities in different areas or needed late re-interventions. The Neyman affixation was used to calculate the sample size with a fixed relative error of 0.1. A homogeneity analysis between groups and a unifactorial analysis of comparison of medians for CRP was done. The groups were homogeneous for age, smoking status, Arterial Hypertension HTA, diabetes mellitus, dyslipemia, homocysteinemia and specific markers of inflammation. In the unifactorial analysis of multiple comparisons of medians according to Scheffé, it was observed that the median values of CRP plasma levels were increased in association with higher clinical severity of PAD (3.81 mg/L [2.14-5.48] vs. 8.33 [4.38-9.19] vs. 12.83 [9.5-14.16]; p < 0.05) as a unique factor of tested ones. CONCLUSION Plasma levels of CRP are associated with not only the presence of atherosclerosis but also with its chronological clinical severity.
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Affiliation(s)
- Joaquin De Haro
- Department of Angiology and Vascular Surgery, Getafe University Hospital
| | - Francisco Acin
- Department of Angiology and Vascular Surgery, Getafe University Hospital
| | | | | | - Jose Ramon March
- Department of Angiology and Vascular Surgery, Getafe University Hospital
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Lutsey PL, Diez Roux AV, Jacobs DR, Burke GL, Harman J, Shea S, Folsom AR. Associations of acculturation and socioeconomic status with subclinical cardiovascular disease in the multi-ethnic study of atherosclerosis. Am J Public Health 2008; 98:1963-70. [PMID: 18511718 DOI: 10.2105/ajph.2007.123844] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES We assessed whether markers of acculturation (birthplace and number of US generations) and socioeconomic status (SES) are associated with markers of subclinical cardiovascular disease-carotid artery plaque, internal carotid intima-media thickness, and albuminuria-in 4 racial/ethnic groups. METHODS With data from the Multi-Ethnic Study of Atherosclerosis (n = 6716 participants aged 45-84 years) and race-specific binomial regression models, we computed prevalence ratios adjusted for demographics and traditional cardiovascular risk factors. RESULTS The adjusted US- to foreign-born prevalence ratio for carotid plaque was 1.20 (99% confidence interval [CI] = 0.97, 1.39) among Whites, 1.91 (99% CI = 0.94, 2.94) among Chinese, 1.62 (99% CI = 1.28, 2.06) among Blacks, and 1.23 (99% CI = 1.15, 1.31) among Hispanics. Greater carotid plaque prevalence was found among Whites, Blacks, and Hispanics with a greater number of generations with US residence (P < .001) and among Whites with less education and among Blacks with lower incomes. Similar associations were observed with intima-media thickness. There was also evidence of an inverse association between albuminuria and SES among Whites and Hispanics. CONCLUSIONS Greater US acculturation and lower SES were associated with a higher prevalence of carotid plaque and greater intima-media thickness but not with albuminuria. Maintenance of healthful habits among recent immigrants should be encouraged.
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Affiliation(s)
- Pamela L Lutsey
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN 55455, USA
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Abstract
Background—
Measurement of the ankle-to-brachial index (ABI) is a noninvasive test to assess peripheral arterial disease. A low ABI is a strong correlate of cardiovascular disease and subsequent mortality. Evidence indicates the existence of vascular components in the pathogenesis of dementia. Here, we examine the association of ABI with dementia and subtypes.
Methods and Results—
Data are from the Honolulu-Asia Aging Study (HAAS), a prospective community-based study of 3734 Japanese American men 71 to 93 years of age at baseline in 1991 to 1993. The analysis included 2588 men who were free of dementia at the first assessment, had an ABI measure, and were examined up to 2 more times for dementia between 1994 and 1999. The sample included 240 incident cases of dementia (144 of Alzheimer’s disease, 46 of vascular dementia, and 50 of dementia of other causes). Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated from Cox proportional-hazards models with age as the time scale after adjustment for education, year of birth, high blood pressure, body mass index, diabetes mellitus, cholesterol concentration, smoking status, alcohol consumption, and apolipoprotein E ε4 allele. A low ABI was associated with an increased risk of dementia and vascular dementia (HR, 1.66; 95% CI, 1.16 to 2.37; and HR, 2.25; 95% CI, 1.07 to 4.73, respectively). ABI was weakly associated with Alzheimer’s disease (HR, 1.57; 95% CI, 0.98 to 2.53), particularly in the apolipoprotein E ε4 carriers (HR, 1.43; 95% CI, 1.02 to 1.96).
Conclusions—
These results suggest that ABI, a measure of atherosclerosis, is associated with the incidence of total dementia, vascular dementia, and Alzheimer’s disease in carriers of the apolipoprotein E ε4 allele.
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Affiliation(s)
- Danielle Laurin
- From Laval University Geriatrics Research Unit, Centre de recherche du CHA, and Faculty of Pharmacy, Laval University, Quebec City, Quebec, Canada (D.L.); Pacific Health Research Institute and Kuakini Medical Center, Honolulu, Hawaii (K.H.M., L.R.W.); and Neuroepidemiology Section, Laboratory of Epidemiology, Demography, and Biometry, National Institute on Aging, National Institutes of Health, Bethesda, Md (L.J.L.)
| | - Kamal H. Masaki
- From Laval University Geriatrics Research Unit, Centre de recherche du CHA, and Faculty of Pharmacy, Laval University, Quebec City, Quebec, Canada (D.L.); Pacific Health Research Institute and Kuakini Medical Center, Honolulu, Hawaii (K.H.M., L.R.W.); and Neuroepidemiology Section, Laboratory of Epidemiology, Demography, and Biometry, National Institute on Aging, National Institutes of Health, Bethesda, Md (L.J.L.)
| | - Lon R. White
- From Laval University Geriatrics Research Unit, Centre de recherche du CHA, and Faculty of Pharmacy, Laval University, Quebec City, Quebec, Canada (D.L.); Pacific Health Research Institute and Kuakini Medical Center, Honolulu, Hawaii (K.H.M., L.R.W.); and Neuroepidemiology Section, Laboratory of Epidemiology, Demography, and Biometry, National Institute on Aging, National Institutes of Health, Bethesda, Md (L.J.L.)
| | - Lenore J. Launer
- From Laval University Geriatrics Research Unit, Centre de recherche du CHA, and Faculty of Pharmacy, Laval University, Quebec City, Quebec, Canada (D.L.); Pacific Health Research Institute and Kuakini Medical Center, Honolulu, Hawaii (K.H.M., L.R.W.); and Neuroepidemiology Section, Laboratory of Epidemiology, Demography, and Biometry, National Institute on Aging, National Institutes of Health, Bethesda, Md (L.J.L.)
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Physical activity and reducing the risk of cardiovascular morbidity and mortality in older men and women: Lessons learned in 2006. CURRENT CARDIOVASCULAR RISK REPORTS 2007. [DOI: 10.1007/s12170-007-0041-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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