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Golledge J. Update on the pathophysiology and medical treatment of peripheral artery disease. Nat Rev Cardiol 2022; 19:456-474. [PMID: 34997200 DOI: 10.1038/s41569-021-00663-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2021] [Indexed: 12/15/2022]
Abstract
Approximately 6% of adults worldwide have atherosclerosis and thrombosis of the lower limb arteries (peripheral artery disease (PAD)) and the prevalence is rising. PAD causes leg pain, impaired health-related quality of life, immobility, tissue loss and a high risk of major adverse events, including myocardial infarction, stroke, revascularization, amputation and death. In this Review, I describe the pathophysiology, presentation, outcome, preclinical research and medical management of PAD. Established treatments for PAD include antithrombotic drugs, such as aspirin and clopidogrel, and medications to treat dyslipidaemia, hypertension and diabetes mellitus. Randomized controlled trials have demonstrated that these treatments reduce the risk of major adverse events. The drug cilostazol, exercise therapy and revascularization are the current treatment options for the limb symptoms of PAD, but each has limitations. Novel therapies to promote collateral and new capillary growth and treat PAD-related myopathy are under investigation. Methods to improve the implementation of evidence-based medical management, novel drug therapies and rehabilitation programmes for PAD-related pain, functional impairment and ischaemic foot disease are important areas for future research.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia. .,The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia. .,The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia.
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Altes P, Perez P, Esteban C, Sánchez Muñoz-Torrero JF, Aguilar E, García-Díaz AM, Álvarez LR, Jiménez PE, Sahuquillo JC, Monreal M. Raised Fibrinogen Levels and Outcome in Outpatients With Peripheral Artery Disease. Angiology 2017; 69:507-512. [PMID: 29113452 DOI: 10.1177/0003319717739720] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The influence of raised fibrinogen levels on outcome in stable outpatients with peripheral arterial disease (PAD) has not been consistently investigated. We used data from the Factores de Riesgo y ENfermedad Arterial (FRENA) registry to compare ischemic events, major bleeding, and mortality in stable outpatients with PAD, according to their baseline plasma fibrinogen levels. Of 1363 outpatients with PAD recruited in FRENA, 558 (41%) had fibrinogen levels >450 mg/100 mL. Over 18 months, 43 patients presented with acute myocardial infarction, 37 had an ischemic stroke, 51 underwent limb amputation, 19 had major bleeding, and 90 died. Compared to patients with normal levels, those with raised fibrinogen levels had an over 2-fold higher rate of ischemic stroke (rate ratio [RR]: 2.30; 95% confidence interval [CI]: 1.19-4.59), limb amputation (RR: 2.58; 95% CI: 1.46-4.67), or death (RR: 2.27; 95% CI: 1.49-3.51) and an over 3-fold higher rate of major bleeding (RR: 3.90; 95% CI: 1.45-12.1). On multivariate analysis, patients with raised fibrinogen levels had an increased risk of developing subsequent ischemic events (hazard ratio [HR]: 1.61; 95% CI: 1.11-2.32) and major bleeding (HR: 3.42; 95% CI: 1.22-9.61). Stable outpatients with PAD and raised plasma fibrinogen levels had increased rates of subsequent ischemic events and major bleeding.
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Affiliation(s)
- Pere Altes
- 1 Department of Vascular Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Facultat de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Paulina Perez
- 1 Department of Vascular Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Facultat de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Carlos Esteban
- 1 Department of Vascular Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Facultat de Medicina, Universitat Autònoma de Barcelona, Spain
| | | | - Eduardo Aguilar
- 3 Department of Internal Medicine, Hospital de Alcañiz, Alcañiz, Teruel, Spain
| | | | - Lorenzo Ramón Álvarez
- 5 Department of Vascular Surgery, CST-Hospital de Terrassa, Terrassa, Barcelona, Spain
| | | | | | - Manuel Monreal
- 8 Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Facultat de Medicina, Universitat Autònoma de Barcelona, Spain
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Sigvant B, Lundin F, Wahlberg E. The Risk of Disease Progression in Peripheral Arterial Disease is Higher than Expected: A Meta-Analysis of Mortality and Disease Progression in Peripheral Arterial Disease. Eur J Vasc Endovasc Surg 2016; 51:395-403. [DOI: 10.1016/j.ejvs.2015.10.022] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
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Perez P, Esteban C, Caballero PEJ, Muñoz-Torrero JFS, Soria MTP, Aguilar E, Rodríguez LRÁ, Sahuquillo JC, Díaz AMG, Monreal M. Anemia and Outcome in Outpatients With Peripheral Artery Disease. Angiology 2015; 67:484-9. [DOI: 10.1177/0003319715599864] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The influence of anemia on outcome in stable outpatients with peripheral artery disease (PAD) has not been consistently investigated. We used data from the Factores de Riesgo y ENfermedad Arterial (FRENA) Registry to compare ischemic events and mortality rates in stable outpatients with symptomatic PAD and anemia. Of 1663 patients with PAD, 208 (12.5%) had anemia. Over 18 months, patients with anemia had a higher rate of myocardial infarction (MI; rate ratio [RR]: 2.10; 95% confidence interval [CI]: 1.04-3.99), limb amputation (RR: 2.98; 95%CI: 1.70-5.05), and higher mortality (RR: 3.58; 95%CI: 2.39-5.28) than those without anemia. The rates of ischemic stroke (RR: 0.75; 95%CI: 0.23-1.93) and major bleeding (RR: 0.93; 95%CI: 0.15-3.51) were similar. On multivariable analysis, anemia was associated with an increased risk to die (hazard ratio [HR]: 2.32; 95%CI: 1.53-3.50) but not to develop MI (HR: 1.49; 95%CI: 0.73-3.05) or to have limb amputation (HR: 1.49; 95%CI: 0.86-2.59). In stable outpatients with PAD, anemia was associated with increased mortality but not with an increased rate of subsequent ischemic events or major bleeding.
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Affiliation(s)
- Paulina Perez
- Department of Vascular Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Facultad de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Carlos Esteban
- Department of Vascular Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | | | | | - Eduardo Aguilar
- Department of Internal Medicine, Hospital de Alcañiz, Alcañiz, Teruel, Spain
| | | | | | | | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
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Perez P, Esteban C, Sauquillo JC, Yeste M, Manzano L, Mujal A, Jiménez Caballero PE, Aguilar E, Sánchez Muñoz-Torrero JF, Monreal M. Cilostazol and outcome in outpatients with peripheral artery disease. Thromb Res 2014; 134:331-5. [PMID: 24951338 DOI: 10.1016/j.thromres.2014.05.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 05/22/2014] [Accepted: 05/30/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cilostazol increases the walking distance in patients with intermittent claudication, but there is scarce evidence of any effect on the risk for subsequent ischemic events, bleeding or death. PATIENTS AND METHODS We used data from the FRENA Registry to compare the clinical outcome in stable outpatients with intermittent claudication, according to the use of cilostazol. RESULTS As of January 2013, 1,317 patients with intermittent claudication were recruited in FRENA, of whom 191 (14.5%) received cilostazol. Over a mean follow-up of 18months, 39 patients developed myocardial infarction, 23 ischemic stroke, 20 underwent limb amputation, 15 had major bleeding and 70 died. There were no significant differences in the rate of subsequent ischemic events, major bleeding or death between patients receiving or not receiving cilostazol. On multivariate analysis, the use of cilostazol had no influence on the risk for subsequent myocardial infarction (hazard ratio [HR]: 0.97; 95% CI: 0.33-20.8), ischemic stroke (HR: 1.46; 95% CI: 0.48-4.43), limb amputation (HR: 0.34; 95% CI: 0.04-20.6), major bleeding (HR: 1.52; 95% CI: 0.33-7.09) or death (HR: 0.90; 95% CI: 0.40-20.0). CONCLUSIONS In stable outpatients with intermittent claudication, the use of cilostazol was not associated with increased rates of subsequent ischemic events, major bleeding or death.
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Affiliation(s)
- Paulina Perez
- Department of Vascular Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Facultad de Medicina, Universitat Autónoma de Barcelona, Spain
| | - Carlos Esteban
- Department of Vascular Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | | | - Monserrat Yeste
- Department of Angiology and Vascular Surgery, Hospital de Terrassa, Terrassa, Barcelona, Spain
| | - Luis Manzano
- Department of Internal Medicine, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Abel Mujal
- Department of Internal Medicine, Hospital Universitari Parc Taulí Sabadell, Sabadell, Spain
| | | | - Eduardo Aguilar
- Department of Internal Medicine, Hospital de Alcañiz, Alcañiz, Teruel, Spain
| | | | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain.
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Sanclemente C, Yeste M, Suarez C, Coll R, Aguilar E, Sahuquillo JC, Lerma R, Monreal M. Predictors of outcome in stable outpatients with peripheral artery disease. Intern Emerg Med 2014; 9:69-77. [PMID: 23054402 DOI: 10.1007/s11739-012-0854-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 09/15/2012] [Indexed: 11/26/2022]
Abstract
Patients with peripheral artery disease (PAD) are at increased risk for subsequent ischemic events. We used data from the FRENA Registry to find predictors of subsequent myocardial infarction (MI), ischemic stroke, and limb amputation in stable outpatients with PAD. As of January 2012, 1,270 patients with PAD were recruited, of whom 1,042 (82 %) had Fontaine stage II; 113 (8.9 %) stage III; and 115 (9.1 %) stage IV. Over a mean follow-up of 14 months, 35 patients developed MI, 25 had stroke, 39 underwent limb amputation, and 91 died. Among patients with Fontaine stage II, the incidence of MI (2.09 events per 100 patient-years; 95 % CI 1.43-2.97) or stroke (0.93; 95 % CI 0.52-1.56) was similar to that of limb amputation (3.22; 95 % CI 2.37-4.29). On multivariate analysis, patients with diabetes [hazard ratio (HR) 2.09; 95 % CI 1.05-4.18], prior coronary disease (HR 5.35; 95 % CI 2.24-12.8), or atrial fibrillation (HR 3.11; 95 % CI 1.52-6.37) were at increased risk for MI; female (HR 2.94; 95 % CI 1.32-6.67), those with prior stroke (HR 5.21; 95 % CI 1.22-22.2) or atrial fibrillation (HR 3.37; 95 % CI 1.45-7.85) at increased risk for stroke; and female (HR 2.38; 95 % CI 1.23-4.55), those with diabetes (HR 3.50; 95 % CI 1.58-7.73) or advanced stages of PAD were at increased risk for limb amputation. Prior coronary artery disease, diabetes and atrial fibrillation predicted subsequent MI; female gender, prior stroke and atrial fibrillation predicted stroke; and female gender, diabetes, and advanced stages of PAD predicted limb amputation.
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Affiliation(s)
- Carmen Sanclemente
- Department of Internal Medicine, Hospital Universitari de Bellvitge, Barcelona, Spain
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Sossai P, Amenta F, Sponga B, Porcellati C. Observational study of hypertension and snoring in Northeastern Italy (Limana Hypertension Study). Clin Exp Hypertens 2013; 36:263-7. [PMID: 23865467 DOI: 10.3109/10641963.2013.810230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate through an observational study on volunteers some important cardiovascular disease risk factors such as hypertension and snoring in a population from Limana, a town of a subalpine zone of northeastern Italy. DESIGN Limana residents were informed by post and at a public meeting and then attended an outpatient clinic set up by the town of Limana for clinical history, measurement of blood pressure, weight and height. PATIENTS Of 202 subjects (94 men and 108 women), 92.6% of whom were residents of Limana, having a mean age of 59.7 years, which was significantly higher than the mean (44.7 years), took part in the study. RESULTS Only 32.3% of study subjects with hypertension had normal blood pressure values while 38.6% of the subjects without hypertension treatment, were hypertensive. We found no significant association between hypertension and smoking and there were significant associations between hypertension and age and hypertension and snoring. CONCLUSIONS Given the limitations of an observational study based on volunteer participation, nevertheless, our study presents some interesting results: (1) a low number of subjects with hypertension whose blood pressure is well controlled; (2) a significant number of "normal" subjects with high values of blood pressure; (3) no significant relationship between hypertension and smoking; (4) a significant relationship between subjects who snored and were hypertensive.
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Affiliation(s)
- Paolo Sossai
- Center of Clinical Research, School of Medicinal and Health Products Sciences, University of Camerino , Italy and
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Smoking cessation and outcome in stable outpatients with coronary, cerebrovascular, or peripheral artery disease. Eur J Prev Cardiol 2011; 20:486-95. [DOI: 10.1177/1741826711426090] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Garcia-Diaz AM, Marchena PJ, Toril J, Arnedo G, Muñoz-Torrero JFS, Yeste M, Aguilar E, Monreal M. Alcohol consumption and outcome in stable outpatients with peripheral artery disease. J Vasc Surg 2011; 54:1081-7. [DOI: 10.1016/j.jvs.2011.03.285] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 03/29/2011] [Accepted: 03/31/2011] [Indexed: 10/18/2022]
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Monreal M. Factores de riesgo de complicaciones vasculares en extremidades inferiores en pacientes diabéticos. Med Clin (Barc) 2011; 136:386-7. [DOI: 10.1016/j.medcli.2010.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 10/14/2010] [Indexed: 10/18/2022]
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Sun J, Buys N, Stewart D, Shum D, Farquhar L. Smoking in Australian university students and its association with socio‐demographic factors, stress, health status, coping strategies, and attitude. HEALTH EDUCATION 2011. [DOI: 10.1108/09654281111108535] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Camafort M, Alvarez-Rodríguez LR, Muñoz-Torrero JFS, Sahuquillo JC, López-Jiménez L, Coll R, Monreal M. Glucose control and outcome in patients with stable diabetes and previous coronary, cerebrovascular or peripheral artery disease. Findings from the FRENA Registry. Diabet Med 2011; 28:73-80. [PMID: 21166848 DOI: 10.1111/j.1464-5491.2010.03153.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIM The aim of this study was to address the controversy over the influence of intensive glucose control on the risk for cardiovascular events in patients with Type 2 diabetes. METHODS FRENA is an ongoing registry of stable outpatients with symptomatic coronary artery disease, cerebrovascular disease or peripheral artery disease. We compared the incidence of subsequent ischaemic events (myocardial infarction, stroke or critical limb ischaemia) in patients with Type 2 diabetes and mean HbA(1c) levels < 7.0% (< 53 mmol/mol) vs. those with HbA(1c) levels > 7.0% (> 53 mmol/mol). RESULTS Of 974 patients with Type 2 diabetes, 480 (49%) had mean HbA(1c) levels < 7% (< 53 mmol/mol). Over a mean follow-up of 14 months, 126 patients (13%) had subsequent ischaemic events: myocardial infarction (43), stroke (29) and critical limb ischaemia (64). The incidence of subsequent ischaemic events was significantly lower in patients with mean HbA(1c) levels < 7.0% (< 53 mmol/mol) than in those with HbA(1c) levels > 7.0% (> 53 mmol/mol) (8.6 vs. 14 per 100 patient-years; rate ratio 0.6; 95% CI 0.4-0.9). These differences persisted after adjusting for potential confounders. However, this better outcome was only found in patients presenting with coronary artery disease (rate ratio 0.4; 95% CI 0.2-0.8), not in those with cerebrovascular disease (rate ratio 0.9; 95% CI 0.4-2.0) or peripheral artery disease (rate ratio 0.8; 95% CI 0.5-1.3). Patients with mean HbA(1c) levels < 7.0% (< 53 mmol/mol) also had a lower mortality (rate ratio 0.6; 95% CI 0.3-0.99). CONCLUSIONS In secondary prevention, patients with diabetes and HbA(1c) levels < 7.0% (< 53 mmol/mol) had a lower incidence of subsequent ischaemic events and a lower mortality than those with HbA(1c) levels > 7.0% (> 53 mmol/mol). These differences appeared only in patients with coronary artery disease.
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Affiliation(s)
- M Camafort
- Department of Internal Medicine, Health Research Institute, Pere Virgili, Hospital Comarcal Mora d'Ebre, Tarragona, Spain
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Abstract
Berries are a good source of polyphenols, especially anthocyanins, micronutrients, and fiber. In epidemiological and clinical studies, these constituents have been associated with improved cardiovascular risk profiles. Human intervention studies using chokeberries, cranberries, blueberries, and strawberries (either fresh, or as juice, or freeze-dried), or purified anthocyanin extracts have demonstrated significant improvements in LDL oxidation, lipid peroxidation, total plasma antioxidant capacity, dyslipidemia, and glucose metabolism. Benefits were seen in healthy subjects and in those with existing metabolic risk factors. Underlying mechanisms for these beneficial effects are believed to include upregulation of endothelial nitric oxide synthase, decreased activities of carbohydrate digestive enzymes, decreased oxidative stress, and inhibition of inflammatory gene expression and foam cell formation. Though limited, these data support the recommendation of berries as an essential fruit group in a heart-healthy diet.
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Affiliation(s)
- Arpita Basu
- Department of Nutritional Sciences, Oklahoma State University (OSU), Stillwater, Oklahoma 74078-6141, USA.
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