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Košuta D, Hvala U, Fras Z, Jug B. Prognostic impact of optimal lifestyle advice and medical therapy in patients with peripheral arterial disease. VASA 2024; 53:39-44. [PMID: 38079164 DOI: 10.1024/0301-1526/a001106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Background: Secondary prevention remains under-implemented in patients with peripheral arterial disease (PAD). In the present study, we sought to assess the extent, the predictors and the prognostic impact of optimal lifestyle advice (OLA) and optimal medical therapy (OMT) given at discharge to patients with PAD undergoing invasive peripheral procedures. Patients and methods: We included consecutive patients with PAD undergoing invasive peripheral procedures, between 2012 and 2013. Data were obtained from a mandatory fill-in clinical pathway. The primary outcome was all-cause mortality, verified using the National Mortality Registry. Results: A total of 2014 participants were included (mean age 70±11 years, 38.1% women). OLA was given to 279 (14%), OMT to 1186 (59%) participants. Male gender and absence of chronic limb-threatening ischaemia were significant predictors of OLA and OMT. During the median follow-up of 729 days (interquartile range 645) 392 (19.5%) participants died giving an overall mortality rate of 97/1000 patient years. On multivariate analysis both OLA and OMT emerged as independent predictors of survival (HR for all-cause mortality: 0.59; 95% CI: 0.42-0.82, p 0.005 and HR: 0.41; 95% CI: 0.22-0.76, p 0.002). Conclusions: OLA and OMT are associated with better long-term prognosis in patients with PAD, however they are still under-implemented, suggesting a considerable potential for improvement, especially in women.
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Affiliation(s)
- Daniel Košuta
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Slovenia
| | - Urška Hvala
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Zlatko Fras
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Slovenia
| | - Borut Jug
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Slovenia
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Xu Y, Pong CY, Yap CJQ, Khoo V, Graves N, Chong TT, Tang TY, Chan SL. Understanding the use of evidence-based medical therapy in patients with peripheral artery disease: A qualitative study using the Tailored Implementation for Chronic Diseases Framework. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:651-659. [PMID: 38920158 DOI: 10.47102/annals-acadmedsg.2023146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction The global burden of peripheral artery disease (PAD) has been increasing. Guidelines for PAD recommend evidence-based medical therapy (EBMT) to reduce the risks of cardiovascular events and death but the implementation of this is highly variable. This study aimed to understand the current practices regarding EBMT prescription in PAD patients and the key barriers and facilitators for implementing PAD guidelines. Method A qualitative study was conducted in the largest tertiary hospital in Singapore from December 2021 to March 2023. The participants included healthcare professionals and in-patient pharmacists involved in the care of PAD patients, as well as patients with PAD who had undergone a lower limb angioplasty revascularisation procedure. Data were collected through in-depth, individual semi-structured interviews conducted face-to-face or remotely by a trained research assistant. Interviews were audio-recorded, transcribed and systematically coded using data management software NVivo 12.0. The Tailored Implementation for Chronic Diseases (TICD) framework was used to guide the interviews and analysis. Results Twelve healthcare professionals (4 junior consultants, 7 senior consultants, and 1 senior in-patient pharmacist) and 4 patients were recruited. Nine themes in 7 domains emerged. Only a small proportion of doctors were aware of the relevant guidelines, and the generalisability of guidelines to patients with complicated conditions was the doctors' main concern. Other barriers included cost, frequent referrals, lack of interprofessional collaboration, not being the patients' long-term care providers, short consultation time and patients' limited medication knowledge. Conclusion Findings from this study may inform strategies for improving healthcare professionals' adherence to guidelines and patients' medication adherence.
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Affiliation(s)
- Yingqi Xu
- Health Services Research Centre, Singapore Health Services, Singapore
| | - Candelyn Yu Pong
- Health Services Research Centre, Singapore Health Services, Singapore
| | - Charyl Jia Qi Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Vanessa Khoo
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Nicholas Graves
- Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Tjun Yip Tang
- The Vascular and Endovascular Clinic, Gleneagles Hospital, Singapore
| | - Sze Ling Chan
- Health Services Research Centre, Singapore Health Services, Singapore
- Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore
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Chan SL, Yap CJQ, Graves N, Chong TT, Tang TY. Suboptimal adherence to medical therapy in patients undergoing lower limb angioplasty in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:216-218. [PMID: 38904535 DOI: 10.47102/annals-acadmedsg.2022404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Affiliation(s)
- Sze Ling Chan
- Health Services Research Centre, SingHealth, Singapore
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Charyl Jia Qi Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Nicholas Graves
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Tjun Yip Tang
- The Vascular and Endovascular Clinic Pte Ltd, Gleneagles Hospital, Singapore
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Jagt VL, Hazenberg CEVB, Kapelle J, Cramer MJ, Visseren FLJ, Westerink J. Screen-detected abnormal ankle brachial index: A risk indicator for future cardiovascular morbidity and mortality in patients with manifest cardiovascular disease. PLoS One 2022; 17:e0265050. [PMID: 35271641 PMCID: PMC8912207 DOI: 10.1371/journal.pone.0265050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 02/22/2022] [Indexed: 01/04/2023] Open
Abstract
Objectives
The ankle brachial index (ABI) can be used to diagnose peripheral arterial disease (PAD). The clinical relevance of the ABI, especially in patients with known clinically manifest cardiovascular disease (CVD), is unknown. The authors set out to investigate the relationship between a screen-detected ABI and the risk for future cardiovascular morbidity and mortality in patients with clinically manifest CVD.
Design, materials and methods
Patients with clinically manifest CVD were selected from the UCC-SMART cohort (n = 8360) and divided into four groups: normal ABI (0.91–1.39), screen-detected low ABI ≤ 0.9, screen-detected high ABI ≥ 1.4, and patients with known PAD irrespective of their ABI. Adjusted Cox Proportional Hazard Ratios (HRs) for Major Adverse Cardiovascular Events (MACE), Major Adverse Limb Events (MALE), and all-cause mortality were calculated. In addition, stratified analyses for women and men and for the presence of diabetes were performed.
Results
During a median follow-up of 8.3 years (IQR 7.7) 1646 MACE, 601 MALE and 1958 all-cause mortalities were observed. Compared with normal ABI patients, patients with a screen-detected low ABI and patients with manifest PAD had a higher risk of MACE, MALE, and all-cause mortality with HRs of 1.9 (95% CI 1.6–2.2) for MACE, 7.6 (95% CI 5.7–10.1) for MALE, 1.7 (95% CI 1.5–2.0) for mortality and 1.3 (95% CI 1.2–1.5) for MACE, 13.8 (95% CI 11.1–17.1) for MALE, 1.7 (95% CI 1.5–1.9) for mortality, respectively. Screen-detected high ABI did not increase the risk of either MACE or MALE, however, was associated with lower risk of all-cause mortality with a HR of 0.6 (95% CI 0.5–0.9). Stratified analyses for women & men and for diabetes status were comparable for all three outcomes.
Conclusions
In patients with manifest CVD but without PAD, a screen-detected low ABI is a powerful risk indicator for cardiovascular events, limb events, and all-cause mortality.
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Affiliation(s)
- Vivianne L. Jagt
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Jaap Kapelle
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten J. Cramer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank L. J. Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- * E-mail:
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Macabrey D, Deslarzes-Dubuis C, Longchamp A, Lambelet M, Ozaki CK, Corpataux JM, Allagnat F, Déglise S. Hydrogen Sulphide Release via the Angiotensin Converting Enzyme Inhibitor Zofenopril Prevents Intimal Hyperplasia in Human Vein Segments and in a Mouse Model of Carotid Artery Stenosis. Eur J Vasc Endovasc Surg 2021; 63:336-346. [PMID: 34916111 DOI: 10.1016/j.ejvs.2021.09.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 09/01/2021] [Accepted: 09/17/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Hypertension is a major risk factor for intimal hyperplasia (IH) and re-stenosis following vascular and endovascular interventions. Preclinical studies suggest that hydrogen sulphide (H2S), an endogenous gasotransmitter, limits re-stenosis. While there is no clinically available pure H2S releasing compound, the sulfhydryl containing angiotensin converting enzyme inhibitor zofenopril is a source of H2S. Here, it was hypothesised that zofenopril, due to H2S release, would be superior to other non-sulfhydryl containing angiotensin converting enzyme inhibitors (ACEi) in reducing intimal hyperplasia. METHODS Spontaneously hypertensive male Cx40 deleted mice (Cx40-/-) or wild type (WT) littermates were randomly treated with enalapril 20 mg or zofenopril 30 mg. Discarded human vein segments and primary human smooth muscle cells (SMCs) were treated with the active compound enalaprilat or zofenoprilat. IH was evaluated in mice 28 days after focal carotid artery stenosis surgery and in human vein segments cultured for seven days ex vivo. Human primary smooth muscle cell (SMC) proliferation and migration were studied in vitro. RESULTS Compared with control animals (intima/media thickness 2.3 ± 0.33 μm), enalapril reduced IH in Cx40-/- hypertensive mice by 30% (1.7 ± 0.35 μm; p = .037), while zofenopril abrogated IH (0.4 ± 0.16 μm; p < .002 vs. control and p > .99 vs. sham operated Cx40-/- mice). In WT normotensive mice, enalapril had no effect (0.9665 ± 0.2 μm in control vs. 1.140 ± 0.27 μm; p > .99), while zofenopril also abrogated IH (0.1623 ± 0.07 μm; p < .008 vs. control and p > .99 vs. sham operated WT mice). Zofenoprilat, but not enalaprilat, also prevented IH in human vein segments ex vivo. The effect of zofenopril on carotid and SMCs correlated with reduced SMC proliferation and migration. Zofenoprilat inhibited the mitogen activated protein kinase and mammalian target of rapamycin pathways in SMCs and human vein segments. CONCLUSION Zofenopril provides extra beneficial effects compared with non-sulfhydryl ACEi in reducing SMC proliferation and re-stenosis, even in normotensive animals. These findings may hold broad clinical implications for patients suffering from vascular occlusive diseases and hypertension.
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Affiliation(s)
- Diane Macabrey
- Department of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland; Department of Biomedical Sciences, University of Lausanne, Lausanne, Switzerland
| | - Céline Deslarzes-Dubuis
- Department of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland; Department of Biomedical Sciences, University of Lausanne, Lausanne, Switzerland
| | - Alban Longchamp
- Department of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland; Department of Biomedical Sciences, University of Lausanne, Lausanne, Switzerland
| | - Martine Lambelet
- Department of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland; Department of Biomedical Sciences, University of Lausanne, Lausanne, Switzerland
| | - Charles K Ozaki
- Department of Surgery and the Heart and Vascular Centre, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jean-Marc Corpataux
- Department of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland; Department of Biomedical Sciences, University of Lausanne, Lausanne, Switzerland
| | - Florent Allagnat
- Department of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland; Department of Biomedical Sciences, University of Lausanne, Lausanne, Switzerland.
| | - Sébastien Déglise
- Department of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland; Department of Biomedical Sciences, University of Lausanne, Lausanne, Switzerland
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Sex-related disparities in intervention rates and type of intervention in patients with aortic and peripheral arterial diseases in the National Inpatient Sample Database. J Vasc Surg 2021; 73:2081-2089.e7. [PMID: 33301865 PMCID: PMC9945691 DOI: 10.1016/j.jvs.2020.11.034] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 11/25/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The first annual Women's Vascular Summit highlighted sex- and gender-related knowledge gaps in vascular disease diagnosis and treatment. This finding suggests an opportunity for further research to improve care and outcomes in people who identify as women, specifically. The purpose of this study was to a large national dataset to identify all operations performed for abdominal aortic aneurysm (AAA), carotid artery stenosis (CAS), and peripheral arterial disease (PAD) in the United States, and to provide data on sex-related disparities in treatment. METHODS All hospitalizations of adult patients (≥18 years old) diagnosed with AAA, CAS, or PAD who underwent vascular surgery from 2000 to 2016 were identified in the Healthcare Cost and Utilization Project National Inpatient Sample. Sex-stratified U.S. Census data and sex-specific population disease prevalence estimates from the National Institute of Health and Agency for Healthcare Research and Quality were used to calculate the number of U.S. adults with AAA, CAS, and PAD. Sex-stratified rates of surgery and incidence rate ratios were estimated using Poisson regression. Among those undergoing surgery, multivariable logistic regression was used to assess differences in endovascular vs open approach. RESULTS Over 16 years, there were 1,021,684 hospitalizations for vascular surgery: 13% AAA (21% female, 79% male), 40% CAS (42% female, 58% male), and 47% PAD (42% female, 58% male). Females were older than males at time of surgery (median age, 71.3 years vs 69.7 years) and less likely to have private insurance (18% vs 23%); minimal differences were seen across race/ethnicity, comorbidities, and hospital characteristics. After accounting for disease prevalence, females were still 25% less likely to undergo surgery for AAA and 30% less likely to undergo surgery for PAD compared with males with the same disease. These results were consistent over time. After adjustment, females, compared with males, were less likely to receive an endovascular procedure compared with open for AAA or CAS, and more likely to receive one for PAD. CONCLUSIONS From 2000 to 2016 in the United States, females were less likely to undergo intervention for AAA and PAD than males. This finding is particularly significant for PAD, because the prevalence is the same for both sexes, indicating that females are likely undertreated for PAD. Additionally, females were less likely to undergo endovascular surgery for AAA and more likely to undergo endovascular surgery for PAD than males. These findings suggest that improvement in AAA and PAD identification and management in females may improve outcomes.
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Chan SL, Rajesh R, Tang TY. Evidence-based medical treatment of peripheral arterial disease:
A rapid review. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021. [DOI: 10.47102/annals-acadmedsg.2020649] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
ABSTRACT
Introduction: Peripheral arterial disease (PAD) treatment guidelines recommend the use of statins
and antiplatelets in all PAD patients to reduce adverse cardiovascular and limb-related outcomes. In
addition, hypertension and diabetes should be treated to reach recommended targets. The aim of this
rapid review was to evaluate the level of adherence to evidence-based medical therapy (EBMT)
recommended by PAD treatment guidelines in the real-world setting.
Methods: We searched PubMed and Embase using keywords, MeSH and Emtree terms related to the
population, exposure and outcomes from their inception to 22 September 2020. We included randomised
controlled trials, non-randomised studies, and observational studies reporting adherence to at least 1 of
these 4 drug classes: (1) statins, (2) antiplatelets, (3) antihypertensives and (4) antidiabetic drugs.
Non-English articles, abstracts, dissertations, animal studies and case reports or series were excluded.
A narrative summary of the results was performed.
Results: A total of 42 articles were included in the review. The adherence to lipid-lowering drugs/statins
ranged from 23.5 to 92.0% and antiplatelets from 27.5 to 96.3%. Only 7 and 5 studies reported use of
“any anti-hypertensive” and “any anti-diabetic” medications, respectively, and the proportion of the cohort
treated were generally close to the proportion with hypertension and/or diabetes. Adherence in studies
published in 2016–2020 ranged from 52.4–89.6% for lipid-lowering drugs and 66.2–96.3% for antiplatelets.
Conclusion: EBMT adherence in PAD patients was highly variable and a substantial proportion in
many settings were undertreated. There was also a notable lack of studies in Asian populations.
Keywords: Evidence-practice gap, medication adherence, pharmacoepidemiology
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Affiliation(s)
- Sze Ling Chan
- Health Services Research Centre, SingHealth, Singapore
| | - Revvand Rajesh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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Keohane CR, Twyford M, Hannon E, Tawfick W, Walsh SR. Medical management of PAD: Expand or consolidate? ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:376-378. [PMID: 34100514 DOI: 10.47102/annals-acadmedsg.2021163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Colum R Keohane
- Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
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Zhang YS, Chen JH, Mei T, Li S, Lu YM. Efficacy and safety of DOACs in patients with peripheral arterial disease: A systematic review and meta-analysis. Vascular 2021; 29:846-855. [PMID: 33504278 DOI: 10.1177/1708538120987935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The efficacy and safety of direct oral anticoagulants (DOACs) in patients with peripheral arterial disease are not completely understood. Therefore, we conducted a meta-analysis to explore the effects of DOACs in this population. METHODS We systematically searched the PubMed, Cochrane Library, and Web of Science till April 2020 for relevant randomized controlled trials and observational studies, with no linguistic restrictions. The efficacy outcomes were cardiovascular death, stroke, myocardial infraction, major adverse cardiovascular events (MACE), acute limb ischemia, amputation, and target lesion revascularization. The safety outcome was major bleeding events. Random effects risk ratios with 95% confidence intervals were calculated. RESULTS A total four randomized controlled trials were included in this meta-analysis. Among peripheral arterial disease patients, DOACs did not reduce the risk of cardiovascular death (RR = 1.02 95%CI 0.75-1.37, P = 0.92), stroke (RR = 0.73 95%CI 0.46-1.14, P = 0.16), myocardial infraction (RR = 0.85 95%CI 0.70-1.03, P = 0.10), MACE (RR = 0.73 95%CI 0.46-1.14, P = 0.16), or amputation (RR = 0.73 95%CI 0.46-1.14, P = 0.16) compared with control. However, DOACs were associated with reduction in acute limb ischemia (RR = 0.67 95%CI 0.55-0.80, P < 0.01) and target lesion revascularization (RR = 0.89 95%CI 0.81-0.99, P = 0.02) at the expense of major bleeding events (RR = 1.43 95%CI 1.16-1.77, P < 0.01) compared with control. CONCLUSIONS Based on current evidence, no significant difference in cardiovascular death, stroke, myocardial infraction, MACE, and amputation was found when DOACs were compared to antiplatelet monotherapy. The benefits of preventing target lesion revascularization and acute limb ischemia were balanced by amplified risk of major bleeding. Larger randomized controlled trials are needed to figure out the uncertainty around efficacy and safety of medications for peripheral arterial disease.
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Affiliation(s)
- Yuan-Su Zhang
- Department of Vascular Surgery, 56709Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Jin-Hui Chen
- Department of Vascular Surgery, 56709Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Tong Mei
- Department of Vascular Surgery, 56709Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Shuai Li
- Department of Vascular Surgery, 56709Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Yong-Ming Lu
- Department of Vascular Surgery, 56709Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
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Novaković M, Krevel B, Rajkovič U, Vižintin Cuderman T, Janša Trontelj K, Fras Z, Jug B. Moderate-pain versus pain-free exercise, walking capacity, and cardiovascular health in patients with peripheral artery disease. J Vasc Surg 2019; 70:148-156. [PMID: 30922760 DOI: 10.1016/j.jvs.2018.10.109] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 10/22/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Supervised exercise training (walking) is recommended in patients with intermittent claudication, both as a means to improve symptoms (walking distance and quality of life [QoL]) and as a means to improve general cardiovascular health (including vascular function and heart rate variability [HRV]). Our aim was to compare two types of supervised training (moderate-pain and pain-free walking) with comparable intensity based on heart rate, in terms of walking capacity, QoL, vascular function, biomarkers, and HRV in patients with intermittent claudication. METHODS Thirty-six adults with intermittent claudication were randomized to either moderate-pain or pain-free exercise training (36 sessions, two or three times a week) or usual care (no supervised exercise). Initial walking distance and absolute walking distance using treadmill testing, flow-mediated vasodilation and pulse wave velocity using ultrasound, N-terminal pro-B-type natriuretic peptide and fibrinogen levels, HRV, and QoL (36-Item Short Form Health Survey questionnaire) were determined at baseline and after the intervention period. RESULTS Twenty-nine patients (mean age, 64 ± 9 years; 72% male) completed the study. Both training programs similarly improved walking capacity. Initial walking distance and absolute walking distance significantly increased with either moderate-pain walking (median, 50 m to 107 m [P = .005] and 85 m to 194 m [P = .005], respectively) or pain-free walking (median, 53 m to 128 m [P = .003] and 92 m to 163 m [P = .003], respectively). QoL also similarly improved with both training modalities, whereas only moderate-pain walking was also associated with a statistically significant improvement in the vascular parameters flow-mediated vasodilation (4.4% to 8.0%; P = .002) and pulse wave velocity (6.6 m/s to 6.1 m/s; P = .013). Neither training program was associated with changes in biomarker levels and HRV. CONCLUSIONS Both moderate-pain and pain-free training modalities were safe and similarly improved walking capacity and health-related QoL. Conversely, vascular function improvements were associated with only moderate-pain walking.
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Affiliation(s)
- Marko Novaković
- Division of Internal Medicine, Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
| | - Barbara Krevel
- Division of Internal Medicine, Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Uroš Rajkovič
- Faculty of Organizational Sciences, University of Maribor, Kranj, Slovenia
| | - Tjaša Vižintin Cuderman
- Division of Internal Medicine, Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Katja Janša Trontelj
- Division of Internal Medicine, Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Zlatko Fras
- Division of Internal Medicine, Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Borut Jug
- Division of Internal Medicine, Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Thiney M, Della Schiava N, Ecochard R, Feugier P, Lermusiaux P, Millon A, Long A. Effects on Mortality and Cardiovascular Events of Adherence to Guideline-Recommended Therapy 4 Years after Lower Extremity Arterial Revascularization. Ann Vasc Surg 2018; 52:138-146. [DOI: 10.1016/j.avsg.2018.03.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 03/13/2018] [Accepted: 03/19/2018] [Indexed: 11/28/2022]
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Hussain MA, Al-Omran M, Creager MA, Anand SS, Verma S, Bhatt DL. Antithrombotic Therapy for Peripheral Artery Disease. J Am Coll Cardiol 2018; 71:2450-2467. [DOI: 10.1016/j.jacc.2018.03.483] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 03/16/2018] [Accepted: 03/21/2018] [Indexed: 12/18/2022]
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Becker RA, Cluff K, Duraisamy N, Mehraein H, Farhoud H, Collins T, Casale GP, Pipinos II, Subbiah J. Optical probing of gastrocnemius in patients with peripheral artery disease characterizes myopathic biochemical alterations and correlates with stage of disease. Physiol Rep 2017; 5:5/5/e13161. [PMID: 28292886 PMCID: PMC5350172 DOI: 10.14814/phy2.13161] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 01/16/2017] [Indexed: 01/15/2023] Open
Abstract
Peripheral artery disease (PAD) is a condition caused by atherosclerotic blockages in the arteries supplying the lower limbs and is characterized by ischemia of the leg, progressive myopathy, and increased risk of limb loss. The affected leg muscles undergo significant changes of their biochemistry and metabolism including variations in the levels of many key proteins, lipids, and nucleotides. The mechanisms behind these changes are poorly understood. The objective of this study was to correlate the severity of the PAD disease stage and associated hemodynamic limitation (determined by the ankle brachial index, ABI) in the legs of the patients with alterations in the biochemistry of chronically ischemic leg muscle as determined by ATR‐Fourier transform infrared micro‐spectroscopy. Muscle (gastrocnemius) biopsies were collected from 13 subjects including four control patients (ABI≥0.9), five claudicating patients (0.4 ≤ ABI<0.9), and four critical limb ischemia (CLI) patients (ABI<0.4). Slide mounted specimens were analyzed by ATR‐Fourier transform infrared micro‐spectroscopy. An analysis of variance and a partial least squares regression model were used to identify significant differences in spectral peaks and correlate them with the ABI. The spectra revealed significant differences (P < 0.05) across control, claudicating, and CLI patients in the fingerprint and functional group regions. Infrared microspectroscopic probing of ischemic muscle biopsies demonstrates that PAD produces significant and unique changes to muscle biochemistry in comparison to control specimens. These distinctive biochemical profiles correlate with disease progression and may provide insight and direction for new targets in the diagnosis and therapy of muscle degeneration in PAD.
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Affiliation(s)
- Ryan A Becker
- Biomedical Engineering Department, Wichita State University, Wichita, Kansas
| | - Kim Cluff
- Biomedical Engineering Department, Wichita State University, Wichita, Kansas
| | | | - Hootan Mehraein
- Biomedical Engineering Department, Wichita State University, Wichita, Kansas.,Industrial Engineering, Wichita State University, Wichita, Kansas
| | | | - Tracie Collins
- Department of Preventive Medicine & Public Health, School of Medicine, University of Kansas Medical Center, Wichita, Kansas
| | - George P Casale
- Division of General Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Iraklis I Pipinos
- Division of General Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska.,Department of Surgery and VA Research Service, VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
| | - Jeyamkondan Subbiah
- Biological Systems Engineering and Food Science and Technology, University of Nebraska-Lincoln, Lincoln, Nebraska
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Khoumri C, Bailly H, Delpont B, Daubail B, Blanc C, Chazalon C, Durier J, Hervieu-Bègue M, Osseby GV, Rouaud O, Giroud M, Vergely C, Béjot Y. Temporal trends in the premorbid use of preventive treatments in patients with acute ischemic cerebrovascular events and a history of vascular disease: The Dijon Stroke Registry (1985–2010). Presse Med 2017; 46:e259-e267. [DOI: 10.1016/j.lpm.2017.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 11/09/2016] [Accepted: 01/05/2017] [Indexed: 11/25/2022] Open
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15
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Thiney M, Della Schiava N, Feugier P, Lermusiaux P, Ninet J, Millon A, Long A. How Admission to a Vascular Surgery Department Improves Medical Treatment in Patients with Lower Extremity Peripheral Arterial Disease. Ann Vasc Surg 2017; 40:85-93. [DOI: 10.1016/j.avsg.2016.08.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 07/07/2016] [Accepted: 08/08/2016] [Indexed: 12/25/2022]
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16
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Sotoda Y, Hirooka S, Orita H, Wakabayashi I. Association of Serum Uric Acid Levels with Leg Ischemia in Patients with Peripheral Arterial Disease after Treatment. J Atheroscler Thromb 2017; 24:725-734. [PMID: 28202852 PMCID: PMC5517546 DOI: 10.5551/jat.37010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Aim: We investigated the relationships of serum uric acid levels with the progression of atherosclerosis in patients with peripheral arterial disease (PAD) after treatment. Methods: Subjects were male patients diagnosed with PAD. Atherosclerosis at the common carotid artery was evaluated based on its intima-media thickness (IMT). Leg arterial flow was evaluated by measuring ankle-brachial index (ABI) and exercise-induced decrease in ABI. Results: Among various risk factors including age, blood pressure, adiposity, estimated glomerular filtration rate, and blood lipid, blood glucose, uric acid, fibrinogen and C-reactive protein levels, only uric acid levels showed significant correlations with ABI [Pearson's correlation coefficient, −0.292 (p < 0.01)] and leg exercise-induced decrease in ABI [Pearson's correlation coefficient, 0.236 (p < 0.05)]. However, there was no significant correlation between uric acid levels and maximum or mean IMT. Odds ratios of subjects with the 3rd tertile versus subjects with the 1st tertile for uric acid levels were significantly higher than the reference level of 1.00 for low ABI [4.44 (95% confidence interval, 1.45–13.65, p < 0.01)] and for high % decrease in ABI after exercise [4.31 (95% confidence interval, 1.34–13.82, p < 0.05)]. The associations of uric acid levels with the indicators of leg ischemia were also found after adjustment for age, history of revascularization therapy, diabetes, smoking, alcohol consumption, body mass index, triglyceride levels, and renal function. Conclusion: Uric acid levels are associated with the degree of leg ischemia in patients with PAD. Further interventional studies are needed to determine whether the correction of uric acid levels is effective in preventing the progression of PAD.
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Affiliation(s)
- Yoko Sotoda
- Department of Cardiovascular Surgery, Yamagata Saisei Hospital
| | - Shigeki Hirooka
- Department of Cardiovascular Surgery, Yamagata Saisei Hospital
| | - Hiroyuki Orita
- Department of Cardiovascular Surgery, Yamagata Saisei Hospital
| | - Ichiro Wakabayashi
- Department of Environmental and Preventive Medicine, Hyogo College of Medicine
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17
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Good E, Länne T, Wilhelm E, Perk J, Jaarsma T, de Muinck E. High-grade carotid artery stenosis: A forgotten area in cardiovascular risk management. Eur J Prev Cardiol 2016; 23:1453-60. [DOI: 10.1177/2047487316632629] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/25/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Elin Good
- Department of Medicine and Health Sciences, Linköping University, Sweden
| | - Toste Länne
- Department of Medicine and Health Sciences, Linköping University, Sweden
| | - Elisabeth Wilhelm
- Department of Medicine and Health Sciences, Linköping University, Sweden
| | - Joep Perk
- Department of Health and Caring Sciences, Linnaeus University, Sweden
| | - Tiny Jaarsma
- Department of Social and Welfare Studies, Linköping University, Sweden
| | - Ebo de Muinck
- Department of Medicine and Health Sciences, Linköping University, Sweden
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18
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Wann-Hansson C, Wennick A. How do patients with peripheral arterial disease communicate their knowledge about their illness and treatments? A qualitative descriptive study. BMC Nurs 2016; 15:29. [PMID: 27147906 PMCID: PMC4855438 DOI: 10.1186/s12912-016-0151-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 04/25/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Peripheral arterial disease is a chronic illness, and patients with peripheral arterial disease should receive advice about lifestyle changes and medical therapies to reduce further atherosclerotic complications. Previous research has indicated that patients with peripheral arterial disease lack information about their disease and secondary prevention measures. The aim was to elucidate how patients with peripheral arterial disease communicate their knowledge about their illness and treatments. METHODS During 2009, seven focus group interviews were conducted with twenty-one patients (50-81 years old) with peripheral arterial disease and were analysed using content analysis. RESULTS When respondents with PAD communicate their knowledge about the illness and its treatments they "Navigate through uncertainty, believes and facts about PAD, displaying an active or passive information-seeking behaviour". After discharge, they felt a feeling of relief at first, which was later exchanged into uncertainty from their restricted knowledge about the illness and how to behave following revascularisation. For example, during the discussions about risk factors, smoking was noted as a major risk factor, that triggered feelings of guilt. Thus, the respondents needed to consult other sources of information to manage their everyday lives. CONCLUSIONS Following endovascular treatment, the short amount of time spent with peripheral arterial disease patients requires innovative guidance in clinical practice to meet individuals' needs regardless of whether the patient actively or passively understands and manages their peripheral arterial disease.
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Affiliation(s)
- Christine Wann-Hansson
- Department of Care Science, Faculty of Health and Society, Malmö University, Jan Waldenströms gata 25, 20506 Malmö, Sweden ; Vascular department, Skane University Hospital, Malmö, Sweden
| | - Anne Wennick
- Department of Care Science, Faculty of Health and Society, Malmö University, Jan Waldenströms gata 25, 20506 Malmö, Sweden
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Silva Junior JAD, Souza DÚF, Ferreira DR, Valeriano MCP, Santos RF, Britto RR, Pereira DAG. Avaliação da saturação tecidual de oxigênio durante o sintoma claudicante em pacientes com doença arterial periférica. J Vasc Bras 2015. [DOI: 10.1590/1677-5449.002115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo Contexto O relato de sintoma claudicante em pacientes com doença arterial periférica é utilizado como modulador da intensidade de exercício físico para o tratamento clínico, entretanto os valores de oxigenação tecidual nesse momento são desconhecidos. Objetivo Descrever o suprimento tecidual de oxigênio por meio da espectroscopia de luz próxima ao infravermelho ou Near-Infrared Spectroscopy (NIRS) nos momentos em que o paciente relata sintoma claudicante inicial e máximo em testes de exercício. Métodos Nove pacientes, oito homens com 65,63 ± 6,02 anos de idade, previamente diagnosticados com doença arterial periférica, realizaram teste de exercício de carga constante e de carga incremental com monitorização do nível de oxigenação tecidual através da NIRS. As saturações de oxigênio obtidas no momento em que o paciente relata sintoma claudicante inicial e no momento em que relata sintoma claudicante máximo foram comparadas com os valores de saturação da manobra de oclusão arterial por meio do intervalo de confiança de 95% da diferença. Resultados Verificou-se que os valores de saturação nos momentos de sintoma claudicante inicial e máximo são estatisticamente distintos quando comparados àqueles obtidos na manobra de oclusão arterial, entretanto, através da análise percentual do quão distante esses valores encontram-se é possível observar que, do ponto de vista clínico, eles estão próximos. Conclusões A saturação no momento em que o paciente relata sintomas claudicantes inicial e máximo é bastante próxima do valor de saturação no momento de oclusão e do ponto de vista clínico o relato subjetivo de sintoma do paciente é adequado como parâmetro para a prescrição do exercício físico.
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Affiliation(s)
- Leanne Atkin
- Lecturer practitioner and vascular nurse specialist, University of Huddersfield and Mid Yorkshire NHS Trust
| | | | - Emma Bond
- Vascular nurse specialist, Glan Clwyd Hospital, North Wales. Authors are all council members of the Society of Vascular Nursing
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21
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Renard BM, Seth M, Share D, Aronow HD, Laveroni EW, De Gregorio M, Hans SS, Henke PK, Gurm HS, Grossman PM. If not now, when? Prescription of evidence-based medical therapy prior to hospital discharge increases utilization at 6 months in patients with symptomatic peripheral artery disease. Vasc Med 2015; 20:544-50. [DOI: 10.1177/1358863x15599249] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We evaluated the impact of the prescription of evidence-based medical therapy (EBMT) including aspirin (ASA), beta-blockers (BB), ACE-inhibitors or angiotensin receptor blockade (ACE/ARB), and statins prior to discharge after peripheral vascular intervention (PVI) on long-term medication utilization in a large multi-specialty, multicenter quality improvement collaborative. Among patients undergoing coronary revascularization, use of the component medications of EBMT at hospital discharge is a major predictor of long-term utilization. Predictors of EBMT use after PVI are largely unknown. A total of 10,169 patients undergoing PVI between 1 January 2008 and 31 December 2011 were included. Post-PVI discharge and 6-month medication utilization in patients without contra-indications to ASA, BB, ACE/ARB, and statins were compared. ASA was prescribed at discharge to 9345 (92%) patients, BB to 7012 (69%), ACE/ARB to 6424 (63%), and statins to 8342 (82%), and all four component drugs of EBMT in 3953 (39%). Compared with patients not discharged on the appropriate medications, post-procedural use was associated (all p<0.001) with reported 6-month use: ASA (84.5% vs 39.2%), BB (82.5% vs 11.1%), ACE/ARB (78.2% vs 11.8%), statins (84.6% vs 21.8%). Multivariable analysis revealed that prescription of EBMT at the time of discharge remained strongly associated with use at 6 months for each of the individual component drugs as well as for the combination of all four EBMT medications. In conclusion, prescription of the component medications of EBMT at the time of PVI is associated with excellent utilization at 6 months, while failure to prescribe EBMT at discharge is associated with low use of these medications 6 months later. These data suggest that the time of a PVI is a therapeutic window in which to prescribe EBMT in this high-risk cohort and represents an opportunity for quality improvement.
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Affiliation(s)
- Brian M Renard
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Milan Seth
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - David Share
- Department of Family Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Herb D Aronow
- Michigan Heart, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | | | - Michele De Gregorio
- Cardiology and Vascular Associates, St Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | | | - Peter K Henke
- Department of Surgery, Division of Vascular Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Hitinder S Gurm
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - P Michael Grossman
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
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22
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Debus ES, Torsello G, Hupp T, Storck M, Lang W, Grundmann RT. [Peripheral arterial occlusive disease--prognosis, concomitant disease and prevention]. MMW Fortschr Med 2014; 156:56-61. [PMID: 25195411 DOI: 10.1007/s15006-014-3095-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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23
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Delsart P, Lemesle G, Lamblin N, Tricot O, Meurice T, Mycinski C, Elkohen M, Chmait A, Haulon S, Bauters C. Secondary medical prevention and clinical outcome in coronary artery disease patients with a history of non-coronary vascular intervention: A report from the CORONOR investigators. Eur J Prev Cardiol 2014; 22:864-71. [DOI: 10.1177/2047487314538857] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 05/18/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Pascal Delsart
- Centre Hospitalier Régional et Universitaire de Lille, Lille, France
| | - Gilles Lemesle
- Centre Hospitalier Régional et Universitaire de Lille, Lille, France
- Inserm U744, Institut Pasteur de Lille, Université Lille Nord de France, Lille, France
- Faculté de Médecine de Lille, Lille, France
| | - Nicolas Lamblin
- Centre Hospitalier Régional et Universitaire de Lille, Lille, France
- Inserm U744, Institut Pasteur de Lille, Université Lille Nord de France, Lille, France
- Faculté de Médecine de Lille, Lille, France
| | | | | | | | - Mariam Elkohen
- Hôpital Privé de Villeneuve d’Ascq, Villeneuve d’Ascq, France
| | - Akram Chmait
- Clinique de la Côte d’Opale, Boulogne-Sur-Mer, France
| | - Stéphan Haulon
- Centre Hospitalier Régional et Universitaire de Lille, Lille, France
- Faculté de Médecine de Lille, Lille, France
- Inserm U1008, Université Lille Nord de France, Lille, France
| | - Christophe Bauters
- Centre Hospitalier Régional et Universitaire de Lille, Lille, France
- Inserm U744, Institut Pasteur de Lille, Université Lille Nord de France, Lille, France
- Faculté de Médecine de Lille, Lille, France
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[A 6-year evaluation of dyslipidemia in a health center: Importance of improvement actions]. Semergen 2014; 40:241-6. [PMID: 24529919 DOI: 10.1016/j.semerg.2013.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 09/10/2013] [Accepted: 09/20/2013] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Dyslipidemia, especially an increased LDL-cholesterol, has been shown to be one of the most important risk factors in the genesis of coronary involvement. The prevalence of dyslipidemias in Spain is high. The objective of this study is to assess the progress of dyslipidemic patients in our health center over a 6-year period, and see if there has been any improvement in its control after the presentation of the evaluation of the first 3 years, as well as an updated dyslipidemia protocol. PATIENTS AND METHODS Assessment Period 1 (2006-2008): 267 patients with dyslipidemia. Assessment Period 2 (2009-2011): 222 patients, excluding exitus and address changes. VARIABLES age, sex, personal history of CVD, vascular risk factors, lipids, drug treatment, risk levels, and percentages of CV control objectives. RESULTS Mean age was 66.2 years (SD 13.4), 66.3% women. Period 1-Period 2: Total cholesterol: 221.9-196.6 mg/dl (P=.000); LDL-cholesterol: 147.9-115.8 mg/dl (P=.000). In high risk patients, therapeutic targets: 14-50.5% (P=.024); medium risk: 35-68.1% (P=.038); low risk: 44-68.2% (P=NS). Pharmacotherapy 68-77% (P=.000). Changing treatment: 30-43% (P=.001). Adherence: 75-86% (P=.003). Untreated high risk: 15.4-16.3% (P=NS). CONCLUSIONS There was a significant improvement in Period 2, especially in high-risk patients, after presenting the results of the evaluation for Period 1 and with the updated dyslipidemia protocol. There are high risk patients without lipid-lowering treatment to be detected and reviewed.
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Ambrosetti M, Temporelli PL, Faggiano P, Febo O, Diaco T, Favretto G, Calisi P, Gabriele M, Greco C, Tavazzi L. Lower extremities peripheral arterial disease among patients admitted to cardiac rehabilitation: the THINKPAD registry. Int J Cardiol 2013; 171:192-8. [PMID: 24374201 DOI: 10.1016/j.ijcard.2013.12.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 11/21/2013] [Accepted: 12/06/2013] [Indexed: 12/24/2022]
Abstract
BACKGROUND/OBJECTIVES Lower extremities peripheral arterial disease (LE-PAD) across the wide range of conditions for Cardiac Rehabilitation (CR) is poorly understood. The "ATHerosclerosis of the lower extremIties as a liNKed comorbidity in Patients Admitted for carDiac rehabilitation" (THINKPAD) registry explored LE-PAD in CR patients in terms of prevalence and interventions delivered. METHODS Multicenter, consecutive case series of 1506 patients discharged from 16 CR Units in Italy from May 1 to June 30, 2012. RESULTS LE-PAD constituted a primary indication for CR and a comorbidity on admission in 2.6% and 9.3% of patients respectively. LE-PAD patients were significantly older (72 ± 9 vs. 67 ± 12 years, p<0.001) and displayed a worse cardiovascular risk profile (diabetes 38% vs. 23%, hypertension 86% vs. 63%, hypercholesterolemia 74% vs. 52%, smoking 72% vs. 50%, low level of physical activity 84% vs. 69%, impaired diet habits 69% vs. 55%, p<0.01 for all). COPD (17% vs. 11%, p<0.05), CKD (20% vs. 10%, p<0.01), and past history of coronary revascularization (29% vs. 14%, p<0.001) were also more represented in the LE-PAD group. Half of LE-PAD patients received a formal staging, with low provision of ABI (18%) and color Doppler (48%) investigation. Secondary prevention targets at the end of CR for blood pressure and lipid control were accomplished in 83% and 46% of patients respectively (strongly correlated with the presence of CAD), while other guideline-recommended drugs for LE-PAD were prescribed in less than 4% of cases. CONCLUSION LE-PAD represents an uncommon referral indication for CR. Our data confirm its systematic underassessment and undertreatment.
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Affiliation(s)
- Marco Ambrosetti
- Cardiovascular Rehabilitation Unit, Le Terrazze Clinic, Cunardo, VA, Italy.
| | - Pier Luigi Temporelli
- Salvatore Maugeri Foundation, IRCCS - Scientific Institute of Veruno-Cardiac Rehabilitation Division, Veruno, NO, Italy
| | - Pompilio Faggiano
- Division of Cardiology, Spedali Civili, University of Brescia, Brescia, Italy
| | - Oreste Febo
- Salvatore Maugeri Foundation, IRCCS-Scientific Institute of Montescano-Cardiac Rehabilitation Division, Montescano, PV, Italy
| | - Tommaso Diaco
- Cardiac Rehabilitation Unit, Rivolta d'Adda Hospital, Rivolta d'Adda, Italy
| | - Giuseppe Favretto
- Cardiac Rehabilitation Unit, Motta di Livenza Hospital, Motta di Livenza, Italy
| | - Pasqualina Calisi
- ASL 3 Genovese, La Colletta Hospital, Cardiac Rehabilitation Unit, Arenzano, Italy
| | - Michele Gabriele
- Division of Cardiology, Castelvetrano Hospital, Castelvetrano, TP, Italy
| | - Cesare Greco
- San Giovanni-Addolorata Hospital Complex, Division of Cardiology III, Rome, Italy
| | - Luigi Tavazzi
- GVM Hospitals of Care and Research, Ettore Sansavini Health Science Foundation, Cotignola, Italy
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Beta-blocker Use and Clinical Outcomes after Primary Vascular Surgery: A Nationwide Propensity Score-Matched Study. Eur J Vasc Endovasc Surg 2013; 46:93-102. [DOI: 10.1016/j.ejvs.2013.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 04/01/2013] [Indexed: 01/19/2023]
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Abstract
Peripheral arterial disease (PAD) is a common vascular disease that reduces blood flow capacity to the legs of patients. PAD leads to exercise intolerance that can progress in severity to greatly limit mobility, and in advanced cases leads to frank ischemia with pain at rest. It is estimated that 12 to 15 million people in the United States are diagnosed with PAD, with a much larger population that is undiagnosed. The presence of PAD predicts a 50% to 1500% increase in morbidity and mortality, depending on severity. Treatment of patients with PAD is limited to modification of cardiovascular disease risk factors, pharmacological intervention, surgery, and exercise therapy. Extended exercise programs that involve walking approximately five times per week, at a significant intensity that requires frequent rest periods, are most significant. Preclinical studies and virtually all clinical trials demonstrate the benefits of exercise therapy, including improved walking tolerance, modified inflammatory/hemostatic markers, enhanced vasoresponsiveness, adaptations within the limb (angiogenesis, arteriogenesis, and mitochondrial synthesis) that enhance oxygen delivery and metabolic responses, potentially delayed progression of the disease, enhanced quality of life indices, and extended longevity. A synthesis is provided as to how these adaptations can develop in the context of our current state of knowledge and events known to be orchestrated by exercise. The benefits are so compelling that exercise prescription should be an essential option presented to patients with PAD in the absence of contraindications. Obviously, selecting for a lifestyle pattern that includes enhanced physical activity prior to the advance of PAD limitations is the most desirable and beneficial.
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Affiliation(s)
- Tara L Haas
- Angiogenesis Research Group, Muscle Health Research Centre, Faculty of Health, York University, Toronto, Ontario, Canada
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Gresele P, Migliacci R, Arosio E, Bonizzoni E, Minuz P, Violi F. Effect on walking distance and atherosclerosis progression of a nitric oxide-donating agent in intermittent claudication. J Vasc Surg 2012; 56:1622-8, 1628.e1-5. [PMID: 22963812 DOI: 10.1016/j.jvs.2012.05.064] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 05/04/2012] [Accepted: 05/08/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND Peripheral arterial disease (PAD) is almost invariably associated with a generalized atherosclerotic involvement of the arterial tree and endothelial dysfunction. Previous short-term studies showed improvement of vascular reactivity and walking capacity in PAD patients by measures aimed at restoring nitric oxide (NO) production. NO is also known to prevent the progression of atherosclerosis. We wished to assess whether the prolonged administration of an NO-donating agent (NCX 4016) improves the functional capacity of PAD patients and affects the progression of atherosclerosis as assessed by carotid intima-media thickness (IMT). METHODS This prospective, double-blind, placebo-controlled study enrolled 442 patients with stable intermittent claudication who were randomized to NCX 4016 (800 mg, twice daily) or its placebo for 6 months. The primary study outcome was the absolute claudication distance on a constant treadmill test (10% incline, 3 km/h). The main secondary end point was the change of the mean far-wall right common carotid artery IMT. RESULTS The increase of absolute claudication distance at 6 months compared with baseline was 126±140 meters in the placebo-treated group and 117±137 meters in the NCX 4016-treated group, with no significant differences. Carotid IMT increased in the placebo-treated group (+0.01±0.01 mm; P=.55) and decreased in the NCX 4016-treated group (-0.03±0.01 mm; P=.0306). Other secondary end points did not differ between the two treatments. CONCLUSIONS Long-term NO donation does not improve the claudication distance but does reduce progression of atherosclerosis in patients with PAD. Further studies aimed at assessing whether long-term NO donation may prevent ischemic cardiovascular events are warranted.
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Affiliation(s)
- Paolo Gresele
- Department of Internal Medicine, Division of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy.
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Chang VY, Handa KK, Fernandes M, Yacoub C, Pastana A, Caramelli B, Calderaro D. Improving cardiovascular prevention through patient awareness. Rev Assoc Med Bras (1992) 2012. [DOI: 10.1590/s0104-42302012000500011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Chang VY, Handa KK, Fernandes M, Yacoub C, Pastana A, Caramelli B, Calderaro D. Improving cardiovascular prevention through patient awareness. Rev Assoc Med Bras (1992) 2012. [DOI: 10.1016/s0104-4230(12)70248-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Utilización de tratamientos cardiovasculares preventivos y consecución de objetivos terapéuticos en pacientes con enfermedad arterial periférica. Rev Esp Cardiol 2012; 65:713-8. [DOI: 10.1016/j.recesp.2012.02.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 02/17/2012] [Indexed: 01/02/2023]
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Høgh A, Lindholt JS, Nielsen H, Jensen LP, Johnsen SP. Secondary medical prevention after primary vascular surgery between 1996 and 2006: a shift towards more evidence-based treatment. Eur J Prev Cardiol 2012; 20:763-70. [PMID: 22637739 DOI: 10.1177/2047487312449592] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The implementation of evidence-based secondary medical prevention in peripheral arterial disease (PAD) patients has received increasing attention in recent years, but population-based data are sparse. This study examined the use of secondary medical prophylaxis in unselected symptomatic PAD patients in Denmark. DESIGN A nationwide follow-up study based on individual-level record linkages of population-based healthcare registers was performed. PARTICIPANTS All patients who underwent primary vascular reconstruction in Denmark between 1996 and 2006 with a minimum of 6 months of follow-up were included (n = 16,492). METHODS Data were obtained from prescriptions that were filled six months after primary vascular reconstruction (±90 days). The use of secondary medical prevention was examined according to calendar year and place of residence. RESULTS The use of lipid-lowering drugs increased from 32.2% in 1996 to 76.1% in 2006 (adjusted relative risk (RR) 1.95, 95% CI 1.81-2.10). The overall use of antihypertensive therapy was unchanged during the study period, but treatment shifted from diuretics/calcium antagonists towards angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists. The use of combination therapy (concomitant lipid-lowering, antiplatelet and any antihypertensive therapies) increased from 29.1% in 1996 to 67.6% in 2006 (adjusted RR 1.95, 95% CI 1.80-2.12). This shift in the use of secondary medical prevention was independent of sociodemographic and clinical factors. No substantial differences in pharmacological use based on place of residence were observed. CONCLUSION The use of evidence-based secondary medical prevention, especially lipid-lowering drugs, increased substantially among symptomatic PAD patients in Denmark from 1996 to 2006. However, recommendations in current clinical guidelines suggest that room for improvement remains.
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Affiliation(s)
- Annette Høgh
- Department of Vascular Surgery, Regionshospitalet Viborg, Denmark
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Høgh A, Lindholt J, Nielsen H, Jensen L, Johnsen S. Age- and Gender-related Differences in the Use of Secondary Medical Prevention after Primary Vascular Surgery: A Nationwide Follow-up Study. Eur J Vasc Endovasc Surg 2012; 43:300-7. [DOI: 10.1016/j.ejvs.2011.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 12/05/2011] [Indexed: 11/28/2022]
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Abdulhannan P, Russell DA, Homer-Vanniasinkam S. Peripheral arterial disease: a literature review. Br Med Bull 2012; 104:21-39. [PMID: 23080419 DOI: 10.1093/bmb/lds027] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Peripheral arterial disease (PAD) is a common vascular condition that affects both quality of life and life expectancy with an increased risk of cardiovascular events. SOURCES OF DATA A literature search was carried out of Pub-Med, MEDLINE, the Cochrane Library and Google Scholar from the establishment of these databases up to February 2012. The search was performed by using the keywords 'peripheral arterial disease' and one of the following words: 'management', 'investigations', 'risk factors', 'epidemiology', 'revascularization', 'cryoplasty', 'atherectomy' and 'gene therapy'. Studies were limited to those published in English language. AREAS OF AGREEMENT Aggressive risk factors modification is needed to reduce cardiovascular-related mortality in PAD patients. AREAS OF CONTROVERSY Choice of endovascular or surgical intervention remains controversial in an ever-evolving field. GROWING POINTS There is a rapid expansion of endovascular technologies aiming to improve the effectiveness of this modality. AREAS TIMELY FOR DEVELOPING RESEARCH The advances in the fields of gene therapy and therapeutic angiogenesis mean these are potential future treatments. Tissue engineering is a developing area and aims to produce grafts with similar patency and infection profiles to those of autologous material. Further elucidation of the pathophysiology of atherosclerosis is required to provide new targets for pharmacotherapy.
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Affiliation(s)
- P Abdulhannan
- Leeds Vascular Institute, Leeds General Infirmary, Leeds, UK.
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Casillas JM, Troisgros O, Hannequin A, Gremeaux V, Ader P, Rapin A, Laurent Y. Rehabilitation in patients with peripheral arterial disease. Ann Phys Rehabil Med 2011; 54:443-61. [DOI: 10.1016/j.rehab.2011.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 06/28/2011] [Accepted: 07/02/2011] [Indexed: 12/27/2022]
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Frans FA, Bipat S, Reekers JA, Legemate DA, Koelemay MJW. Systematic review of exercise training or percutaneous transluminal angioplasty for intermittent claudication. Br J Surg 2011; 99:16-28. [DOI: 10.1002/bjs.7656] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2011] [Indexed: 11/08/2022]
Abstract
Abstract
Background
The aim was to summarize the results of all randomized clinical trials (RCTs) comparing percutaneous transluminal angioplasty (PTA) with (supervised) exercise therapy ((S)ET) in patients with intermittent claudication (IC) to obtain the best estimates of their relative effectiveness.
Methods
A systematic review was performed of relevant RCTs identified from the MEDLINE, Embase and Cochrane Library databases. Eligible RCTs compared PTA with (S)ET, included patients with IC due to suspected or known aortoiliac and/or femoropopliteal artery disease, and compared their effectiveness in terms of functional outcome and/or quality of life (QoL).
Results
Eleven of 258 articles identified (reporting data on eight randomized clinical trials) met the inclusion criteria. One trial included patients with isolated aortoiliac artery obstruction, three trials studied those with femoropopliteal artery obstruction and five included those with combined lesions. Two trials compared PTA with advice on ET, four PTA with SET, two PTA plus SET with SET and two PTA plus SET with PTA. Although the endpoints in most trials comprised walking distances and QoL, pooling of data was impossible owing to heterogeneity. Generally, the effectiveness of PTA and (S)ET was equivalent, although PTA plus (S)ET improved walking distance and some domains of QoL scales compared with (S)ET or PTA alone.
Conclusion
As IC is a common healthcare problem, defining the optimal treatment strategy is important. A combination of PTA and exercise (SET or ET advice) may be superior to exercise or PTA alone, but this needs to be confirmed. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- F A Frans
- Department of Radiology, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Vascular Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - S Bipat
- Department of Radiology, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J A Reekers
- Department of Radiology, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D A Legemate
- Department of Vascular Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M J W Koelemay
- Department of Vascular Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Lopez-Carmona D, Bernal-Lopez MR, Mancera-Romero J, Jansen-Chaparro S, Portales-Fernandez I, Baca-Osorio AJ, Perez-Gonzalez R, Tinahones FJ, Gomez-Huelgas R. Compliance with cardiovascular drug prevention measures in a general population: the Multidisciplinary Intervention in Primary Care (IMAP) study. Eur J Prev Cardiol 2011; 19:1074-81. [DOI: 10.1177/1741826711418166] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - MR Bernal-Lopez
- Hospital Virgen de la Victoria, Malaga, Spain
- Instituto de Salud Carlos III, Malaga, Spain
| | | | | | | | | | | | - FJ Tinahones
- Hospital Virgen de la Victoria, Malaga, Spain
- Instituto de Salud Carlos III, Malaga, Spain
| | - R Gomez-Huelgas
- Hospital Regional Universitario Carlos Haya, Malaga, Spain
- Instituto de Salud Carlos III, Malaga, Spain
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Bronas UG, Treat-Jacobson D. Peripheral Artery Disease in the Elderly: Prevalence, Clinical Implications, and Therapy. CURRENT CARDIOVASCULAR RISK REPORTS 2011. [DOI: 10.1007/s12170-011-0185-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Escobar C, Blanes I, Ruiz A, Vinuesa D, Montero M, Rodríguez M, Barbera G, Manzano L. Prevalence and clinical profile and management of peripheral arterial disease in elderly patients with diabetes. Eur J Intern Med 2011; 22:275-81. [PMID: 21570647 DOI: 10.1016/j.ejim.2011.02.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 01/27/2011] [Accepted: 02/03/2011] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Peripheral arterial disease (PAD) increases with age and diabetes. The aim of this study was to assess the prevalence of PAD in an elderly population with diabetes. METHODS This multicenter and cross-sectional study included patients >70 years, with an established diagnosis of diabetes. PAD was defined as those patients with a history of revascularization or amputation due to ischemia, or a pathological ankle-brachial index (ABI). Adequate blood pressure (BP), LDL cholesterol and HbA1c control were considered as <130/80 mm Hg, <100 mg⁄dL and <7.0%, respectively. RESULTS A total of 1462 patients were included. The most frequent cardiovascular risk factor and cardiovascular disease were hypertension (80.37%) and PAD (60.60% overall; 83.2% of those assisted by vascular surgeons vs 31.9% of those attended by other medical specialists; p<0.001), respectively. However, when ABI was measured, 70.99% of the study population had PAD (80.2% of those assisted by vascular surgeons vs 59.6% of those attended by other medical specialists; p<0.001). The predictors for a pathological ABI included male gender, smoking, dyslipidemia, family history of premature cardiovascular disease, sedentary lifestyle, diabetic-related complications, heart and cerebrovascular diseases. Although risk factors control was very poor, it was even lower in patients with PAD. CONCLUSIONS The prevalence of PAD is high in diabetic elderly patients. The concomitance with other risk factors and cardiovascular diseases was very high. The ABI allowed increasing the diagnosis of PAD.
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Affiliation(s)
- Carlos Escobar
- Cardiology Department, Hospital Infanta Sofía, Madrid, Spain
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Hamburg NM, Balady GJ. Exercise rehabilitation in peripheral artery disease: functional impact and mechanisms of benefits. Circulation 2011; 123:87-97. [PMID: 21200015 DOI: 10.1161/circulationaha.109.881888] [Citation(s) in RCA: 175] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Naomi M Hamburg
- Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA
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Lindahl AK. Comments regarding "a systematic review of implementation of established recommended secondary prevention measures in PAOD". Eur J Vasc Endovasc Surg 2009; 39:87-8. [PMID: 19906546 DOI: 10.1016/j.ejvs.2009.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Accepted: 10/12/2009] [Indexed: 11/29/2022]
Affiliation(s)
- A K Lindahl
- The Norwegian Knowledge Centre for the Health Services, PO box 7004 St Olavsplass, N-0130 Oslo, Norway.
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