Peripheral arterial disease and atrial fibrillation and risk of stroke, heart failure hospitalization and cardiovascular death: A nationwide cohort study

Temporal Trends and Mortality Patterns in Peripheral Arterial Disease: A Comprehensive Analysis of Hospitalized Patients in Kazakhstan between 2014 and 2021

BACKGROUND

Peripheral artery disease (PAD) is a global health concern associated with arterial narrowing or blockage, leading to significant morbidity and mortality. The aim of this study is to assess the disease burden and trends in mortality utilizing nationwide administrative health data.

METHODS

This retrospective study utilized data from the Unified National Electronic Healthcare System (UNEHS) from 2014 to 2021. Patients meeting PAD criteria were included, with demographic and clinical data analyzed. Cox regression and Competing Risk Analysis assessed mortality risks.

RESULTS

Between 2014 and 2021, 19,507 individuals were hospitalized due to PAD, with 8,332 (43%) being women and 11,175 (57%) men. The incidence of PAD increased markedly over the observation period, rising from 79 individuals per million population (PMP) in 2014 to 309 PMP in 2021. Concurrent heart failure (HF), acute myocardial infarction (AMI), diabetes, and essential hypertension were prevalent in 50%, 27%, 27%, and 26% of the PAD patients, respectively. Competing Risk Analysis showed a subdistribution hazard ratio (SHR) of 6.53 [95% CI: 4.65-9.19] for individuals over 80 years. Heart failure was associated with lower all-cause HR [0.80, 95% CI: 0.76-0.86, p < 0.001] but higher SHR [1.30, 95% CI: 1.18-1.44, p < 0.001]. Comorbidities such as heart failure, stroke, and acute myocardial infarction significantly increased mortality risks, while essential hypertension was associated with lower risk of death.

CONCLUSION

The significant rise in the incidence rate of PAD underscores the growing burden of the disease, highlighting the urgent need for targeted preventive and management strategies in Kazakhstan.

Integrating Toe Brachial Index and longitudinal strain echocardiography for detecting coronary artery disease in patients with diabetic foot syndrome

Coronary artery disease (CAD) is a common problem amongst diabetic foot syndrome (DFS) patients, associated with peripheral arterial disease. This analytic cross-sectional study investigates the diagnostic efficacy of the Toe Brachial Index (TBI) in the detection of CAD in 62 DFS patients. The presence of CAD was assessed by longitudinal strain echocardiography, a sensitive method that provides a more accurate measure of intrinsic left ventricular contractility than left ventricular ejection fraction, especially in diabetic patients. Univariate and multivariate logistic regression identified CAD-associated factors. Receiver operating characteristic curve evaluated TBI and toe pressure's diagnostic performance for CAD. p-Values < 0.05 were considered significant. There was a significant association between TBI and CAD, with each 0.01 increase in TBI associated with a 15% decrease in the odds of CAD development (odds ratio = 0.85, 95% CI: 0.72-0.99, p = 0.039). TBI demonstrated an area under the curve of 0.854, a sensitivity of 80.0% and a specificity of 66.7% at a cut-off of 0.69. Additionally, toe pressure exhibited an area under the curve of 0.845, sensitivity of 74.0% and specificity of 75.0% at a cut-off of 68.0 mmHg. Overall accuracy for TBI and toe pressure was 77.4% and 74.2%, respectively, indicating their potential for CAD risk stratification in the DFS population. This study highlights a significant association between low TBI and the presence of CAD in DFS patients. Consequently, TBI emerges as a valuable screening tool for identifying CAD within this population.

Association between serum uric acid levels and peripheral artery disease in Chinese adults with hypertension

Background

Higher serum uric acid (SUA) can cause gout, which is principally characterized by arthritis due to monosodium urate crystal deposition in the lower extremities. High levels of SUA have been linked to endothelial dysfunction, oxidative stress, and inflammation, all of which are involved in the pathogenesis of peripheral artery disease(PAD). To date, the relationship between SUA levels and PAD is still poorly understood.

Method

An analysis of 9,839 Chinese adults with essential hypertension from the ongoing China H-type Hypertension Registry Study was conducted in this cross-sectional study. Patients with an ABI ≤0.9 was diagnosed with PAD. Hyperuricemia was defined as SUA levels >420 mol/L in men and >360 mol/L in women. The association between SUA levels and PAD was evaluated using multivariable logistic regression models based on odds ratios (ORs) and their 95% confidence intervals (CIs).

Results

The enrolled subjects ranged in age from 27 to 93 years, with a mean age of 63.14 ± 8.99 years. The proportion of male patients was 46.22%, and the prevalence of hyperuricemia was 50.72%. In males, hyperuricemia was positively associated with the risk of PAD (adjusted OR per SD increase: 1.72, 95% CI 1.17 to 2.53, P =0.006). Males in the highest SUA tertile were significantly more likely to have PAD (adjusted OR: 2.63, 95% CI 1.42 to 4.86, P = 0.002; P for trend = 0.001). However, this positive relationship was not observed in females (adjusted OR: 1.29, 95% CI 0.77 to 2.17, P = 0.327; P for trend = 0.347).

Conclusion

According to this cross-sectional study, higher SUA levels were positively associated with PAD in male hypertensive patients, while this positive relationship disappeared in female participants.

Clinical Characteristics and Predictors of Long-Term Prognosis of Acute Peripheral Arterial Ischemia Patients Treated Surgically

BACKGROUND

Acute peripheral arterial ischemia is a rapidly developing loss of perfusion, resulting in ischemic clinical manifestations. This study aimed to assess the incidence of cardiovascular mortality in patients with acute peripheral arterial ischemia and either atrial fibrillation (AF) or sinus rhythm (SR).

METHODS

This observational study involved patients with acute peripheral ischemia treated surgically. Patients were followed-up to assess cardiovascular mortality and its predictors.

RESULTS

The study group included 200 patients with acute peripheral arterial ischemia and either AF (n = 67) or SR (n = 133). No cardiovascular mortality differences between the AF and SR groups were observed. AF patients who died of cardiovascular causes had a higher prevalence of peripheral arterial disease (58.3% vs. 31.6%, p = 0.048) and hypercholesterolemia (31.2% vs. 5.3%, p = 0.028) than those who did not die of such causes. Patients with SR who died of cardiovascular causes more frequently had a GFR <60 mL/min/1.73 m² (47.8% vs. 25.0%, p = 0.03) and were older than those with SR who did not die of such causes. The multivariable analysis shows that hyperlipidemia reduced the risk of cardiovascular mortality in patients with AF, whereas in patients with SR, an age of ≥75 years was the predisposing factor for such mortality.

CONCLUSIONS

Cardiovascular mortality of patients with acute ischemia did not differ between patients with AF and SR. Hyperlipidemia reduced the risk of cardiovascular mortality in patients with AF, whereas in patients with SR, an age of ≥75 years was a predisposing factor for such mortality.

Direct Oral Anticoagulants as the First Choice of Anticoagulation for Patients with Peripheral Artery Disease to Prevent Adverse Vascular Events: A Systematic Review and Meta-Analysis

The best method of anticoagulation for patients with peripheral artery disease (PAD) is still a topic of interest for physicians. We conducted a meta-analysis to compare the effects of direct oral anticoagulants (DOACs) with those of vitamin-K-antagonist (VKA) anticoagulants in patients with peripheral artery disease. Five databases (Medline (via PubMed), EMBASE, Scopus, Web of Science, and CENTRAL) were searched systematically for studies comparing the effects of the two types of anticoagulants in patients with PAD, with an emphasis on lower-limb outcomes, cardiovascular events, and mortality. In PAD patients with concomitant non-valvular atrial fibrillation (NVAF), the use of DOACs significantly reduced the risk of major adverse limb events (HR = 0.58, 95% CI, 0.39-0.86, p < 0.01), stroke/systemic embolism (HR 0.76; 95% CI 0.61-0.95; p < 0.01), and all-cause mortality (HR 0.78; 95% CI 0.66-0.92; p < 0.01) compared with warfarin, but showed similar risks of MI (HR = 0.81, 95% CI, 0.59-1.11, p = 0.2) and cardiovascular mortality (HR = 0.77, 95% CI, 0.58-1.02, p = 0.07). Rivaroxaban at higher doses significantly increased the risk of major bleeding (HR = 1.16, 95% CI, 1.07-1.25, p < 0.01). We found no significant difference in terms of revascularization (OR = 1.49, 95% CI, 0.79-2.79, p = 0.14) in PAD patients in whom a poor distal runoff was the reason for the anticoagulation. DOACs have lower rates of major limb events, stroke, and mortality than VKAs in PAD patients with atrial fibrillation. Rivaroxaban at higher doses increased the risk of major bleeding compared with other DOAC drugs. More high-quality studies are needed to determine the most appropriate anticoagulation regimen for patients with lower-limb atherosclerosis.

Long-term risk and predictors of cerebrovascular events following sepsis hospitalization: A systematic review and meta-analysis

Background

Long-term risk and predictors of cerebrovascular events following sepsis hospitalization have not been clearly elucidated. We aim to determine the association between surviving sepsis hospitalization and cerebrovascular complications in adult sepsis survivors.

Method

We searched MEDLINE, Embase, Scopus, Web of Sciences, Cochrane library, and Google scholar for studies published from the inception of each database until 31 August 2022.

Results

Of 8,601 screened citations, 12 observational studies involving 829,506 participants were analyzed. Surviving sepsis hospitalization was associated with a significantly higher ischemic stroke [adjusted hazard ratio (aHR) 1.45 (95% CI, 1.23-1.71), I ² = 96], and hemorrhagic stroke [aHR 2.22 (95% CI, 1.11-4.42), I ² = 96] at maximum follow-up compared to non-sepsis hospital or population control. The increased risk was robust to several sensitivity analyses. Factors that were significantly associated with increased hazards of stroke were: advanced age, male gender, diabetes mellitus, hypertension, coronary artery disease, chronic heart failure, chronic kidney disease, chronic obstruction pulmonary disease, and new-onset atrial fibrillation. Only diabetes mellites [aHR 1.80 (95% CI, 1.12-2.91)], hypertension [aHR 2.2 (95% CI, 2.03-2.52)], coronary artery disease [HR 1.64 (95% CI, 1.49-1.80)], and new-onset atrial fibrillation [aHR 1.80 (95% CI, 1.42-2.28)], were associated with > 50% increase in hazards.

Conclusion

Our findings showed a significant association between sepsis and a subsequent risk of cerebrovascular events. The risk of cerebrovascular events can be predicated by patient and sepsis-related baseline variables. New therapeutic strategies are needed for the high-risk patients.

The Impact of Atrial Fibrillation on One-Year Mortality in Patients with Severe Lower Extremity Arterial Disease

Atrial fibrillation (Afib) is associated with the presence of lower extremity arterial disease (LEAD), but its effect on a severe LEAD prognosis remains unclear. We investigated the association between Afib and clinical outcomes. We retrospectively enrolled consecutive severe LEAD patients undergoing percutaneous transluminal angioplasty between 1 January 2013 and 31 December 2018. Patients were divided according to the history of any type of Afib and followed for at least one year. The primary outcome was all-cause mortality. Secondary outcomes were cardiac-related mortality and major adverse cardiovascular events (MACEs). The study included 222 patients aged 74 ± 11 years (54% male), and 12.6% had acute limb ischemia. The Afib group had significantly higher rates of all-cause mortality (42.9% vs. 20.1%, p = 0.014) and MACEs (32.1% vs. 14.4%, p = 0.028) than the non-Afib group. Afib was independently associated with all-cause mortality (adjusted HR: 2.153, 95% CI: 1.084–4.276, p = 0.029) and MACEs (adjusted HR: 2.338, 95% CI: 1.054–2.188, p = 0.037). The other factors associated with all-cause mortality included acute limb ischemia (adjusted HR: 2.898, 95% CI: 1.504–5.586, p = 0.001), Rutherford classification, and heart rate. Afib was significantly associated with increased risks of one-year all-cause mortality and MACEs in patients with severe LEAD. Future studies should investigate whether oral anticoagulants benefit these patients.

Venous Thromboembolism and Critical Limb Events in Patients with Atrial Fibrillation: A Nationwide Population-Based Cohort Study

Little is known about whether venous thromboembolism (VTE) causes worse critical limb events in populations with atrial fibrillation (AF). A retrospective cohort study using claims data from Taiwan's National Health Insurance program between 2001 and 2013 compared AF patients with or without VTE. Outcomes were percutaneous transluminal angioplasty (PTA), amputation, systemic thromboembolism, all-cause mortality, cardiovascular death, ischemic stroke, and acute myocardial infarction. Patients (n = 316,817) with newly diagnosed AF were analyzed; of those, 2514 (0.79%) had VTE history. After inverse probability of treatment weighting, a history of VTE was significantly associated with higher risks of PTA (3.3 vs 2.2%; subdistribution hazard ratio [SHR] 1.47; 95% confidence interval [CI] 1.17-1.84); above knee amputation (0.7 vs 0.3%; HR 2.15; 95% CI 1.10-4.21); systemic thromboembolism (5.8 vs 3.9%; SHR 1.48; 95% CI 1.21-1.80); all-cause mortality (53 vs 46.4%; HR 1.20, 95% CI 1.12-1.29); and cardiovascular death (34.8 vs 29.4%; HR 1.25, 95% CI 1.14-1.36). In conclusion, VTE might increase the risk of critical lower limb events (PTA and above-knee amputation), systemic thromboembolism, and mortality in the AF population. However, current data cannot confirm a causal relationship between VTE and clinical outcomes in this population.

Peripheral artery disease and clinical outcomes in patients with atrial fibrillation: A systematic review and meta-analysis

Background

Atrial fibrillation (AF) is the most common cardiac rhythm disturbance and leads to morbidity and mortality. Peripheral artery disease (PAD) is associated with atherosclerotic risk factors and always classified as a vascular disease and deemed to be a bad complication of AF. In patients with AF, the risk and prognostic value of PAD have not been estimated comprehensively.

Hypothesis

PAD is associated with all‐cause mortality, cardiovascular (CV) mortality, and other outcomes in patients with AF.

Methods

We searched PubMed, Embase, and Cochrane Library databases for prospective studies published before April 2021 that provided outcomes data on PAD in confirmed patients with AF. Heterogeneity was estimated using the I² statistic. The fixed‐effects model was used for low to moderate heterogeneity studies, and the random‐effects model was used for high heterogeneity studies.

Results

Eight prospective studies (Newcastle‐Ottawa score range, 7–8) with 39 654 patients were enrolled. We found a significant association between PAD and all‐cause mortality (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.25–1.62; p < .001), CV mortality (HR, 1.64; 95% CI, 1.32–2.05; p < .001) and MACE (HR, 1.75; 95% CI, 1.38–2.22; p < .001) in patients with AF. No significant relationship was found in major bleeding (HR, 1.22; 95% CI, 0.95–1.57; p = 0.118), myocardial infarction (MI) (HR, 2.07; 95% CI, 1.17–3.67; p = .038), and stroke (HR, 1.14; 95% CI, 0.87–1.50, p = 0.351).

Conclusions

PAD is associated with an increased risk of all‐cause mortality, CV mortality, and MACE in patients with AF. However, no significant association was found with major bleeding, MI, and stroke.

The Impact of Hypertension and Atrial Fibrillation on Cognitive Decline and Subclinical Atherosclerosis

BACKGROUND

Assessment of cognitive impairment and the presence of subclinical atherosclerosis are very important especially in patients with cardiovascular risk factors.

METHODS

We included 155 hypertensive patients (84 with AF versus 71 without AF) to identify the premature cognitive impairment, the earliest signs of subclinical atherosclerosis and onset of myocardial dysfunction and to evaluate the type of anticoagulation used, the importance of CHA₂DS₂-VASc score (3), age (65 years) in hypertensive patients with AF.

RESULTS

Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment Scale (MoCA), Left Ventricular Ejection Fraction (LVEF) were significantly decreased, and Activities of Daily Living Score (ADL), Geriatric Depression Scale(GDS-15), and intima-media thickness (IMT) were significantly increased in hypertensive patients with AF vs. without AF (p < 0.05). MMSE was significantly decreased, ADL and IMT were significant increased in patients with AF and CHA₂DS₂-VASc>3 and non-vitamin K antagonists oral anticoagulants therapy (NOACs)(p < 0.05). Patients with age >65 with AF had higher rates of cognitive impairment (MMSE significant decrease) and a larger IMT (significant increase) versus patients with AF and age <65 (p < 0.05).

CONCLUSIONS

Cognitive impairment is encountered in hypertensive patients having AF. Our conclusions suggest a direct link between cognitive impairment, depression, hypertension, AF, age, CHA₂DS₂-VASc score, type of anticoagulants used, LVEF, cognitive parameters, and IMT. We acknowledge the importance of identifying and preventing cognitive changes.

Peripheral artery disease and clinical outcomes in patients with atrial fibrillation: A report from the FANTASIIA registry

BACKGROUND

Atrial fibrillation (AF) and peripheral artery disease (PAD) are common conditions that increase cardiovascular risk. We determined the association between PAD and prognosis in a cohort of real-world patients receiving oral anticoagulant therapy for nonvalvular AF.

METHODS

We prospectively included 1956 patients (mean age 73.8 ± 9.5 years, 44.0% women) receiving oral anticoagulant therapy for AF. Clinical characteristics were collected at baseline. Patients were followed for a period of 3 years. Survival analysis and multivariable regression analyses were performed to assess variables related to death, stroke, bleeding, myocardial infarction and major adverse cardiovascular events (MACE).

RESULTS

Patients with PAD (n = 118; 6%) exhibited higher rates of cardiovascular risk factors and cardiovascular diseases. After 3 years of follow-up, there were a total of 255 deaths (no PAD 233, vs PAD 22), 45 strokes (43 vs 2), 146 major bleedings (136 vs 10) and 168 MACE (148 vs 20). On univariate analysis, there was a higher risk of cardiovascular mortality (2.02%/year no PAD vs 4.08%/year PAD, P = .02), myocardial infarction (0.99%/year no PAD vs 2.43%/year PAD, P = .02) and MACE (3.18%/year no PAD vs 6.99%/year PAD, P < .01). There was no statistically significant association with these events after multivariable adjustment.

CONCLUSIONS

In a large cohort of anticoagulated patients with AF, the presence of PAD represents a higher risk subgroup and is associated with worse crude outcomes. The exact contribution of the PAD independently of other cardiovascular diseases or risk factors requires further investigation.

Thromboembolic events in atrial fibrillation: Different level of risk and pattern between peripheral artery disease and coronary artery disease

BACKGROUND

The existence of vascular disease in patients with atrial fibrillation (AF) is associated with an increased risk of thromboembolic events. It is unclear whether coronary artery disease (CAD) and/or peripheral artery disease (PAD) have similar presentations and complication rates.

AIM

To investigate thromboembolic events among patients with AF who have CAD, PAD or polyvascular disease.

METHODS

Patients with a new diagnosis of AF without anticoagulation (n=306,386) were identified from the National Health Insurance Research Database in Taiwan (2001-2013). Ischaemic stroke (IS), systemic thromboembolism (STE) and their combination (IS/STE) were compared in four groups (No-CAD/PAD, CAD-only, PAD-only, CAD+PAD), and secondarily in patients with only CAD versus only PAD. Last, we compared propensity score-matched patients with only CAD or PAD with those with CAD and PAD.

RESULTS

There were 185,169 patients without CAD or PAD, 8113 patients with only PAD, 105,715 patients with only CAD, and 7389 patients with CAD and PAD eligible for analysis (mean±SD follow-up 3.2±3.2 years). The incidences of STE and IS/STE differed in the four groups, with the highest in the CAD+PAD group and the lowest in the No-CAD/PAD group. The proportions of IS and STE also varied, with higher proportions of STE in patients with PAD, but higher proportions of IS in patients with CAD. After propensity score matching, the PAD-only group had significantly higher incidences of STE and IS/STE than the CAD-only group, across all levels of CHA₂DS₂-VASc score. Patients with CAD and PAD had a significantly higher incidence of STE and IS/STE than propensity score-matched patients with CAD or PAD.

CONCLUSIONS

PAD or CAD in patients with AF did not contribute equally to the risk prediction and presentation of IS and STE. Patients with polyvascular disease should be considered at higher risk than those with either condition.

Gender Difference in the Risk of Adverse Outcomes After Diabetic Foot Disease: A Mini-Review

Diabetic foot disease (DFD) is a complication of diabetes mellitus, characterized by multiple pathogenetic factors, bearing a very high burden of disability as well as of direct and indirect costs for individuals or healthcare systems. A further characteristic of DFD is that it is associated with a marked risk of subsequent hospitalizations for incident cardiovascular events, chronic renal failure or of allcause mortality. Additionally, DFD is strongly linked to the male sex, being much more prevalent among men. However, even if DFD mainly affects males, several past reports suggest that females are disadvantaged as regards the risk of subsequent adverse outcomes. This review aims to clarify this point, attempting to provide an explanation for this apparent oddity: being DFD a typically male complication of diabetes but, seemingly, with a greater load of subsequent consequences for females.

Discordant Values in Lower Extremity Physiologic Studies Predict Increased Cardiovascular Risk

Background

Ankle‐brachial indexes (ABI) are a noninvasive diagnostic tool for peripheral arterial disease and a marker of increased cardiovascular risk. ABI is calculated using the highest systolic blood pressure of the 4 ankle arteries (bilateral dorsalis pedis and posterior tibial). Accordingly, patients may be assigned a normal ABI when the result would be abnormal if calculated using one of the other blood pressure readings. Cardiovascular outcomes for patients with discordant ABIs are undescribed.

Methods and Results

We performed a retrospective study of patients who underwent ABI measurement for any indication between January 1996 and June 2018. Those with normal ABIs (1.00–1.39) were included. We compared patients with all 4 normal ABIs (calculated using all 4 ankle arteries; n=15 577, median age 64.0 years, 54.4% men) to those with discordant ABIs (at least 1 abnormal ABI ≤0.99; n=2095, median age 66.0 years, 47.8% men). The outcomes assessed were ischemic stroke, myocardial infarction, and all‐cause mortality. Compared with patients with concordant normal ABIs, patients with discordant ABIs were older; women; smoked; and had chronic kidney disease, coronary artery disease, diabetes mellitus, chronic obstructive pulmonary disease, hypertension, or prior stroke. Patients with discordant ABIs had a greater risk of myocardial infarction (hazard ratio [HR], 1.31; 95% CI, 1.10–1.56), ischemic stroke (HR, 1.53; 95% CI, 1.37–1.72), and all‐cause mortality (HR, 1.27; 95% CI, 1.16–1.39), including after adjustment for baseline comorbidities.

Conclusions

Discordant ABI results were associated with an increased risk of myocardial infarction, stroke, and all‐cause mortality in the studied population. Clinicians should examine ABI calculations using all 4 ankle arteries to better characterize a patient's cardiovascular risk.

Atrial Fibrillation and Surgical Patients with Peripheral Arterial Disease

BACKGROUND

Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice and its prevalence rate significantly increases with age. The prognostic implication of AF in surgical patients with peripheral arterial disease (PAD) has not been analyzed. The aims of this study were to analyze the prevalence of AF among patients operated on with symptomatic PAD, and to determine whether these patients are at a higher risk of death or amputation.

METHODS

We designed a retrospective cohort study, from January 2013 to December 2017, in which we analyzed the medical records of all consecutive patients with symptomatic PAD admitted to our hospital and underwent a vascular procedure. We compared the outcomes of patients with and without AF. All statistically significant demographic variables that underwent a univariate analysis were inserted in the stepwise multivariate model along with AF. A survival analysis was performed to evaluate the factors associated with mortality through a Cox regression model. P-value of 0.05 was considered statistically significant.

RESULTS

Four hundred three patients were admitted in-hospital with symptomatic PAD and they underwent a vascular intervention. The mean follow-up was 2 years. Seventy-six patients (18.8%) had AF. These patients were older (78 ± 9.1 years) than the 327 patients without AF (68 ± 12.37 years) (P < 0.0001), and more likely to undergo emergency surgery (18.42% vs. 7.34%, P = 0.0029). Age and emergency admission were dependent associates of AF. The patients with AF were frequently men (69.7%) with previous hypertension (96% %). The presence of AF was associated with higher rate of all-cause mortality (55.26%, P < 0.0001, hazard ratio 2.24, confidence interval 1.55-3.25), but the multivariate analysis adjusted for risk factors showed that the mortality was only associated with age because these patients were older and with many comorbidities. The majority of this population with AF showed some tissue lesion when they were admitted in-hospital (Rutherford V-VI, AF 80.2%, P = 0.0004), and this fact justified that a 22.36% underwent a major amputation affecting the ischemic lower limb in admission (P = 0.018). During the follow-up the free amputation rate was similar between groups (60.5% AF vs. 78.3% non-AF).

CONCLUSIONS

This study showed the high prevalence of AF in patients with symptomatic PAD that required surgical admission in-hospital. The presence of AF was related with a greater and serious risk of mortality, but this was independently associated to age, because patients with AF were older and frailer. Clearly, this group of patients had a high risk of amputation when they arrived to the hospital and they needed emergency surgery.

Association between anatomical distribution of symptomatic peripheral artery disease and cerebrovascular disease

AIM

Peripheral arterial disease is frequently associated with significant atherosclerosis of other vascular beds. The aim of the present study was to investigate a possible association between peripheral arterial disease segment-specific disease burden and cerebrovascular disease.

METHODS

Two-hundred and twenty-six patients with clinically symptomatic peripheral arterial disease from the prospective PureASO registry were followed up after revascularization. The breadth of peripheral arterial disease was quantified at the time patients entered the study. The segment-specific peripheral arterial disease burden was correlated to cerebrovascular disease and imaging findings during a five-year follow-up.

RESULTS

At five years, cerebrovascular disease-free survival after lower limb revascularization was 31%. Patients with peripheral arterial disease involving the crural arteries had significantly more ischemic degenerative changes at brain imaging (p = 0.031), whereas patients with aorto-iliac and femoropopliteal segment peripheral arterial disease had more significant (>50% uni- or bilaterally) internal carotid artery stenosis compared to patients with crural peripheral arterial disease (p = 0.006). According to Cox regression analyses, crural arteries burden was associated with a significantly increased risk of mortality (adjusted HR 2.07, CI 95% 1.12-3.28, p = 0.021) and cerebrovascular events (adjusted HR 1.97, CI 95% 1.19-3.26, p = 0.008).

CONCLUSIONS

Present results suggest that atherosclerosis burden at different lower limb artery segments is associated with defined cerebrovascular disease. This further suggests that risk factors and pathophysiological mechanisms are congruent across particular vascular beds.

Fasting plasma glucose variability and HbA1c are associated with peripheral artery disease risk in type 2 diabetes

BACKGROUND

This study investigated whether visit-to-visit fasting plasma glucose (FPG) variability, as measured by the coefficient of variation (CV), increased peripheral artery disease (PAD) risk.

METHODS

Individuals with type 2 diabetes from the National Diabetes Care Management Program during the period 2002-2004, ≥ 30 years of age, and free of PAD (n = 30,932) were included and monitored until 2011. Cox proportional hazards regression models were implemented to analyze related determinants of PAD.

RESULTS

A total of 894 incident cases of PAD were identified during an average 8.2 years of follow-up, resulting in a crude incidence rate of 3.53 per 1000 person-years. Both FPG-CV and HbA1c were significantly associated with PAD after multivariate adjustment, with corresponding hazard ratios of 1.24 [95% confidence interval (CI) 1.04-1.47] for FPG-CV in the third tertile and 1.50 (95% CI 1.10-2.04) for HbA1c ≥ 10%. The findings of the sensitivity analysis remained consistent after excluding potential confounders, demonstrating the consistency of the results.

CONCLUSIONS

The associations between HbA1c, variability in FPG-CV, and PAD suggest a linked pathophysiological mechanism, suggesting the crucial role of glycemic variability in clinical management and therapeutic goals in preventing PAD in type 2 diabetes.

Effect of concomitant antiplatelet therapy in patients with nonvalvular atrial fibrillation initiating non-vitamin K antagonists

BACKGROUND

Antiplatelet therapy (APT) use in combination with oral anticoagulation is common among patients with atrial fibrillation, but there is scarce information regarding its effect on outcomes in patients on non-vitamin K antagonist oral anticoagulants (NOAC). We aimed to evaluate the safety and efficacy of APT use in a 'real-world' cohort of nonvalvular atrial fibrillation (NVAF) patients initiating NOAC.

DESIGN

We conducted a retrospective multicentre study including 2361 consecutive NVAF patients initiating NOAC between January 2013 and December 2016. Patients with an acute ischaemic event within the last 12 months (acute coronary syndrome, stroke or revascularization) were excluded. Patients were followed up, and all clinical events were recorded at 3 months. The primary outcome of the study was major bleeding, and the secondary outcomes were stroke, nonfatal myocardial infarction, intracranial bleeding and death.

RESULTS

One hundred forty-five (6.1%) patients received concomitant APT, and aspirin was the more common (79%). At 3 months, 25 (1.1%) patients had major bleeding, 8 (0.3%) had nonfatal myocardial infarction, 7 (0.3%) had ischaemic stroke, and 40 (1.7%) died. After multivariate adjustment, concomitant APT was associated with higher risk for major bleeding (HR = 3.62, 95% CI 1.32-9.89; P = .012), but was not associated with a higher risk of other clinical outcomes.

CONCLUSIONS

Concomitant APT use is uncommon among these patients and does not seem to be associated with lower rates of ischaemic events or death. However, there are signals for an increased risk of bleeding, which reinforces current guideline recommendations.

Gender difference in the risk for cardiovascular events or mortality of patients with diabetic foot syndrome

AIMS

Diabetic foot syndrome (DFS) increases the risk for atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), or mortality. The present study aims at ascertaining whether such DFS-related excess risk differs between genders, retrospectively investigating a population with diabetes from Tuscany, Italy, followed-up for 6 years (2011-2016).

METHODS

People with diabetes living in Tuscany on January 1st 2011 identified by administrative databases, were divided by baseline history of prior DFS hospitalizations, stratified by presence/absence of peripheral vascular disease and evaluating, by Cox regression analysis, whether adjusted DFS-related excess risk of incident ASCVD, CKD or mortality differed between genders.

RESULTS

In an overall population of 165,650 subjects with diabetes (81,829M/83,821F), basal prevalence of DFS was twice higher among males, who were moreover at a significantly greater risk of all considered outcomes along the 6-year period. On the contrary, baseline DFS significantly increased the hospitalization risk for ASCVD, CKD and mortality equally or at a slightly greater extent in females, while the risk for stroke was significantly associated with DFS only among females (HR: 1.622 (1.314-1.980); p = 0.0001 vs. HR: 1.132 (0.955-1.332); p = NS). This finding was even reinforced in non-vascular DFS, which was associated with a significant raised risk for stroke, heart failure or mortality exclusively in females.

CONCLUSIONS

In this population, DFS prevalence and overall risk for ASCVD, CKD or mortality were significantly higher among males. Baseline co-presence of DFS, however, conferred a similar adjusted risk for all these outcomes between genders, and in case of non-vascular DFS the risk was significantly increased only among females.

Living a burdensome and demanding life: A qualitative systematic review of the patients experiences of peripheral arterial disease

Background

Peripheral arterial disease (PAD) has a significant negative impact on the quality of life of individuals. Understanding the experiences of people living with PAD will be useful in developing comprehensive patient-centred secondary prevention therapies for this population.

Aim

The aim of this study is to identify first-hand accounts of patients’ experiences of living with PAD.

Methods

Six databases (CINALH, PsyclNFO, MEDLINE, AMED, EMBASE, Social citation index/Science citation index via Web of Science (WOS)) and reference lists of identified studies were searched until September 2017 (updated February 2018). Qualitative studies reporting patients’ account of living with PAD were eligible for inclusion. A framework thematic synthesis was implemented.

Results

Fourteen studies with 360 participants were included. Pain and walking limitation were recurrent among the varied symptom descriptions. Patients’ ignorance and trivialisation of symptoms contributed to delays in diagnosis. Inadequate engagement in disease understanding and treatment decisions meant patients had poor attitudes towards walking treatments and unrealistic expectations about surgery. Depending on symptom progression, patients battle with walking impairment, powerlessness, and loss of independence which were a source of burden to them. Lack of disease understanding is central through patients’ journey with PAD and, although they subsequently began adaptation to long term living with PAD, many worried about their future.

Conclusions

Disease understanding is vital across the illness trajectory in patients with PAD. Although certain experiences are common throughout patient journey, some might be unique to a particular stage (e.g. unrealistic expectation about surgery, or rationale of walking in spite of pain in a supervised exercise program). Given that PAD is an overarching construct ranging from the mildest form of intermittent claudication to severe critical limb ischemia with ulceration and gangrene, consideration of important patient constructs specific to each stage of the disease may enhance treatment success. Systematic review registration CRD42017070417.

Effectiveness and Safety of Anticoagulants in Adults with Non-valvular Atrial Fibrillation and Concomitant Coronary/Peripheral Artery Disease

BACKGROUND

Direct oral anticoagulants (DOAC) are at least non-inferior to warfarin in efficacy and safety among patients with nonvalvular atrial fibrillation. Limited evidence is available regarding outcomes for nonvalvular atrial fibrillation patients with coronary/peripheral artery disease.

METHODS

Non-valvular atrial fibrillation patients aged ≥65 years diagnosed with coronary/peripheral artery disease in the US Medicare population, newly initiating DOACs (apixaban, rivaroxaban, dabigatran) or warfarin were selected from January 1, 2013 to September 30, 2015. Propensity score matching was used to compare DOACs vs warfarin. Cox proportional hazards models were used to estimate the risk of stroke/systemic embolism, major bleeding, and composite of stroke/myocardial infarction/all-cause mortality.

RESULTS

There were 15,527 apixaban-warfarin, 6,962 dabigatran-warfarin, and 25,903 rivaroxaban-warfarin-matched pairs, with a mean follow-up of 5-6 months. Compared with warfarin, apixaban was associated with lower rates of stroke/systemic embolism (hazard ratio [HR] 0.48; 95% confidence interval [CI], 0.37-0.62), major bleeding (HR 0.66; 95% CI, 0.58-0.75), and stroke/myocardial infarction/all-cause mortality (HR 0.63; 95% CI, 0.58-0.69); dabigatran and rivaroxaban were associated with lower rates of stroke/myocardial infarction/all-cause mortality (HR 0.79; 95% CI, 0.70-0.90 and HR 0.87; 95% CI, 0.81-0.92, respectively). Rivaroxaban was associated with a lower rate of stroke/systemic embolism (HR 0.72; 95% CI, 0.60-0.89) and a higher rate of major bleeding (HR 1.14; 95% CI, 1.05-1.23) vs warfarin.

CONCLUSIONS

All DOACs were associated with lower stroke/myocardial infarction/all-cause mortality rates compared with warfarin; differences were observed in rates of stroke/systemic embolism and major bleeding. Findings from this observational analysis provide important insights about oral anticoagulation therapy among non-valvular atrial fibrillation patients with coronary/peripheral artery disease and may help physicians in the decision-making process when treating this high-risk group of patients.

Peripheral Arterial Disease

Peripheral arterial disease (PAD) affects 15% of the Australian population and is a powerful and serious predictor of cardiovascular mortality yet continues to be under-recognised and undertreated. Diagnosis is simple and management is centred upon symptom relief and risk minimisation. While novel and specialised therapies play a role, the bulk of management is approachable and feasible. In this review, we cover the epidemiology, risk factors, associated conditions, classification, and natural history of PAD. We then discuss current diagnostic and therapeutic options as well as emerging therapies for this common condition.

Atrial fibrillation as a prognostic indicator of myocardial infarction and cardiovascular death: a systematic review and meta-analysis

This study aimed to investigate whether atrial fibrillation (AF) predicts myocardial infarction (MI) or cardiovascular (CV) death. AF is a well-established risk factor for thrombotic stroke and all-cause mortality. PubMed, EmBase, and Cochrane Central were searched for articles comparing the incidence rates of MI, CV death, or CV events between AF and non-AF patients. Relative risk ratio (RR) was used as effect estimate. Crude and adjusted RRs were calculated. Data were pooled using a random-effects model. The meta-analysis included 27 studies. In the unadjusted analysis, AF patients had a nonsignificant trend toward a higher risk of MI compared with non-AF patients; however, a significant association was found. The crude data analysis showed that AF was associated with increased risk of CV death (P < 0.05) and CV events (P < 0.05). These associations remained significant after pooling data from adjusted models (CV death: RR = 1.95, 95% CI 1.51–2.51, P < 0.05; CV events: RR = 2.10, 95% CI 1.50–2.95, P < 0.05). These results showed that AF is an independent risk factor for MI, CV death, and CV events.

Presentations of major peripheral arterial disease and risk of major outcomes in patients with type 2 diabetes: results from the ADVANCE-ON study

Background

Peripheral arterial disease (PAD) is known to be associated with high cardiovascular risk, but the individual impact of PAD presentations on risk of macrovascular and microvascular events has not been reliably compared in patients with type 2 diabetes. We aimed to evaluate the impact of major PAD, and its different presentations, on the 10-year risk of death, major macrovascular events, and major clinical microvascular events in these patients.

Methods

Participants in the action in diabetes and vascular disease: PreterAx and DiamicroN modified-release controlled evaluation (ADVANCE) trial and the ADVANCE-ON post-trial study were followed for a median of 5.0 (in-trial), 5.4 (post-trial), and 9.9 (overall) years. Major PAD at baseline was subdivided into lower-extremity chronic ulceration or amputation secondary to vascular disease and history of peripheral revascularization by angioplasty or surgery.

Results

Among 11,140 participants, 516 (4.6 %) had major PAD at baseline: 300 (2.7 %) had lower-extremity ulceration or amputation alone, 190 (1.7 %) had peripheral revascularization alone, and 26 (0.2 %) had both presentations. All-cause mortality, major macrovascular events, and major clinical microvascular events occurred in 2265 (20.3 %), 2166 (19.4 %), and 807 (7.2 %) participants, respectively. Compared to those without PAD, patients with major PAD had increased rates of all-cause mortality (HR 1.35, 95 % CI 1.15–1.60, p = 0.0004), and major macrovascular events (1.47 [1.23–1.75], p < 0.0001), after multiple adjustments for region of origin, cardiovascular risk factors and treatments, peripheral neuropathy markers, and randomized treatments. We have also observed a trend toward an association of baseline PAD with risk of major clinical microvascular events [1.31 (0.96–1.78), p = 0.09]. These associations were comparable for patients with a lower-extremity ulceration or amputation and for those with a history of peripheral revascularization. Furthermore, the risk of retinal photocoagulation or blindness, but not renal events, increased in patients with lower-extremity ulceration or amputation [1.53 (1.01–2.30), p = 0.04].

Conclusions

Lower-extremity ulceration or amputation, and peripheral revascularization both increased the risks of death and cardiovascular events, but only lower-extremity ulceration or amputation increased the risk of severe retinopathy in patients with type 2 diabetes. Screening for major PAD and its management remain crucial for cardiovascular prevention in patients with type 2 diabetes (ClinicalTrials.gov number, NCT00949286).

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-016-0446-x) contains supplementary material, which is available to authorized users.