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Flores AM, Schuler A, Eberhard AV, Olin JW, Cooke JP, Leeper NJ, Shah NH, Ross EG. Unsupervised Learning for Automated Detection of Coronary Artery Disease Subgroups. J Am Heart Assoc 2021; 10:e021976. [PMID: 34845917 PMCID: PMC9075403 DOI: 10.1161/jaha.121.021976] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 10/14/2021] [Indexed: 12/24/2022]
Abstract
Background The promise of precision population health includes the ability to use robust patient data to tailor prevention and care to specific groups. Advanced analytics may allow for automated detection of clinically informative subgroups that account for clinical, genetic, and environmental variability. This study sought to evaluate whether unsupervised machine learning approaches could interpret heterogeneous and missing clinical data to discover clinically important coronary artery disease subgroups. Methods and Results The Genetic Determinants of Peripheral Arterial Disease study is a prospective cohort that includes individuals with newly diagnosed and/or symptomatic coronary artery disease. We applied generalized low rank modeling and K-means cluster analysis using 155 phenotypic and genetic variables from 1329 participants. Cox proportional hazard models were used to examine associations between clusters and major adverse cardiovascular and cerebrovascular events and all-cause mortality. We then compared performance of risk stratification based on clusters and the American College of Cardiology/American Heart Association pooled cohort equations. Unsupervised analysis identified 4 phenotypically and prognostically distinct clusters. All-cause mortality was highest in cluster 1 (oldest/most comorbid; 26%), whereas major adverse cardiovascular and cerebrovascular event rates were highest in cluster 2 (youngest/multiethnic; 41%). Cluster 4 (middle-aged/healthiest behaviors) experienced more incident major adverse cardiovascular and cerebrovascular events (30%) than cluster 3 (middle-aged/lowest medication adherence; 23%), despite apparently similar risk factor and lifestyle profiles. In comparison with the pooled cohort equations, cluster membership was more informative for risk assessment of myocardial infarction, stroke, and mortality. Conclusions Unsupervised clustering identified 4 unique coronary artery disease subgroups with distinct clinical trajectories. Flexible unsupervised machine learning algorithms offer the ability to meaningfully process heterogeneous patient data and provide sharper insights into disease characterization and risk assessment. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00380185.
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Affiliation(s)
- Alyssa M. Flores
- Division of Vascular SurgeryDepartment of SurgeryStanford University School of MedicineStanfordCA
| | - Alejandro Schuler
- Center for Biomedical Informatics ResearchStanford UniversityStanfordCA
| | - Anne Verena Eberhard
- Division of Vascular SurgeryDepartment of SurgeryStanford University School of MedicineStanfordCA
| | - Jeffrey W. Olin
- Zena and Michael A. Wiener Cardiovascular InstituteMarie‐Josée and Henry R. Kravis Center for Cardiovascular HealthIcahn School of Medicine at Mount SinaiNew YorkNY
| | - John P. Cooke
- Department of Cardiovascular SciencesHouston Methodist Research InstituteHoustonTX
| | - Nicholas J. Leeper
- Division of Vascular SurgeryDepartment of SurgeryStanford University School of MedicineStanfordCA
- Division of Cardiovascular MedicineDepartment of MedicineStanford University School of MedicineStanfordCA
- Stanford Cardiovascular InstituteStanfordCA
| | - Nigam H. Shah
- Center for Biomedical Informatics ResearchStanford UniversityStanfordCA
| | - Elsie G. Ross
- Division of Vascular SurgeryDepartment of SurgeryStanford University School of MedicineStanfordCA
- Center for Biomedical Informatics ResearchStanford UniversityStanfordCA
- Stanford Cardiovascular InstituteStanfordCA
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2
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Accuracy of Ankle-Brachial Index, Toe-Brachial Index, and Risk Classification Score in Discriminating Peripheral Artery Disease in Patients With Chronic Kidney Disease. Am J Cardiol 2021; 160:117-123. [PMID: 34583809 DOI: 10.1016/j.amjcard.2021.08.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 11/24/2022]
Abstract
The accuracy of ankle-brachial index (ABI) and toe-brachial index (TBI) in discriminating lower extremity peripheral artery disease (PAD) has not been evaluated in patients with chronic kidney disease (CKD). We measured ABI, TBI, and Doppler ultrasound in 100 predialysis patients with CKD without revascularization or amputation. Leg-specific ABI was calculated using higher systolic blood pressure (SBP) in posterior tibial or dorsalis pedis artery divided by higher brachial SBP; alternative ABI was calculated using lower SBP in posterior tibial or dorsalis pedis artery. PAD was defined as ≥50% stenosis detected by Doppler ultrasound. PAD risk classification score was calculated using cardiovascular disease risk factors. The area under the curve (AUC, 95% confidence interval [CI]) for discriminating ultrasound-diagnosed PAD was 0.78 (0.69 to 0.87) by ABI, 0.80 (0.71 to 0.89) by alternative ABI, and 0.74 (0.63 to 0.86) by TBI. Sensitivity and specificity were 25% and 97% for ABI ≤0.9, 41% and 95% for alternative ABI ≤0.9, and 45% and 93% for TBI ≤0.7, respectively. AUC (95% CI) of PAD risk classification score was 0.86 (0.78 to 0.94) with sensitivity and specificity of 95% and 60% for risk score ≥0.10, 76% and 76% for risk score ≥0.25, and 43% and 95% for risk score ≥0.55. Combining risk score with ABI, alternative ABI, and TBI increased AUC (95% CI) to 0.89 (0.82 to 0.96), 0.89 (0.80 to 0.98), and 0.87 (0.78 to 0.96), respectively. In conclusion, current ABI and TBI diagnostic criteria have high specificity but low sensitivity for classifying PAD in patients with CKD. PAD classification risk score based on cardiovascular disease risk factors improves the accuracy of PAD classification.
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3
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Hiatt WR, Hess CN, Bonaca MP, Kavanagh S, Patel MR, Baumgartner I, Berger JS, Blomster JI, Jones WS, Katona BG, Mahaffey KW, Norgren L, Rockhold FW, Fowkes FGR. Ankle-Brachial Index for Risk Stratification in Patients With Symptomatic Peripheral Artery Disease With and Without Prior Lower Extremity Revascularization: Observations From the EUCLID Trial. Circ Cardiovasc Interv 2021; 14:e009871. [PMID: 34253048 DOI: 10.1161/circinterventions.120.009871] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- William R Hiatt
- Division of Cardiology, University of Colorado School of Medicine, Aurora (W.R.H., C.N.H., M.P.B.).,CPC Clinical Research, Aurora, CO (W.R.H., C.N.H., M.P.B., S.K.)
| | - Connie N Hess
- Division of Cardiology, University of Colorado School of Medicine, Aurora (W.R.H., C.N.H., M.P.B.).,CPC Clinical Research, Aurora, CO (W.R.H., C.N.H., M.P.B., S.K.)
| | - Marc P Bonaca
- Division of Cardiology, University of Colorado School of Medicine, Aurora (W.R.H., C.N.H., M.P.B.).,CPC Clinical Research, Aurora, CO (W.R.H., C.N.H., M.P.B., S.K.)
| | - Sarah Kavanagh
- CPC Clinical Research, Aurora, CO (W.R.H., C.N.H., M.P.B., S.K.)
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., W.S.J., F.W.R.)
| | - Iris Baumgartner
- Swiss Cardiovascular Center, University of Bern, Switzerland (I.B.)
| | - Jeffrey S Berger
- Departments of Medicine and Surgery, New York University School of Medicine (J.S.B.)
| | | | - W Schuyler Jones
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P., W.S.J., F.W.R.)
| | | | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Stanford University School of Medicine, CA (K.W.M.)
| | - Lars Norgren
- Faculty of Medicine and Health, Örebro University, Sweden (L.N.)
| | | | - F Gerry R Fowkes
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom (F.G.R.F)
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4
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Kyle D, Boylan L, Wilson L, Haining S, Oates C, Sims A, Guri I, Allen J, Wilkes S, Stansby G. Accuracy of Peripheral Arterial Disease Registers in UK General Practice: Case-Control Study. J Prim Care Community Health 2021; 11:2150132720946148. [PMID: 32959726 PMCID: PMC7513392 DOI: 10.1177/2150132720946148] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Approximately 20% of the UK population aged 55 to 75 years have evidence of
peripheral arterial disease (PAD). PAD affects quality of life and life
expectancy if not appropriately diagnosed and managed. At risk patients
require accurate diagnosis to ensure optimal treatment to slow disease
progression and minimize adverse outcomes. Aim: To assess the accuracy of general practice (GP) registration of the diagnosis
of peripheral arterial disease (PAD). Design and Setting: An observational analytic case-control study. As part of a National Institute
for Health Research–funded (ISRCTN13301188) project assessing novel
diagnostic methods set in GP practice. Methods: A total of 125 patients registered as having PAD and 125 age- and sex-matched
controls were recruited from 15 general practices across North East England.
The register was then assessed for accuracy of diagnosis. Duplex vascular
ultrasound scanning (DUS) undertaken by vascular scientists was used as the
gold standard reference for PAD. Results: The PAD register had a sensitivity of 86% (95% CI 77%-92%) and specificity of
74% (95% CI 67%-81%) when compared with DUS. The positive predictive value,
however, was 69.6% (95% CI 63%-75%) and negative predictive value 88.8% (95%
CI 82%-92%). The overall diagnostic effectiveness of the PAD register was
79.2% (95% CI 73%-84%). Conclusion: This analysis indicates that while PAD is detected with reasonable
sensitivity in primary care, many patients registered with a diagnosis of
PAD lacked DUS-proven disease. Improved approaches to the objective
diagnosis of PAD may improve diagnosis and management of PAD in primary
care.
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Affiliation(s)
- Daniel Kyle
- Freeman Hospital, The Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, UK.,University of Newcastle, Newcastle upon Tyne, UK
| | - Luke Boylan
- Freeman Hospital, The Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, UK.,University of Newcastle, Newcastle upon Tyne, UK
| | - Lesley Wilson
- Freeman Hospital, The Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, UK
| | - Shona Haining
- North of England Commissioning Support (NECS), Durham, UK
| | - Crispian Oates
- Freeman Hospital, The Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, UK
| | - Andrew Sims
- Freeman Hospital, The Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, UK.,University of Newcastle, Newcastle upon Tyne, UK
| | - Ina Guri
- Freeman Hospital, The Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, UK.,University of Newcastle, Newcastle upon Tyne, UK
| | - John Allen
- Freeman Hospital, The Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, UK.,University of Newcastle, Newcastle upon Tyne, UK
| | - Scott Wilkes
- University of Sunderland, Sunderland, Tyne and Wear, UK
| | - Gerry Stansby
- Freeman Hospital, The Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, UK
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5
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Abstract
The prevalence of peripheral arterial disease (PAD) in the United States exceeds 10 million people, and PAD is a significant cause of morbidity and mortality across the globe. PAD is typically caused by atherosclerotic obstructions in the large arteries to the leg(s). The most common clinical consequences of PAD include pain on walking (claudication), impaired functional capacity, pain at rest, and loss of tissue integrity in the distal limbs that may lead to lower extremity amputation. Patients with PAD also have higher than expected rates of myocardial infarction, stroke, and cardiovascular death. Despite advances in surgical and endovascular procedures, revascularization procedures may be suboptimal in relieving symptoms, and some patients with PAD cannot be treated because of comorbid conditions. In some cases, relieving obstructive disease in the large conduit arteries does not assure complete limb salvage because of severe microvascular disease. Despite several decades of investigational efforts, medical therapies to improve perfusion to the distal limb are of limited benefit. Whereas recent studies of anticoagulant (eg, rivaroxaban) and intensive lipid lowering (such as PCSK9 [proprotein convertase subtilisin/kexin type 9] inhibitors) have reduced major cardiovascular and limb events in PAD populations, chronic ischemia of the limb remains largely resistant to medical therapy. Experimental approaches to improve limb outcomes have included the administration of angiogenic cytokines (either as recombinant protein or as gene therapy) as well as cell therapy. Although early angiogenesis and cell therapy studies were promising, these studies lacked sufficient control groups and larger randomized clinical trials have yet to achieve significant benefit. This review will focus on what has been learned to advance medical revascularization for PAD and how that information might lead to novel approaches for therapeutic angiogenesis and arteriogenesis for PAD.
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Affiliation(s)
- Brian H Annex
- Vascular Biology Center, Department of Medicine, Medical College of Georgia, Augusta University (B.H.A.)
| | - John P Cooke
- Department of Cardiovascular Sciences, Houston Methodist Research Institute, TX (J.P.C.)
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6
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Unkart JT, Allison MA, Araneta MRG, Ix JH, Matsushita K, Criqui MH. Burden of Peripheral Artery Disease on Mortality and Incident Cardiovascular Events. Am J Epidemiol 2020; 189:951-962. [PMID: 32242233 DOI: 10.1093/aje/kwaa051] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 03/23/2020] [Accepted: 03/24/2020] [Indexed: 02/07/2023] Open
Abstract
Using data from the Multi-Ethnic Study of Atherosclerosis (United States, 2000-2015), 6,527 racially/ethnically diverse adults (mean age, 62 (standard deviation, 10) years) free of known cardiovascular (CVD) had ankle brachial index (ABI) assessment of their bilateral dorsalis pedis/posterior tibial arteries (4 vessels total) and were followed for total mortality and incident CVD events/mortality. Individuals were classified into categories of 0-, 1-, 2-, 3- or 4-vessel peripheral artery disease (PAD) (ABI of ≤0.9). There were 1,202 deaths (18%), 656 incident CVD events (10%), and 282 CVD deaths (4.3%). Of the 6,527 individuals, 5,711 (87.5%) had 0-, 460 (7.0%) had 1-, 218 (3.3%) had 2-, 69 (1.1%) had 3-, and 69 (1.1%) had 4-vessel PAD, respectively. In multivariable Cox models, higher number of vessels with PAD was associated with higher risk of mortality (P for trend <0.001), CVD events (P for trend = 0.002), and CVD mortality (P for trend = 0.001). Compared with individuals who had 0-vessel disease, hazard ratios for mortality were 1.29 (95% confidence interval (CI): 1.06, 1.59) for 1-, 1.45 (95% CI: 1.14, 1.86) for 2-, 1.58 (95% CI: 1.13, 2.21) for 3-, and 2.15 (95% CI: 1.58, 2.94) for 4-vessel disease. A similar pattern was seen for CVD events/mortality. These results suggest the importance of accounting for ABI values of all 4 leg arteries in clinical practice and research.
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7
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Abstract
Peripheral arterial disease (PAD) affects many individuals worldwide and is associated with increased morbidity and mortality. Controversy exists on whether or not to screen asymptomatic patients. Further complicating this is that many patients with a chronic lower extremity wound are often asymptomatic. PAD and traditional noninvasive vascular studies may be inaccurate in providing a correct diagnosis. A review of current and novel vascular assessment modalities along with their benefits and limitations are presented here. A combination of these vascular assessments may help improve accuracy in diagnosis, providing timely care to those patients in need.
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Affiliation(s)
- Jonathan F Arnold
- Mercy Healing Center, 701 10th Street Southeast, Cedar Rapids, IA 52403, USA.
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8
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Abstract
Peripheral artery disease is a common disorder and a major cause of morbidity and mortality worldwide. Therapy is directed at reducing the risk of major adverse cardiovascular events and at ameliorating symptoms. Medical therapy is effective at reducing the incidence of myocardial infarction and stroke to which these patients are prone but is inadequate in relieving limb-related symptoms, such as intermittent claudication, rest pain, and ischemic ulceration. Limb-related morbidity is best addressed with surgical and endovascular interventions that restore perfusion. Current medical therapies have only modest effects on limb blood flow. Accordingly, there is an opportunity to develop medical approaches to restore limb perfusion. Vascular regeneration to enhance limb blood flow includes methods to enhance angiogenesis, arteriogenesis, and vasculogenesis using angiogenic cytokines and cell therapies. We review the molecular mechanisms of these processes; briefly discuss what we have learned from the clinical trials of angiogenic and cell therapies; and conclude with an overview of a potential new approach based upon transdifferentiation to enhance vascular regeneration in peripheral artery disease.
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Affiliation(s)
- John P Cooke
- From the Department of Cardiovascular Sciences, Center for Cardiovascular Regeneration, Houston Methodist Research Institute, TX
| | - Shu Meng
- From the Department of Cardiovascular Sciences, Center for Cardiovascular Regeneration, Houston Methodist Research Institute, TX
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9
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Brown RJL. Review of article: The intrinsic prognostic value of the ankle-brachial index is independent from its mode of calculation. Le Bivic L, Magne J, Guy-Moyat B, Wojtyna H, Lacroix P, Blossier J, Le Guyader A, Desormais I, and Aboyans V. Journal of Vascular Medicine 2019;24(1):23-31. JOURNAL OF VASCULAR NURSING 2019; 37:150-152. [PMID: 31155163 DOI: 10.1016/j.jvn.2019.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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10
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Le Bivic L, Magne J, Guy-Moyat B, Wojtyna H, Lacroix P, Blossier JD, Le Guyader A, Desormais I, Aboyans V. The intrinsic prognostic value of the ankle-brachial index is independent from its mode of calculation. Vasc Med 2018; 24:23-31. [PMID: 30426857 DOI: 10.1177/1358863x18807003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The object of this study was to compare the prognostic value of different methods of ankle-brachial index (ABI) calculation. From April 1998 to September 2008, we calculated the ABI in 1223 patients before coronary artery bypass grafting. The ABI was calculated according to five different calculation modes of the numerator. The patients were classified into three groups: clinical peripheral artery disease (PAD), subclinical PAD if no clinical history but abnormal ABI (< 0.90 or > 1.40), and no PAD. The primary outcome was total mortality. During a follow-up of 7.6 years (0.1-15.9), 406 patients (33%) died. The prevalence of the subclinical PAD varied from 22% to 29% according to the different modes of ABI calculation. Areas under the ROC curve to predict mortality according to different calculation modes varied from 0.608 ± 0.020 to 0.625 ± 0.020 without significant differences. The optimal ABI threshold to predict mortality varied for every method, ranging from 0.87 to 0.95. In multivariate models, ABI was significantly and independently associated with total mortality (hazard ratio (HR) = 1.46, 95% CI: 1.15-1.85, p = 0.002); however, this association was not significantly different between the various methods (HRs varying from 1.46 to 1.67). The use of the optimal ABI threshold for each calculation mode (rather than standard 0.90) allowed a slight improvement of the model. In conclusion, the ABI prognostic value to predict mortality is independent from its method of calculation. The use of different optimal thresholds for each method enables a comparable prognosis value.
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Affiliation(s)
- Louis Le Bivic
- 1 CHU Limoges, Hôpital Dupuytren, Service Cardiologie, Limoges, France
| | - Julien Magne
- 1 CHU Limoges, Hôpital Dupuytren, Service Cardiologie, Limoges, France.,2 INSERM 1094, Faculté de Médecine de Limoges, Limoges, France
| | - Benoit Guy-Moyat
- 1 CHU Limoges, Hôpital Dupuytren, Service Cardiologie, Limoges, France
| | - Hélène Wojtyna
- 1 CHU Limoges, Hôpital Dupuytren, Service Cardiologie, Limoges, France
| | - Philippe Lacroix
- 2 INSERM 1094, Faculté de Médecine de Limoges, Limoges, France.,3 CHU Limoges, Hôpital Dupuytren, Service de Chirurgie Thoracique et Vasculaire, et Médecine Vasculaire, Limoges, France
| | - Jean-David Blossier
- 4 CHU Limoges, Hôpital Dupuytren, Service de Chirurgie Cardiaque, Limoges, France
| | - Alexandre Le Guyader
- 4 CHU Limoges, Hôpital Dupuytren, Service de Chirurgie Cardiaque, Limoges, France
| | - Iléana Desormais
- 2 INSERM 1094, Faculté de Médecine de Limoges, Limoges, France.,3 CHU Limoges, Hôpital Dupuytren, Service de Chirurgie Thoracique et Vasculaire, et Médecine Vasculaire, Limoges, France
| | - Victor Aboyans
- 1 CHU Limoges, Hôpital Dupuytren, Service Cardiologie, Limoges, France.,2 INSERM 1094, Faculté de Médecine de Limoges, Limoges, France
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11
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Buschmann EE, Li L, Brix M, Zietzer A, Hillmeister P, Busjahn A, Bramlage P, Buschmann I. A novel computer-aided diagnostic approach for detecting peripheral arterial disease in patients with diabetes. PLoS One 2018; 13:e0199374. [PMID: 29928037 PMCID: PMC6013098 DOI: 10.1371/journal.pone.0199374] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 06/06/2018] [Indexed: 12/19/2022] Open
Abstract
Peripheral arterial disease (PAD) is an important manifestation of systemic atherosclerosis, with diabetes being one of its most significant risk factors. Owing to medial arterial calcification (MAC), the ankle–brachial index (ABI) is not always a reliable tool for detecting PAD. Arterial Doppler flow parameters, such as systolic maximal acceleration (ACCmax) and relative pulse slope index (RPSI), may serve as effective surrogates to detect stenosis-induced flow alteration. In the present study, ACCmax and RPSI were prospectively evaluated in 166 patients (304 arteries) with clinical suspicion of PAD, including 76 patients with and 90 patients without diabetes. In the overall sample, the sensitivity of ACCmax (69%) was superior to that of ABI (58%) and RPSI (56%). In patients with diabetes, the sensitivity of ACCmax (57%), ABI (56%) and RPSI (57%) were similar, though a parallel test taking both ACCmax and RPSI into account further increased sensitivity to 68%. The specificity (98%) and accuracy (78%) of ACCmax were superior to those of ABI (83% and 70%, respectively), as were the specificity (95%) and accuracy (77%) of RPSI in patients with diabetes. The diagnostic properties of ACCmax and RPSI were superior to those of ABI for detecting PAD in patients with diabetes. Our acceleration algorithm (Gefäßtachometer®) provides a rapid, safe, noninvasive tool for identifying PAD in patients with diabetes.
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Affiliation(s)
- Eva Elina Buschmann
- Dept. for Cardiology, Center of Internal Medicine, Medical University Graz, Graz, Austria
- Dept. for Angiology, Center for Internal Medicine 1, Medical University Brandenburg (MHB), Brandenburg/ Havel, Germany
- * E-mail:
| | - Lulu Li
- Dept. for Angiology, Center for Internal Medicine 1, Medical University Brandenburg (MHB), Brandenburg/ Havel, Germany
- Richard-Thoma Laboratories for Arteriogenesis, Center for Cardiovascular Research (CCR), Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Michèle Brix
- Department of Physiology Charité Benjamin Franklin, Berlin, Germany
| | - Andreas Zietzer
- Richard-Thoma Laboratories for Arteriogenesis, Center for Cardiovascular Research (CCR), Charité Universitaetsmedizin Berlin, Berlin, Germany
- Medizinische Klinik II, Universität Bonn, Bonn, Germany
| | - Philipp Hillmeister
- Dept. for Angiology, Center for Internal Medicine 1, Medical University Brandenburg (MHB), Brandenburg/ Havel, Germany
- Richard-Thoma Laboratories for Arteriogenesis, Center for Cardiovascular Research (CCR), Charité Universitaetsmedizin Berlin, Berlin, Germany
| | | | - Peter Bramlage
- Dept. for Angiology, Center for Internal Medicine 1, Medical University Brandenburg (MHB), Brandenburg/ Havel, Germany
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Ivo Buschmann
- Dept. for Angiology, Center for Internal Medicine 1, Medical University Brandenburg (MHB), Brandenburg/ Havel, Germany
- Richard-Thoma Laboratories for Arteriogenesis, Center for Cardiovascular Research (CCR), Charité Universitaetsmedizin Berlin, Berlin, Germany
- Department of Physiology Charité Benjamin Franklin, Berlin, Germany
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12
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Wilcox T, Newman JD, Maldonado TS, Rockman C, Berger JS. Peripheral vascular disease risk in diabetic individuals without coronary heart disease. Atherosclerosis 2018; 275:419-425. [PMID: 29801688 DOI: 10.1016/j.atherosclerosis.2018.04.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 04/05/2018] [Accepted: 04/24/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND AIMS Diabetes mellitus is a coronary heart disease (CHD) risk-equivalent for the outcome of peripheral vascular disease. The impact of diabetes with comorbid risk factors on the outcome of peripheral vascular disease remains unexplored. METHODS We performed a cross-sectional analysis of participants in Lifeline Vascular Screening Inc. age 40-90 who were screened for peripheral vascular disease, defined as lower extremity peripheral artery disease (PAD, ABI <0.9) and/or carotid artery stenosis (CAS, internal CAS ≥50%). CHD was defined as prior myocardial infarction or revascularization. Risk factors included hypertension, hyperlipidemia, smoking, obesity, sedentary lifestyle and family history of cardiovascular disease. RESULTS Among 3,517,804 participants, PAD and CAS was identified in 4.4% and 3.7%, respectively. Diabetes was identified in 376,528 participants, 324,680 (86%) of whom did not have CHD. Among diabetic participants without CHD, prevalence of PAD increased with 1-2 (4.3%), 3-4 (7.3%), and ≥5 (12.0%) comorbid risk factors (p trend < 0.0001). The pattern was similar for CAS (3.7%, 6.2%, 8.8%, p trend < 0.0001). Compared to participants without diabetes, those with diabetes and 1-2, 3-4 and ≥5 risk factors had increasing odds of PAD and CAS after adjustment for age, sex and race/ethnicity (1.0, 95% CI 0.98-1.06; 1.8, 95% CI 1.8-1.89; 3.5, 95% CI 3.43-3.64, respectively, p trend < 0.0001). By comparison, in nondiabetic participants, CHD increased odds of PAD and CAS by 2-fold (2.06, 95% CI 2.02-2.1; 2.19, 95% CI 2.15-2.23 respectively). CONCLUSIONS Diabetes, particularly with comorbid risk factors, confers increased odds of PAD and CAS, even in the absence of CHD. Counseling regarding screening and prevention for peripheral vascular disease among individuals with diabetes and multiple risk factors may be useful.
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Affiliation(s)
- Tanya Wilcox
- New York University School of Medicine, Department of Medicine, 227 E. 30th Street, TRB rm. 853, New York, NY 10016, USA.
| | - Jonathan D Newman
- New York University School of Medicine, Department of Medicine, Division of Cardiology, 227E. 30th Street, TRB rm. 853, New York, NY 10016, USA.
| | - Thomas S Maldonado
- New York University School of Medicine, Department of Vascular Surgery, 530 1st Ave, New York, NY, 10016, USA
| | - Caron Rockman
- New York University School of Medicine, Department of Vascular Surgery, 530 1st Ave, New York, NY, 10016, USA
| | - Jeffrey S Berger
- New York University School of Medicine, Department of Medicine, Division of Cardiology, 227E. 30th Street, TRB rm. 853, New York, NY 10016, USA
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13
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Robinet P, Milewicz DM, Cassis LA, Leeper NJ, Lu HS, Smith JD. Consideration of Sex Differences in Design and Reporting of Experimental Arterial Pathology Studies-Statement From ATVB Council. Arterioscler Thromb Vasc Biol 2018; 38:292-303. [PMID: 29301789 DOI: 10.1161/atvbaha.117.309524] [Citation(s) in RCA: 191] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 12/20/2017] [Indexed: 12/15/2022]
Abstract
There are many differences in arterial diseases between men and women, including prevalence, clinical manifestations, treatments, and prognosis. The new policy of the National Institutes of Health, which requires the inclusion of sex as a biological variable for preclinical studies, aims to foster new mechanistic insights and to enhance our understanding of sex differences in human diseases. The purpose of this statement is to suggest guidelines for designing and reporting sex as a biological variable in animal models of atherosclerosis, thoracic and abdominal aortic aneurysms, and peripheral arterial disease. We briefly review sex differences of these human diseases and their animal models, followed by suggestions on experimental design and reporting of animal studies for these vascular pathologies.
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Affiliation(s)
- Peggy Robinet
- From the Department of Cellular and Molecular Medicine, Cleveland Clinic, OH (P.R., J.D.S.); Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (D.M.M.); Department of Pharmacology and Nutritional Sciences (L.A.C.) and Saha Cardiovascular Research Center and Department of Physiology (H.S.L.), University of Kentucky, Lexington; and Division of Vascular Surgery, Department of Surgery, Stanford University, CA (N.J.L.)
| | - Dianna M Milewicz
- From the Department of Cellular and Molecular Medicine, Cleveland Clinic, OH (P.R., J.D.S.); Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (D.M.M.); Department of Pharmacology and Nutritional Sciences (L.A.C.) and Saha Cardiovascular Research Center and Department of Physiology (H.S.L.), University of Kentucky, Lexington; and Division of Vascular Surgery, Department of Surgery, Stanford University, CA (N.J.L.)
| | - Lisa A Cassis
- From the Department of Cellular and Molecular Medicine, Cleveland Clinic, OH (P.R., J.D.S.); Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (D.M.M.); Department of Pharmacology and Nutritional Sciences (L.A.C.) and Saha Cardiovascular Research Center and Department of Physiology (H.S.L.), University of Kentucky, Lexington; and Division of Vascular Surgery, Department of Surgery, Stanford University, CA (N.J.L.)
| | - Nicholas J Leeper
- From the Department of Cellular and Molecular Medicine, Cleveland Clinic, OH (P.R., J.D.S.); Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (D.M.M.); Department of Pharmacology and Nutritional Sciences (L.A.C.) and Saha Cardiovascular Research Center and Department of Physiology (H.S.L.), University of Kentucky, Lexington; and Division of Vascular Surgery, Department of Surgery, Stanford University, CA (N.J.L.)
| | - Hong S Lu
- From the Department of Cellular and Molecular Medicine, Cleveland Clinic, OH (P.R., J.D.S.); Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (D.M.M.); Department of Pharmacology and Nutritional Sciences (L.A.C.) and Saha Cardiovascular Research Center and Department of Physiology (H.S.L.), University of Kentucky, Lexington; and Division of Vascular Surgery, Department of Surgery, Stanford University, CA (N.J.L.)
| | - Jonathan D Smith
- From the Department of Cellular and Molecular Medicine, Cleveland Clinic, OH (P.R., J.D.S.); Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (D.M.M.); Department of Pharmacology and Nutritional Sciences (L.A.C.) and Saha Cardiovascular Research Center and Department of Physiology (H.S.L.), University of Kentucky, Lexington; and Division of Vascular Surgery, Department of Surgery, Stanford University, CA (N.J.L.).
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14
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Arroyo D, Betriu A, Valls J, Gorriz JL, Pallares V, Abajo M, Gracia M, Valdivielso JM, Fernandez E. Factors influencing pathological ankle-brachial index values along the chronic kidney disease spectrum: the NEFRONA study. Nephrol Dial Transplant 2017; 32:513-520. [PMID: 27190385 DOI: 10.1093/ndt/gfw039] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 02/03/2016] [Indexed: 11/14/2022] Open
Abstract
Background The ankle-brachial index (ABI) is widely used to diagnose subclinical peripheral artery disease (PAD) in the general population, but data assessing its prevalence and related factors in different chronic kidney disease (CKD) stages are scarce. The aim of this study is to evaluate the prevalence and associated factors of pathological ABI values in CKD patients. Methods NEFRONA is a multicentre prospective project that included 2445 CKD patients from 81 centres and 559 non-CKD subjects from 9 primary care centres across Spain. A trained team collected clinical and laboratory data, performed vascular ultrasounds and measured the ABI. Results PAD prevalence was higher in CKD than in controls (28.0 versus 12.3%, P < 0.001). Prevalence increased in more advanced CKD stages, due to more patients with an ABI ≥1.4, rather than ≤0.9. Diabetes was the only factor predicting both pathological values in all CKD stages. Age, female sex, carotid plaques, higher carotid intima-media thickness, higher high-sensitivity C-reactive protein (hsCRP) and triglycerides, and lower 25-hydroxi-vitamin D were independently associated with an ABI ≤0.9. Higher phosphate and hsCRP, lower low-density lipoprotein (LDL)-cholesterol and dialysis were associated with an ABI ≥1.4. A stratified analysis showed different associated factors in each CKD stage, with phosphate being especially important in earlier CKD, and LDL-cholesterol being an independent predictor only in Sage 5D CKD. Conclusions Asymptomatic PAD is very prevalent in all CKD stages, but factors related to a low or high pathological ABI differ, revealing different pathogenic pathways. Diabetes, dyslipidaemia, inflammation and mineral-bone disorders play a role in the appearance of PAD in CKD.
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Affiliation(s)
- David Arroyo
- Nephrology Department, Hospital Universitari Arnau de Vilanova, Lleida, Spain.,Unit for Detection and Treatment of Atherotrombotic Disease (UDETMA), Nephrology Department, Hospital Universitari Arnau de Vilanova, Lleida, Spain.,Experimental Nephrology Laboratory, IRB-Lleida, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Angels Betriu
- Nephrology Department, Hospital Universitari Arnau de Vilanova, Lleida, Spain.,Unit for Detection and Treatment of Atherotrombotic Disease (UDETMA), Nephrology Department, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Joan Valls
- Biostatistics Unit, IRB-Lleida, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Jose L Gorriz
- Nephrology Department, Hospital Universitario Doctor Peset, Valencia, Spain and
| | - Vicente Pallares
- Unidad de Vigilancia de la Salud, Unión de Mutuas, Medicine Department, Universitat Jaume I, Castellón, Spain
| | - Maria Abajo
- Experimental Nephrology Laboratory, IRB-Lleida, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Marta Gracia
- Experimental Nephrology Laboratory, IRB-Lleida, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Jose Manuel Valdivielso
- Experimental Nephrology Laboratory, IRB-Lleida, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Elvira Fernandez
- Nephrology Department, Hospital Universitari Arnau de Vilanova, Lleida, Spain.,Unit for Detection and Treatment of Atherotrombotic Disease (UDETMA), Nephrology Department, Hospital Universitari Arnau de Vilanova, Lleida, Spain.,Experimental Nephrology Laboratory, IRB-Lleida, Hospital Universitari Arnau de Vilanova, Lleida, Spain
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15
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Miname M, Bensenor IM, Lotufo PA. Different methods of calculating ankle-brachial index in mid-elderly men and women: the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). ACTA ACUST UNITED AC 2017; 49:e5734. [PMID: 27901176 PMCID: PMC5188861 DOI: 10.1590/1414-431x20165734] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 10/11/2016] [Indexed: 11/22/2022]
Abstract
The ankle-brachial index (ABI) is a marker of subclinical atherosclerosis related to
health-adverse outcomes. ABI is inexpensive compared to other indexes, such as
coronary calcium score and determination of carotid artery intima-media thickness
(IMT). Our objective was to identify how the ABI can be applied to primary care.
Three different methods of calculating the ABI were compared among 13,921 men and
women aged 35 to 74 years who were free of cardiovascular diseases and enrolled in
the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). The ABI ratio had the
same denominator for the three categories created (the highest value for arm systolic
blood pressure), and the numerator was based on the four readings for leg systolic
blood pressure: the highest (ABI-HIGH), the mean (ABI-MEAN), and the lowest
(ABI-LOW). The cut-off for analysis was ABI<1.0. All determinations of blood
pressure were done with an oscillometric device. The prevalence of ABI<1% was 0.5,
0.9, and 2.7 for the categories HIGH, MEAN and LOW, respectively. All methods were
associated with a high burden of cardiovascular risk factors. The association with
IMT was stronger for ABI-HIGH than for the other categories. The proportion of
participants with a 10-year Framingham Risk Score of coronary heart disease >20%
without the inclusion of ABI<1.0 was 4.9%. For ABI-HIGH, ABI-MEAN and ABI-LOW, the
increase in percentage points was 0.3, 0.7, and 2.3%, respectively, and the relative
increment was 6.1, 14.3, and 46.9%. In conclusion, all methods were acceptable, but
ABI-LOW was more suitable for prevention purposes.
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Affiliation(s)
- M Miname
- Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brasil.,Instituto do Coração, Universidade de São Paulo, São Paulo, SP, Brasil
| | - I M Bensenor
- Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brasil.,Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - P A Lotufo
- Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brasil.,Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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16
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Newman JD, Rockman CB, Kosiborod M, Guo Y, Zhong H, Weintraub HS, Schwartzbard AZ, Adelman MA, Berger JS. Diabetes mellitus is a coronary heart disease risk equivalent for peripheral vascular disease. Am Heart J 2017; 184:114-120. [PMID: 28224925 DOI: 10.1016/j.ahj.2016.09.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/08/2016] [Indexed: 10/21/2022]
Abstract
Diabetes mellitus (diabetes) is associated with significantly increased risk of peripheral vascular disease. Diabetes is classified as a coronary heart disease (CHD) risk equivalent, but it is unknown whether diabetes is a CHD risk equivalent for peripheral vascular disease. The objective was to evaluate the odds of peripheral arterial disease (PAD) or carotid artery stenosis (CAS) among participants with diabetes, CHD, or both, compared with participants without diabetes or CHD, in a nationwide vascular screening database. We hypothesized that diabetes and CHD would confer similar odds of PAD and CAS. METHODS A cross-sectional analysis of all eligible Life Line Screening Inc participants age 30 to 90 years with ankle brachial indices for PAD (ankle brachial index <0.9 in either leg) and carotid artery duplex ultrasonographic imaging for CAS (internal CAS ≥50%) was performed (N=3,522,890). RESULTS Diabetes and CHD were present in 372,330 (10.7%) and 182,760 (5.8%) of participants, respectively; PAD and CAS were present in 155,000 (4.4%) and 130,347 (3.7%) of participants. After multivariable adjustment, PAD odds were 1.56 (95% CI 1.54-1.59) and 1.69 (95% CI 1.65-1.73) for participants with diabetes or CHD, respectively. Participants with both diabetes and CHD had 2.75-fold increased odds of PAD (95% CI 2.66-2.85). Findings were similar for CAS; compared with no diabetes or CHD, CAS odds increased for participants with diabetes alone (1.53, 95% CI 1.50-1.56), CHD alone (1.72, 95% CI 1.68-1.76), and both diabetes and CHD (2.57, 95% CI 2.49-2.66). Findings were consistent for women and men. CONCLUSION In a large database of more than 3.5 million self-referred participants, diabetes was a CHD risk equivalent for PAD and CAS, and participants with comorbid diabetes and CHD had an especially robust association with PAD and CAS. Counseling regarding screening and prevention of peripheral vascular disease may be useful for patients with diabetes.
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17
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Brutto OHD, Mera RM, Brown DL, Nieves JL, Sedler MJ. Reliability of Two Ankle-Brachial Index Methods to Predict Silent Lacunar Infarcts: A Population-Based Study in Stroke-Free Older Adults (the Atahualpa Project). Int J Angiol 2016; 25:e173-e176. [PMID: 28031690 DOI: 10.1055/s-0036-1584418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Individuals with an abnormal ankle-brachial index (ABI) are four times more likely to have a silent lacunar infarct (SLI), but reliability of ABI in predicting the presence of these lesions has not been estimated yet. We compared two methods of calculating ABI to assess their reliability in predicting SLIs. Stroke-free Atahualpa residents aged ≥ 60 years underwent MRI of the brain and ABI determinations. Persons with ABI ≥ 1.4 were excluded. Using receiver operator characteristic curve analysis, we calculated the reliability of the traditional as well as an alternative ABI method to identify individuals with SLI. The traditional ABI uses the higher systolic pressure of either the dorsalis pedis or the posterior tibial arteries as the numerator, whereas the alternative ABI uses the lower pressure. Of the 247 participants, 38 (15%) had traditional and 95 (38%) had alternative ABIs ≤ 0.9. Twenty-one individuals had SLI. Traditional and alternative ABIs ≤ 0.9 identified 9 and 13 individuals with SLI, respectively. The traditional ABI had sensitivity of 42.9% (22.6-65.6%) and specificity of 87.2% (81.9-91.1%). The alternative ABI had sensitivity of 61.9% (38.6-81%) and specificity of 63.7% (57-69.9%). The area under the curve for the predictive value of SLI was 0.65 (0.54-0.76) for the traditional and 0.63 (0.52-0.74) for the alternative ABI ≤ 0.9. The ABI is moderately reliable for identifying candidates for MRI screening in studies assessing the burden of SLI in older adults. The traditional ABI seems to be more suitable for this purpose.
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Affiliation(s)
- Oscar H Del Brutto
- School of Medicine, Universidad Espíritu Santo-Ecuador, Guayaquil, Ecuador
| | | | - David L Brown
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
| | | | - Mark J Sedler
- School of Medicine, Stony Brook University, New York, New York
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18
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Ross EG, Shah NH, Dalman RL, Nead KT, Cooke JP, Leeper NJ. The use of machine learning for the identification of peripheral artery disease and future mortality risk. J Vasc Surg 2016; 64:1515-1522.e3. [PMID: 27266594 PMCID: PMC5079774 DOI: 10.1016/j.jvs.2016.04.026] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 04/04/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVE A key aspect of the precision medicine effort is the development of informatics tools that can analyze and interpret "big data" sets in an automated and adaptive fashion while providing accurate and actionable clinical information. The aims of this study were to develop machine learning algorithms for the identification of disease and the prognostication of mortality risk and to determine whether such models perform better than classical statistical analyses. METHODS Focusing on peripheral artery disease (PAD), patient data were derived from a prospective, observational study of 1755 patients who presented for elective coronary angiography. We employed multiple supervised machine learning algorithms and used diverse clinical, demographic, imaging, and genomic information in a hypothesis-free manner to build models that could identify patients with PAD and predict future mortality. Comparison was made to standard stepwise linear regression models. RESULTS Our machine-learned models outperformed stepwise logistic regression models both for the identification of patients with PAD (area under the curve, 0.87 vs 0.76, respectively; P = .03) and for the prediction of future mortality (area under the curve, 0.76 vs 0.65, respectively; P = .10). Both machine-learned models were markedly better calibrated than the stepwise logistic regression models, thus providing more accurate disease and mortality risk estimates. CONCLUSIONS Machine learning approaches can produce more accurate disease classification and prediction models. These tools may prove clinically useful for the automated identification of patients with highly morbid diseases for which aggressive risk factor management can improve outcomes.
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Affiliation(s)
- Elsie Gyang Ross
- Division of Vascular Surgery, Stanford Health Care, Stanford, Calif
| | - Nigam H Shah
- Center for Biomedical Informatics Research, Stanford University, Stanford, Calif
| | - Ronald L Dalman
- Division of Vascular Surgery, Stanford Health Care, Stanford, Calif
| | - Kevin T Nead
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pa
| | - John P Cooke
- Department of Cardiovascular Sciences, Houston Methodist Research Institute, Houston, Tex; Center for Cardiovascular Regeneration, Houston Methodist DeBakey Heart and Vascular Center, Houston, Tex
| | - Nicholas J Leeper
- Division of Vascular Surgery, Stanford Health Care, Stanford, Calif.
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Kalra P, Yeragani VK, Prasanna Kumar KM. Cardiac autonomic function and vascular profile in subclinical hypothyroidism: Increased beat-to-beat QT variability. Indian J Endocrinol Metab 2016; 20:605-611. [PMID: 27730068 PMCID: PMC5040038 DOI: 10.4103/2230-8210.190527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Patients with subclinical hypothyroidism (SH) may have higher incidence of coronary heart disease and autonomic dysfunction. DESIGN OF THE STUDY Prospective case control study. AIM AND OBJECTIVES To evaluate beat-to-beat QT variability and vascular stiffness in patients with SH compared to normal controls. MATERIALS AND METHODS We compared linear and nonlinear measures of cardiac repolarization liability using beat-to-beat QT intervals derived from the surface electrocardiogram during supine posture and vascular indices including pulse wave velocity and ankle-brachial index (ABI) during supine posture between female patients with SH and age- and sex-matched normal controls. Spectral analysis was done at very low frequency (LF) (0.003-0.04 Hz), Low frequency (LF) (0.04-0.15 Hz), and high frequency (HF) (0.15-0.4 Hz). The HF represents vagal regulation (parasympathetic) and LF represents both parasympathetic and sympathetic regulation. RESULTS We recruited 58 women with a mean age of 31.83 ± 8.9 years and 49 controls with mean age of 32.4 ± 9.9 years (P = NS). QT variability index (QTvi) was higher in cases compared to controls (P = 0.01). The ratio of LF/HF of R-R interval which is an index of sympathovagal tone was significantly more in cases compared to controls (P = 0.02). The difference in the left minus the right ABI was significant between cases and controls (P = 0.03). CONCLUSIONS The cases had lower parasympathetic activity as compared to controls, and there was a predominance of sympathetic activity in cases. QTvi may be an important noninvasive tool in this group of patients to study the risk of cardiovascular mortality.
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Affiliation(s)
- Pramila Kalra
- Department of Endocrinology, M.S. Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Vikram K. Yeragani
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - K. M. Prasanna Kumar
- Centre for Diabetes and Endocrine Care, Bangalore Diabetes Hospital, Bengaluru, Karnataka, India
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20
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Hajibandeh S, Hajibandeh S, Shah S, Child E, Antoniou GA, Torella F. Prognostic significance of ankle brachial pressure index: A systematic review and meta-analysis. Vascular 2016; 25:208-224. [PMID: 27411571 DOI: 10.1177/1708538116658392] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose To synthesize and quantify the excess risk of morbidity and mortality in individuals with low ankle-brachial pressure index. Methods Electronic databases were searched to identify studies investigating morbidity and mortality outcomes in individuals undergoing ankle-brachial pressure index measurement. Meta-analysis of the outcomes was performed using fixed- or random-effects models. Uncertainties related to varying follow-up periods among the studies were resolved by meta-analysis of time-to-event outcomes. Results Forty-three observational cohort studies, enrolling 94,254 participants, were selected. A low ankle-brachial pressure index (<0.9) was associated with a significant risk of all-cause mortality (risk ratio: 2.52, 95% CI 2.26-2.82, P < 0.00001); cardiovascular mortality (risk ratio: 2.94, 95% CI 2.72-3.18, P < 0.00001); cerebrovascular event (risk ratio: 2.17, 95% CI 1.90-2.47, P < 0.00001); myocardial infarction (risk ratio: 2.28, 95% CI 2.07-2.51, P < 0.00001); fatal myocardial infarction (risk ratio: 2.81, 95% CI 2.33-3.40, P < 0.00001); fatal stroke (risk ratio: 2.28, 95% CI 1.80-2.89, P < 0.00001); and the composite of myocardial infarction, stroke, and death (risk ratio: 2.29, 95% CI 1.87-2.81, P < 0.00001). Similar findings resulted from analyses of individuals with asymptomatic PAD, individuals with cardiovascular or cerebrovascular co-morbidity, and patients with diabetes. Conclusions A low ankle-brachial pressure index is associated with an increased risk of subsequent cardiovascular and cerebrovascular morbidity and mortality. Randomised controlled trials are required to investigate the effectiveness of screening for PAD in asymptomatic and undiagnosed individuals and to evaluate benefits of early treatment of screen-detected PAD.
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Affiliation(s)
- Shahab Hajibandeh
- 1 Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital & University Hospital Aintree, Liverpool, UK
| | - Shahin Hajibandeh
- 1 Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital & University Hospital Aintree, Liverpool, UK
| | - Sohan Shah
- 1 Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital & University Hospital Aintree, Liverpool, UK
| | - Emma Child
- 2 Library Resource & Information Centre, University Hospital Aintree, Liverpool, UK
| | - George A Antoniou
- 3 Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Francesco Torella
- 1 Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital & University Hospital Aintree, Liverpool, UK
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21
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Chen J, Mohler ER, Garimella PS, Hamm LL, Xie D, Kimmel S, Townsend RR, Budoff M, Pan Q, Nessel L, Steigerwalt S, Wright JT, He J. Ankle Brachial Index and Subsequent Cardiovascular Disease Risk in Patients With Chronic Kidney Disease. J Am Heart Assoc 2016; 5:e003339. [PMID: 27247339 PMCID: PMC4937276 DOI: 10.1161/jaha.116.003339] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 05/04/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The clinical implications of ankle-brachial index (ABI) cutpoints are not well defined in patients with chronic kidney disease (CKD) despite increased prevalence of high ABI attributed to arterial stiffness. We examined the relationship of ABI with cardiovascular disease (CVD) and all-cause mortality among CKD patients. METHODS AND RESULTS Three thousand six hundred twenty-seven participants without clinical peripheral artery disease (PAD) at baseline from the Chronic Renal Insufficiency Cohort Study were included. ABI was obtained per standard protocol and CVD events were confirmed by medical record adjudication. A U-shaped association of ABI with PAD, myocardial infarction (MI), composite CVD, and all-cause mortality was observed. Individuals with an ABI between 1.0 and <1.4 had the lowest risk of outcomes. Compared to participants with an ABI between 1.0 and <1.4, multiple-adjusted hazard ratios (95% confidence intervals) for those with an ABI of <0.9, 0.9 to <1.0, and ≥1.4 were 5.78 (3.57, 9.35), 2.76 (1.56, 4.88), and 4.85 (2.05, 11.50) for PAD; 1.67 (1.23, 2.29), 1.85 (1.33, 2.57), and 2.08 (1.10, 3.93) for MI; 1.51 (1.27, 1.79), 1.39 (1.15, 1.68), and 1.23 (0.82, 1.84) for composite CVD; and 1.55 (1.28, 1.89), 1.36 (1.10, 1.69), and 1.00 (0.62, 1.62) for all-cause mortality, respectively. CONCLUSIONS This study indicates that ABI <1.0 was related to risk of PAD, MI, composite CVD, and all-cause mortality whereas ABI ≥1.4 was related to clinical PAD. These findings suggest that ABI cutpoints of <1.0 or ≥1.4 for diagnosing PAD and ABI <1.0 for CVD risk stratification should be further evaluated among CKD patients.
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Affiliation(s)
- Jing Chen
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | - Emile R Mohler
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - L Lee Hamm
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Dawei Xie
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Stephen Kimmel
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Matthew Budoff
- Los Angeles BioMed at Harbor-UCLA Medical Center, Los Angeles, CA
| | - Qiang Pan
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Lisa Nessel
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Susan Steigerwalt
- Division of Nephrology, University of Michigan School of Medicine, Ann Arbor, MI
| | - Jackson T Wright
- University Hospitals of Case Western Reserve University, Cleveland, OH
| | - Jiang He
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
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Betriu À, Farràs C, Abajo M, Martinez-Alonso M, Arroyo D, Barbé F, Buti M, Lecube A, Portero M, Purroy F, Torres G, Valdivielso JM, Fernández E. Randomised intervention study to assess the prevalence of subclinical vascular disease and hidden kidney disease and its impact on morbidity and mortality: The ILERVAS project. Nefrologia 2016; 36:389-96. [PMID: 27044887 DOI: 10.1016/j.nefro.2016.02.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/27/2016] [Accepted: 02/15/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Chronic kidney disease (CKD) and atherosclerosis are 2 interrelated diseases that increase the risk of cardiovascular morbidity and mortality. The objectives of the ILERVAS project are: 1) to determine the prevalence of subclinical arterial disease and hidden kidney disease; 2) to assess the impact of early diagnosis of both diseases on cardiovascular morbidity and mortality and also on the progression of CKD; 3) to have a platform of data and biological samples. METHODS Randomized intervention study. From 2015 to 2017, 19,800 people (9,900 in the intervention group and 9,900 in the control group) aged between 45 and 70 years without previous history of cardiovascular disease and with at least one cardiovascular risk factor will be randomly selected from the primary health care centres across the province of Lérida. A team of experts will travel around in a mobile unit to carry out the following baseline tests on the intervention group: Artery ultrasound; (carotid, femoral, transcranial and abdominal aorta); ankle-brachial index; spirometry; determination of advanced glycation end products; dried blood spot and urine spot tests. Additionally, blood and urine samples will be collected and stored in the biobank to identify new biomarkers using omics studies. Participants will be followed up until 2025 for identification of cardiovascular events, treatment changes and changes in lifestyle. CONCLUSIONS The ILERVAS project will reveal the prevalence of subclinical vascular disease and hidden kidney disease, determine whether or not their early diagnosis brings health benefits and will also allow investigation of new risk factors.
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Affiliation(s)
- Àngels Betriu
- Institut de Recerca Biomèdica (IRBLleida), Lérida, España; Unidad de Diagnóstico y Tratamiento Enfermedades Aterotrombóticas (UDETMA), Servicio de Nefrología, Hospital Universitari Arnau de Vilanova, Lérida, España
| | | | - María Abajo
- Institut de Recerca Biomèdica (IRBLleida), Lérida, España
| | | | - David Arroyo
- Servicio de Nefrología, Hospital Universitari Arnau de Vilanova, Lérida, España
| | - Ferran Barbé
- Servicio de Neumología, Hospital Universitari Arnau de Vilanova, Lérida, España; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, España
| | - Miquel Buti
- Dirección de Atención Primaria, Lérida, España
| | - Albert Lecube
- Servicio de Endocrinología, Hospital Universitari Arnau de Vilanova, Lérida, España
| | - Manuel Portero
- Grupo de Fisiopatología Metabólica, Departamento de Medicina Experimental, IRBLleida, Lérida, España
| | - Francisco Purroy
- Servicio de Neurología, Hospital Universitari Arnau de Vilanova, Lérida, España
| | - Gerard Torres
- Servicio de Medicina Interna, Hospital Universitari de Santa María, Lérida, España
| | - José Manuel Valdivielso
- Institut de Recerca Biomèdica (IRBLleida), Lérida, España; Laboratorio de Nefrología Experimental, IRBLleida, Lérida, España
| | - Elvira Fernández
- Institut de Recerca Biomèdica (IRBLleida), Lérida, España; Unidad de Diagnóstico y Tratamiento Enfermedades Aterotrombóticas (UDETMA), Servicio de Nefrología, Hospital Universitari Arnau de Vilanova, Lérida, España; Servicio de Nefrología, Hospital Universitari Arnau de Vilanova, Lérida, España.
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Uyar B, Solak A, Genç B, Akyıldız M, Şahin N, Uyar İS, Saklamaz A. Evaluation of Arterial Stiffness in Patients with Behçet's Disease by Using Noninvasive Radiological Methods such as Intima-Media Thickness of the Carotid, Ankle-Brachial Pressure Index, Coronary Artery Calcium Scoring, and Their Relation to Serum Fetuin-A Levels: A Case-Control Study. Ann Dermatol 2015; 27:702-8. [PMID: 26719639 PMCID: PMC4695422 DOI: 10.5021/ad.2015.27.6.702] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 12/26/2014] [Accepted: 03/05/2015] [Indexed: 11/23/2022] Open
Abstract
Background Behçet's disease (BD) is a chronic, recurrent inflammatory systemic vasculitis. Evidence for increased atherosclerosis in BD has been observed. The relation between cardiovascular risk factors and increased atherosclerosis in patients with BD is still controversial. Objective We performed this study to evaluate arterial stiffness in patients with BD by using noninvasive radiological methods such as carotid artery intima-media thickness (CIMT), ankle-brachial pressure index (ABPI), coronary artery calcium score (CACaS), and their relation to serum fetuin-A levels, which was recently found to be important in vascular calcification. Methods This prospective study included 26 patients with BD and 25 control subjects. In all patients, the CIMT, ABPI, CACaS, and serum fetuin-A levels were examined. Results The CIMT and CACaS were statistically higher and the ABPI was statistically lower in BD patients than in the control group. All p-values were <0.001. Positive correlations were found between the CACaS and CIMT, and negative correlations were found between the CACaS and ABPI. Although the values of fetuin-A were higher in BD, the difference was not statistically significant (p=0.064). However, the correlations found between fetuin-A levels and CIMT and between fetuin-A levels and CACaS were significant. Conclusion The CIMT, CACaS, and ABPI are all useful in detecting structural and functional vascular damage in BD.
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Affiliation(s)
- Belkız Uyar
- Department of Dermatology, Faculty of Medicine, Sifa University, Izmir, Turkey
| | - Aynur Solak
- Department of Radiology, Faculty of Medicine, Sifa University, Izmir, Turkey
| | - Berhan Genç
- Department of Radiology, Faculty of Medicine, Sifa University, Izmir, Turkey
| | - Muhittin Akyıldız
- Department of Biochemistry, Faculty of Medicine, Sifa University, Izmir, Turkey
| | - Neslin Şahin
- Department of Radiology, Faculty of Medicine, Sifa University, Izmir, Turkey
| | - İhsan Sami Uyar
- Department of Cardiovascular Surgery, Faculty of Medicine, Sifa University, Izmir, Turkey
| | - Ali Saklamaz
- Department of Endocrinology, Faculty of Medicine, Sifa University, Izmir, Turkey
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Co-existence of vascular disease in different arterial beds: Peripheral artery disease and carotid artery stenosis--Data from Life Line Screening(®). Atherosclerosis 2015; 241:687-91. [PMID: 26122189 DOI: 10.1016/j.atherosclerosis.2015.06.029] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 05/26/2015] [Accepted: 06/08/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Atherosclerosis is a systemic vascular disorder, involving multiple arterial territories. This project sought to investigate the relationship between lower extremity peripheral artery disease (PAD) and carotid artery stenosis (CAS) in a large self-referred population. METHODS Data from the ankle brachial index (ABI) and carotid duplex ultrasound were analyzed from 3.67 million US subjects in the Life Line Screening program between 2004 and 2008. PAD was defined by ABI<0.9 and CAS was defined by greater than 50% stenosis. Multivariate logistic regression analysis was used to estimate odds of CAS by PAD status and severity. RESULTS Mean age of the population was 63.7 ± 10.6 years and 64% were women. The prevalence of PAD and CAS was 4.1% and 3.9%, respectively. Subjects with PAD had a higher prevalence of CAS than those without PAD (18.8% vs. 3.3%, P < 0.0001). In multivariate analysis, PAD was associated with greater odds of CAS (OR 3.28, 95% CI 3.22-3.34). Both symptomatic (OR 3.66, 95% CI 3.58-3.75) and asymptomatic PAD (OR 2.91, 95% CI 2.84-2.98) was associated with CAS. Increasing severity of PAD was associated with greater odds of CAS (OR 2.32, 3.61, 4.19, 5.14, and 7.59 for ABI categories 0.81-0.90, 0.71-0.80, 0.61-0.70, 0.41-0.60, ≤0.40, respectively). CONCLUSION Presence and severity of PAD was associated with prevalence of CAS in the large self-referred and self-paying Life Line cohort, regardless of lower extremity symptoms.
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Proton Pump Inhibitor Usage and the Risk of Myocardial Infarction in the General Population. PLoS One 2015; 10:e0124653. [PMID: 26061035 PMCID: PMC4462578 DOI: 10.1371/journal.pone.0124653] [Citation(s) in RCA: 214] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 03/17/2015] [Indexed: 12/12/2022] Open
Abstract
Background and Aims Proton pump inhibitors (PPIs) have been associated with adverse clinical outcomes amongst clopidogrel users after an acute coronary syndrome. Recent pre-clinical results suggest that this risk might extend to subjects without any prior history of cardiovascular disease. We explore this potential risk in the general population via data-mining approaches. Methods Using a novel approach for mining clinical data for pharmacovigilance, we queried over 16 million clinical documents on 2.9 million individuals to examine whether PPI usage was associated with cardiovascular risk in the general population. Results In multiple data sources, we found gastroesophageal reflux disease (GERD) patients exposed to PPIs to have a 1.16 fold increased association (95% CI 1.09–1.24) with myocardial infarction (MI). Survival analysis in a prospective cohort found a two-fold (HR = 2.00; 95% CI 1.07–3.78; P = 0.031) increase in association with cardiovascular mortality. We found that this association exists regardless of clopidogrel use. We also found that H2 blockers, an alternate treatment for GERD, were not associated with increased cardiovascular risk; had they been in place, such pharmacovigilance algorithms could have flagged this risk as early as the year 2000. Conclusions Consistent with our pre-clinical findings that PPIs may adversely impact vascular function, our data-mining study supports the association of PPI exposure with risk for MI in the general population. These data provide an example of how a combination of experimental studies and data-mining approaches can be applied to prioritize drug safety signals for further investigation.
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Affiliation(s)
- John P Cooke
- From the Department of Cardiovascular Sciences, Houston Methodist Research Institute, Houston, TX (J.P.C.); and Division of Cardiology, University of California San Diego (Z.C.).
| | - Zhen Chen
- From the Department of Cardiovascular Sciences, Houston Methodist Research Institute, Houston, TX (J.P.C.); and Division of Cardiology, University of California San Diego (Z.C.)
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27
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Bunte MC, Jacob J, Nudelman B, Shishehbor MH. Validation of the relationship between ankle–brachial and toe–brachial indices and infragenicular arterial patency in critical limb ischemia. Vasc Med 2015; 20:23-9. [DOI: 10.1177/1358863x14565372] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The relationship between ankle–brachial index (ABI) remains uncertain relative to clinical and angiographic features of critical limb ischemia (CLI). From July 2011 to February 2013, 89 consecutive patients with CLI had non-invasive testing for indications of rest pain ( n=23, 26%), as well as minor ( n=29, 33%) and major ( n=37, 42%) ischemic tissue loss. All patients subsequently underwent ABI testing and lower extremity angiography with visualization of the infragenicular arteries. Toe–brachial index (TBI) testing was available among 31 of these patients. Among patients with any ischemic tissue loss, 29% had an ABI between 0.7 and 1.4. Patients with rest pain alone had reduced odds of abnormal arterial runoff in univariate (OR 0.75, 95% CI 0.63–0.90; p=0.002) but not multivariate ( p=0.50) analysis. Advanced age, increased ABI, reduced creatinine clearance, hyperlipidemia, and prior coronary artery disease were predictive of abnormal infragenicular runoff. Despite limitations in statistical power, median TBI, compared to ABI, tended to increase when infragenicular arterial runoff was preserved. Overall, the association of TBI with abnormal runoff was not significant ( p=0.38). In conclusion, in the evaluation of CLI, nearly one-third of patients with any ischemic tissue loss had a normal or mildly reduced ABI. Assessment of TBI may augment the diagnostic accuracy of ABI in the evaluation of CLI.
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Affiliation(s)
- Matthew C Bunte
- Robert & Suzanne Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jessen Jacob
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin Nudelman
- Robert & Suzanne Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mehdi H Shishehbor
- Robert & Suzanne Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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Stein RA, Rockman CB, Guo Y, Adelman MA, Riles T, Hiatt WR, Berger JS. Association between physical activity and peripheral artery disease and carotid artery stenosis in a self-referred population of 3 million adults. Arterioscler Thromb Vasc Biol 2015; 35:206-12. [PMID: 25359858 PMCID: PMC4518860 DOI: 10.1161/atvbaha.114.304161] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 10/20/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Although the relationship between physical activity and coronary heart disease is well characterized, a paucity of data exists on physical activity and vascular disease in other arterial territories. This study examined the prevalence of peripheral artery disease (PAD) and carotid artery stenosis (CAS) in association with physical activity. APPROACH AND RESULTS The association between physical activity and vascular disease was examined in >3 million self-referred US participants in the United States from 2003 to 2008 who completed a medical and lifestyle questionnaire in the Life Line screening program. All subjects were evaluated by screening ankle brachial indices <0.90 for PAD and ultrasound imaging for CAS >50%. Multivariable logistic regression modeling was used to estimate odds of disease. Among 3 250 350 subjects, 63% of the population engaged in some leisure time vigorous physical activity. After adjustment for age, sex, race/ethnicity, hypertension, hypercholesterolemia, smoking status, diabetes mellitus, body mass index, and family history of cardiovascular disease, subjects who reported any physical activity had a significantly lower odds of PAD (odds ratio, 0.64; 95% confidence interval, 0.63-0.65) and CAS (odds ratio, 0.80; 95% confidence interval, 0.79-0.81). The association between physical activity with PAD and CAS was robust when stratified by sex, race, and age categories. Physical activity intensity frequency was associated with lower PAD and CAS in a graded manner (P trend <0.0001 for both). Findings seemed unaffected by confounding by comorbidity or indication. CONCLUSIONS In a large population-based study, higher levels of physical activity were independently associated with lower odds of vascular disease in the lower extremities and carotid arteries.
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Affiliation(s)
- Richard A Stein
- From the Division of Cardiology, Department of Medicine (R.A.S., J.S.B.), Division of Vascular Surgery, Department of Surgery (C.B.R., M.A.A., T.R., J.S.B.), Division of Biostatistics, Department of Population Health (Y.G.), New York University Langone Medical Center, New York; and Division of Cardiology, Department of Medicine, University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
| | - Caron B Rockman
- From the Division of Cardiology, Department of Medicine (R.A.S., J.S.B.), Division of Vascular Surgery, Department of Surgery (C.B.R., M.A.A., T.R., J.S.B.), Division of Biostatistics, Department of Population Health (Y.G.), New York University Langone Medical Center, New York; and Division of Cardiology, Department of Medicine, University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
| | - Yu Guo
- From the Division of Cardiology, Department of Medicine (R.A.S., J.S.B.), Division of Vascular Surgery, Department of Surgery (C.B.R., M.A.A., T.R., J.S.B.), Division of Biostatistics, Department of Population Health (Y.G.), New York University Langone Medical Center, New York; and Division of Cardiology, Department of Medicine, University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
| | - Mark A Adelman
- From the Division of Cardiology, Department of Medicine (R.A.S., J.S.B.), Division of Vascular Surgery, Department of Surgery (C.B.R., M.A.A., T.R., J.S.B.), Division of Biostatistics, Department of Population Health (Y.G.), New York University Langone Medical Center, New York; and Division of Cardiology, Department of Medicine, University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
| | - Thomas Riles
- From the Division of Cardiology, Department of Medicine (R.A.S., J.S.B.), Division of Vascular Surgery, Department of Surgery (C.B.R., M.A.A., T.R., J.S.B.), Division of Biostatistics, Department of Population Health (Y.G.), New York University Langone Medical Center, New York; and Division of Cardiology, Department of Medicine, University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
| | - William R Hiatt
- From the Division of Cardiology, Department of Medicine (R.A.S., J.S.B.), Division of Vascular Surgery, Department of Surgery (C.B.R., M.A.A., T.R., J.S.B.), Division of Biostatistics, Department of Population Health (Y.G.), New York University Langone Medical Center, New York; and Division of Cardiology, Department of Medicine, University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
| | - Jeffrey S Berger
- From the Division of Cardiology, Department of Medicine (R.A.S., J.S.B.), Division of Vascular Surgery, Department of Surgery (C.B.R., M.A.A., T.R., J.S.B.), Division of Biostatistics, Department of Population Health (Y.G.), New York University Langone Medical Center, New York; and Division of Cardiology, Department of Medicine, University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.).
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Arroyo D, Betriu A, Martinez-Alonso M, Vidal T, Valdivielso JM, Fernández E. Observational multicenter study to evaluate the prevalence and prognosis of subclinical atheromatosis in a Spanish chronic kidney disease cohort: baseline data from the NEFRONA study. BMC Nephrol 2014; 15:168. [PMID: 25326683 PMCID: PMC4210528 DOI: 10.1186/1471-2369-15-168] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 10/02/2014] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Cardiovascular events (CVE) are more prevalent in chronic kidney disease (CKD) than in general population, being the main cause of morbimortality. Specific risk factors related to CKD have been suggested, because traditional factors do not fully explain this increase in cardiovascular disease rates. However, the role of atheromatosis, its pathogenesis and evolution are still unclear. The potential use of diagnostic tests to detect subclinical atheromatosis has to be determined. METHODS NEFRONA is a prospective multicenter cohort study. 2445 CKD subjects were enrolled from 81 Spanish hospitals and dialysis clinics, from 2010 to 2012. Eligibility criteria included: 18 to 74 years old, CKD stage 3 or higher, and no previous CVE. 559 non-CKD controls were also recruited. Demographical, clinical and analytical data were collected. Carotid and femoral ultrasounds were performed by a single trained team to measure carotid intima-media thickness (cIMT) and detect atheromatous plaques. Ankle-brachial index (ABI) was measured. RESULTS Differences in age, sex and prevalence and control of cardiovascular risk factors were found between controls and CKD patients. These differences are similar to those described in epidemiological studies.No difference was found regarding cIMT between controls and CKD (when subjects with plaques in common carotid arteries were omitted); earlier CKD stages had higher values. CKD patients had a higher rate of atheromatous plaques, with no difference between stages in the unadjusted analysis. A group of patients had plaques in femoral arteries but were plaque-free in carotid arteries, and would have gone underdiagnosed without the femoral study. The percentage of pathologic ABI was higher in CKD, with higher prevalence in more advanced stages, and a higher rate of ABI >1.4 than <0.9, suggesting more vascular calcification. CONCLUSIONS NEFRONA is the first large study describing the actual prevalence of subclinical atheromatosis across different CKD stages. There is a very high rate of atheromatous plaques and pathologic ABI in CKD. Prospective data will add important information to the pathogenesis and evolution of atheromatosis in CKD, compared to non-CKD subjects.
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Affiliation(s)
- David Arroyo
- Nephrology Department, Hospital Universitari Arnau de Vilanova, Avda, Rovira Roure 80, 25198 Lleida, Spain.
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Weir-McCall JR, Khan F, Lambert MA, Adamson CL, Gardner M, Gandy SJ, Ramkumar PG, Belch JJF, Struthers AD, Rauchhaus P, Morris AD, Houston JG. Common carotid intima media thickness and ankle-brachial pressure index correlate with local but not global atheroma burden: a cross sectional study using whole body magnetic resonance angiography. PLoS One 2014; 9:e99190. [PMID: 24933122 PMCID: PMC4059661 DOI: 10.1371/journal.pone.0099190] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 05/12/2014] [Indexed: 11/18/2022] Open
Abstract
Background Common carotid intima media thickness (CIMT) and ankle brachial pressure index (ABPI) are used as surrogate marker of atherosclerosis, and have been shown to correlate with arterial stiffness, however their correlation with global atherosclerotic burden has not been previously assessed. We compare CIMT and ABPI with atheroma burden as measured by whole body magnetic resonance angiography (WB-MRA). Methods 50 patients with symptomatic peripheral arterial disease were recruited. CIMT was measured using ultrasound while rest and exercise ABPI were performed. WB-MRA was performed in a 1.5T MRI scanner using 4 volume acquisitions with a divided dose of intravenous gadolinium gadoterate meglumine (Dotarem, Guerbet, FR). The WB-MRA data was divided into 31 anatomical arterial segments with each scored according to degree of luminal narrowing: 0 = normal, 1 = <50%, 2 = 50–70%, 3 = 70–99%, 4 = vessel occlusion. The segment scores were summed and from this a standardized atheroma score was calculated. Results The atherosclerotic burden was high with a standardised atheroma score of 39.5±11. Common CIMT showed a positive correlation with the whole body atheroma score (β 0.32, p = 0.045), however this was due to its strong correlation with the neck and thoracic segments (β 0.42 p = 0.01) with no correlation with the rest of the body. ABPI correlated with the whole body atheroma score (β −0.39, p = 0.012), which was due to a strong correlation with the ilio-femoral vessels with no correlation with the thoracic or neck vessels. On multiple linear regression, no correlation between CIMT and global atheroma burden was present (β 0.13 p = 0.45), while the correlation between ABPI and atheroma burden persisted (β −0.45 p = 0.005). Conclusion ABPI but not CIMT correlates with global atheroma burden as measured by whole body contrast enhanced magnetic resonance angiography in a population with symptomatic peripheral arterial disease. However this is primarily due to a strong correlation with ilio-femoral atheroma burden.
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Affiliation(s)
- Jonathan R. Weir-McCall
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, University of Dundee, Dundee, United Kingdom
- NHS Tayside Clinical Radiology, Ninewells Hospital, Dundee, United Kingdom
- * E-mail:
| | - Faisel Khan
- Vascular & Inflammatory Diseases Research Unit, Medical Research Institute, University of Dundee, Dundee, United Kingdom
| | - Matthew A. Lambert
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, University of Dundee, Dundee, United Kingdom
| | - Carly L. Adamson
- University of Dundee, Ninewells Hospital & Medical School, Dundee, United Kingdom
| | - Michael Gardner
- University of Dundee, Ninewells Hospital & Medical School, Dundee, United Kingdom
| | - Stephen J. Gandy
- NHS Tayside Medical Physics, Ninewells Hospital, Dundee, United Kingdom
| | | | - Jill J. F. Belch
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, University of Dundee, Dundee, United Kingdom
| | - Allan D. Struthers
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, University of Dundee, Dundee, United Kingdom
| | - Petra Rauchhaus
- Dundee epidemiological and biostatistics unit, University of Dundee, Dundee, United Kingdom
| | - Andrew D. Morris
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, University of Dundee, Dundee, United Kingdom
| | - J. Graeme Houston
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, University of Dundee, Dundee, United Kingdom
- NHS Tayside Clinical Radiology, Ninewells Hospital, Dundee, United Kingdom
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Shah B, Rockman CB, Guo Y, Chesner J, Schwartzbard AZ, Weintraub HS, Adelman MA, Riles TS, Berger JS. Diabetes and vascular disease in different arterial territories. Diabetes Care 2014; 37:1636-42. [PMID: 24705616 PMCID: PMC4030086 DOI: 10.2337/dc13-2432] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the relationship between diabetes and different phenotypes of peripheral vascular disease (lower extremity peripheral artery disease [PAD], carotid artery stenosis [CAS], and abdominal aortic aneurysm [AAA]). RESEARCH DESIGN AND METHODS Prevalence of vascular disease was evaluated in 3,696,778 participants of the Life Line Screening survey between 2003 and 2008. PAD was defined as ankle-brachial pressure index <0.90 or prior revascularization, CAS as ≥50% stenosis or prior revascularization, and AAA as infrarenal aortic diameter ≥3 cm or prior repair. Odds ratios (ORs) and 95% CIs were assessed using logistic regression modeling. RESULTS Diabetes mellitus was present in 10.8% of participants (n = 399,884). Prevalence of PAD, CAS, and AAA was significantly higher (P < 0.0001) in participants with compared with those without diabetes. After multivariate adjustment for baseline demographics and clinical risk factors, a significant interaction existed between diabetes and vascular disease phenotype (P < 0.0001). Diabetes was associated with increased odds of PAD (OR 1.42 [95% CI 1.41-1.4]; P < 0.0001) and CAS (1.45 [1.43-1.47]; P < 0.0001) but decreased odds of AAA (0.86 [0.84-0.88]; P < 0.0001). The strength of association increased with increasing severity of disease in each vascular phenotype, and this association persisted in the population with asymptomatic vascular disease. CONCLUSIONS In a large population-based study, the association between diabetes and vascular disease differed according to vascular phenotype. Future studies exploring the mechanism for these vascular-specific differences are needed.
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Affiliation(s)
- Binita Shah
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, NY
| | - Caron B Rockman
- Department of Surgery, Division of Vascular Surgery, New York University School of Medicine, New York, NY
| | - Yu Guo
- Department of Population Health, Division of Biostatistics, New York University School of Medicine, New York, NY
| | - Jaclyn Chesner
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, NY
| | - Arthur Z Schwartzbard
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, NY
| | - Howard S Weintraub
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, NY
| | - Mark A Adelman
- Department of Surgery, Division of Vascular Surgery, New York University School of Medicine, New York, NY
| | - Thomas S Riles
- Department of Surgery, Division of Vascular Surgery, New York University School of Medicine, New York, NY
| | - Jeffrey S Berger
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, NYDepartment of Surgery, Division of Vascular Surgery, New York University School of Medicine, New York, NYDepartment of Medicine, Division of Hematology, New York University School of Medicine, New York, NY
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Chang P, Nead KT, Olin JW, Cooke JP, Leeper NJ. Clinical and socioeconomic factors associated with unrecognized peripheral artery disease. Vasc Med 2014; 19:289-296. [PMID: 24872403 DOI: 10.1177/1358863x14535475] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Peripheral artery disease (PAD) is a highly prevalent condition that frequently goes undetected and untreated. Socioeconomic factors associated with unrecognized PAD are not known. The ankle-brachial index (ABI) was calculated in 1656 study participants undergoing non-emergent coronary angiography with PAD defined as an ABI <0.9. Subjects were followed for mortality and cardiovascular outcomes. Compared to those without PAD, those with unrecognized PAD at enrollment were older, had higher rates of cardiovascular comorbidities, and had higher major adverse cardiovascular events (MACE) (p<0.03 for all). Among those enrolling without a reported history of PAD, there was a higher prevalence of PAD with decreasing income (p=0.004), education level (p<0.001), social isolation (p=0.027) and depression (p=0.034); 50% of these individuals reported symptoms suggestive of claudication. In conclusion, the prevalence of unrecognized PAD is high amongst a cohort of high-risk individuals referred for coronary angiography. A profile of lower socioeconomic status is associated with unrecognized PAD. These subjects will report symptoms suggestive of claudication and impaired walking ability when directly queried.
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Affiliation(s)
- Peter Chang
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Kevin T Nead
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Jeffrey W Olin
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, NY, USA
| | - John P Cooke
- Methodist Hospital Research Institute, Houston, TX, USA
| | - Nicholas J Leeper
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA, USA Stanford Cardiovascular Institute, Stanford, CA, USA
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DeMaria AN, Adler ED, Bax JJ, Ben-Yehuda O, Feld GK, Greenberg BH, Hall JL, Hlatky MA, Lew WYW, Lima JAC, Mahmud E, Maisel AS, Narayan SM, Nissen SE, Sahn DJ, Tsimikas S. Highlights of the year in JACC 2013. J Am Coll Cardiol 2014; 63:570-602. [PMID: 24524815 DOI: 10.1016/j.jacc.2014.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | - Eric D Adler
- Cardiology Division, UCSD Medical Center, San Diego, California
| | - Jeroen J Bax
- Leiden University Medical Center, Leiden, the Netherlands
| | | | - Gregory K Feld
- Cardiology Division, UCSD Medical Center, San Diego, California
| | | | | | | | | | | | - Ehtisham Mahmud
- Cardiology Division, UCSD Medical Center, San Diego, California
| | - Alan S Maisel
- Veterans Affairs Medical Center, San Diego, California
| | | | | | - David J Sahn
- Department of Pediatric Cardiology, Oregon Health and Science University, Portland, Oregon
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Priest JR, Nead KT, Wehner MR, Cooke JP, Leeper NJ. Self-reported history of childhood smoking is associated with an increased risk for peripheral arterial disease independent of lifetime smoking burden. PLoS One 2014; 9:e88972. [PMID: 24558458 PMCID: PMC3928325 DOI: 10.1371/journal.pone.0088972] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 01/06/2014] [Indexed: 11/19/2022] Open
Abstract
Atherosclerotic disorders are well known to be associated with obesity, lipid profile, smoking, hypertension and other medical comorbidities, and large cohort studies have explored the childhood correlates to these adult risk factors. However, there has been little investigation into the childhood risk factors for peripheral arterial disease (PAD). We endeavored to better understand the role of smoking in childhood in the risk for PAD in a well described cohort of 1,537 adults at high risk for cardiovascular disease. In a multivariate regression model, we observed an increased risk of PAD among those who reported a history of smoking during childhood (OR = 2.86; 95% CI, 1.99-4.11; P<0.001), which remained statistically significant after controlling for lifetime smoking burden (OR = 1.55; 95% CI, 1.00-2.41; P = 0.049). Our novel observation of disproportionate risk of PAD conferred by a history of childhood smoking may reflect an unrecognized biological mechanism such as a unique susceptibility to vascular injury or an unaccounted for covariate such as secondhand smoke exposure in childhood. This observation suggests further investigation is required into the pathophysiology of smoking in the developing vasculature and the need for detailed clinical data about patterns of childhood smoking and smoke exposure.
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Affiliation(s)
- James R. Priest
- Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, California, United States of America
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
| | - Kevin T. Nead
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Mackenzie R. Wehner
- Stanford University School of Medicine, Stanford, California, United States of America
| | - John P. Cooke
- Center for Cardiovascular Regeneration, Methodist DeBakey Heart and Vascular Center, Houston, Texas, United States of America
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
| | - Nicholas J. Leeper
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California, United States of America
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
- * E-mail:
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Downing KP, Nead KT, Kojima Y, Assimes T, Maegdefessel L, Quertermous T, Cooke JP, Leeper NJ. The combination of 9p21.3 genotype and biomarker profile improves a peripheral artery disease risk prediction model. Vasc Med 2013; 19:3-8. [PMID: 24323119 DOI: 10.1177/1358863x13514791] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Peripheral artery disease (PAD) is a highly morbid condition affecting more than 8 million Americans. Frequently, PAD patients are unrecognized and therefore do not receive appropriate therapies. Therefore, new methods to identify PAD have been pursued, but have thus far had only modest success. Here we describe a new approach combining genomic and metabolic information to enhance the diagnosis of PAD. We measured the genotype of the chromosome 9p21 cardiovascular-risk polymorphism rs10757269 as well as the biomarkers C-reactive protein, cystatin C, β2-microglobulin, and plasma glucose in a study population of 393 patients undergoing coronary angiography. The rs10757269 allele was associated with PAD status (ankle-brachial index < 0.9) independent of biomarkers and traditional cardiovascular risk factors (odds ratio = 1.92; 95% confidence interval, 1.29-2.85). Importantly, compared to a previously validated risk factor-based PAD prediction model, the addition of biomarkers and rs10757269 significantly and incrementally improved PAD risk prediction as assessed by the net reclassification index (NRI = 33.5%; p = 0.001) and integrated discrimination improvement (IDI = 0.016; p = 0.017). In conclusion, a model including a panel of biomarkers, which includes both genomic information (which is reflective of heritable risk) and metabolic information (which integrates environmental exposures), predicts the presence or absence of PAD better than established risk models, suggesting clinical utility for the diagnosis of PAD.
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Affiliation(s)
- Kelly P Downing
- Division of Vascular Surgery, Stanford University, Stanford, CA, USA
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Hiatt WR. Should an Alternate ABI Definition Be Adopted to Evaluate Risk? J Am Coll Cardiol 2013; 62:560-1. [DOI: 10.1016/j.jacc.2013.04.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 04/10/2013] [Indexed: 10/26/2022]
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