Asymptomatic peripheral arterial occlusive disease predicted cardiovascular morbidity and mortality in a 7-year follow-up study

The resistive and pulsatility indices of the dorsal metatarsal artery for the screening of peripheral lower artery disease in patients with and without diabetes

BACKGROUND

In lower extremity peripheral artery disease (PAD), the ankle-brachial index (ABI) is an easily reproducible diagnostic tool for PAD, but it loses reliability when > 1.4 due to calcification of the vessel wall. Patients with diabetes are at higher risk for wall calcification. In order to overcome the limitation and reliability of ABI, particularly in patients with diabetes, we decided to assess resistive (RI) and pulsatility index (PI) by ultrasound doppler of the dorsal metatarsal artery (DMA).

RESULTS

We therefore analyzed 51 legs (32 patients), evaluating the correlation between PI, RI, and ABI. Patients with diabetes were 21 (65.6 %), accounting for 33 legs (64.7 %). Out of 51 legs assessed, 37 (72.5 %) cases had compressible arteries, whereas in 14 legs (27.5 %) ABI was not calculable due to wall calcification. PAD was significantly associated with lower both RI and PI of the DMA (both p < 0.000). RI, but not PI, showed a significant correlation (r = 0.535) with ABI, when ABI was less than 1.4, but not when ABI > 1.4. When analyzed separately, patients with diabetes showed a similar figure in comparison with those without diabetes (r = 0.600), RI, but not PI, showed a significant correlation with ABI.

CONCLUSION

Dorsal metatarsal artery resistive index (MARI) showed a significant inverse correlation with PAD, similarly to ABI, irrespective of the presence of diabetes. MARI seems to be an effective screening tool for PAD even in patients with wall calcification. Further studies are needed for confirming the results of the present pilot study.

Lack of Association of Vascular Risk Factors with HIV-Associated Neurocognitive Disorders in cART-Treated Adults Aged ≥ 50 Years in Tanzania

HIV-associated neurocognitive disorders (HAND) are highly prevalent in those ageing with HIV. High-income country data suggest that vascular risk factors (VRFs) may be stronger predictors of HAND than HIV-disease severity, but data from sub-Saharan Africa are lacking. We evaluated relationships of VRFs, vascular end-organ damage and HAND in individuals aged ≥ 50 in Tanzania. c-ART-treated individuals were assessed for HAND using consensus criteria. The prevalence of VRFs and end organ damage markers were measured. The independent associations of VRFs, end organ damage and HAND were examined using multivariable logistic regression. Data were available for 153 individuals (median age 56, 67.3% female). HAND was highly prevalent (66.7%, 25.5% symptomatic) despite well-managed HIV (70.5% virally suppressed). Vascular risk factors included hypertension (34%), obesity (10.5%), hypercholesterolemia (33.3%), diabetes (5.3%) and current smoking (4.6%). End organ damage prevalence ranged from 1.3% (prior myocardial infarction) to 12.5% (left ventricular hypertrophy). Measured VRFs and end organ damage were not independently associated with HAND. The only significant association was lower diastolic BP (p 0.030, OR 0.969 (0.943-0.997). Our results suggest that vascular risk factors are not major drivers of HAND in this setting. Further studies should explore alternative aetiologies such as chronic inflammation.

Mobile health technologies to improve walking distance in people with intermittent claudication

BACKGROUND

Peripheral arterial disease (PAD) is the obstruction or narrowing of the large arteries of the lower limbs, which can result in impaired oxygen supply to the muscle and other tissues during exercise, or even at rest in more severe cases. PAD is classified into five categories (Fontaine classification). It may be asymptomatic or various levels of claudication pain may be present; at a later stage, there may be ulceration or gangrene of the limb, with amputation occasionally being required. About 20% of people with PAD suffer from intermittent claudication (IC), which is muscular discomfort in the lower extremities induced by exertion and relieved by rest within 10 minutes; IC causes restriction of movement in daily life. Treatment for people with IC involves addressing lifestyle risk factors. Exercise is an important part of treatment, but supervised exercise programmes for individuals with IC have low engagement levels and high attrition rates. The use of mobile technologies has been suggested as a new way to engage people with IC in walking exercise interventions. The novelty of the intervention, low cost for the user, automation, and ease of access are some of the advantages mobile health (mhealth) technologies provide that give them the potential to be effective in boosting physical activity in adults.

OBJECTIVES

To assess the benefits and harms of mobile health (mhealth) technologies to improve walking distance in people with intermittent claudication.

SEARCH METHODS

The Cochrane Vascular Information Specialist conducted systematic searches of the Cochrane Vascular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL, and also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov. The most recent searches were carried out on 19 December 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in people aged 18 years or over with symptomatic PAD and a clinical diagnosis of IC. We included RCTs comparing mhealth interventions to improve walking distance versus usual care (no intervention or non-exercise advice), exercise advice, or supervised exercise programmes. We excluded people with chronic limb-threatening ischaemia (Fontaine III and IV).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were change in absolute walking distance from baseline, change in claudication distance from baseline, amputation-free survival, revascularisation-free survival. Our secondary outcomes were major adverse cardiovascular events, major adverse limb events, above-ankle amputation, quality of life, and adverse events. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included four RCTs involving a total of 614 participants with a clinical diagnosis of IC. The duration of intervention of the four included RCTs ranged from 3 to 12 months. Participants were randomised to either mhealth or control (usual care or supervised exercise programme). All four studies had an unclear or high risk of bias in one or several domains. The most prevalent risk of bias was in the area of performance bias, which was rated high risk as it is not possible to blind participants and personnel in this type of trial. Based on GRADE criteria, we downgraded the certainty of the evidence to low, due to concerns about risk of bias, imprecision, and clinical inconsistency. Comparing mhealth with usual care, there was no clear evidence of an effect on absolute walking distance (mean difference 9.99 metres, 95% confidence interval (CI) -27.96 to 47.93; 2 studies, 503 participants; low-certainty evidence). None of the included studies reported on change in claudication walking distance, amputation-free survival, or revascularisation-free survival. Only one study reported on major adverse cardiovascular events (MACE) and found no clear difference between groups (risk ratio 1.37, 95% CI 0.07 to 28.17; 1 study, 305 participants; low-certainty evidence). None of the included studies reported on major adverse limb events (MALE) or above-ankle amputations.

AUTHORS' CONCLUSIONS

Mobile health technologies can be used to provide lifestyle interventions for people with chronic conditions, such as IC. We identified a limited number of studies that met our inclusion criteria. We found no clear difference between mhealth and usual care in improving absolute walking distance in people with IC; however, we judged the evidence to be low certainty. Larger, well-designed RCTs are needed to provide adequate statistical power to reliably evaluate the effects of mhealth technologies on walking distance in people with IC.

Assessment of Subclinical Atherosclerosis in Asymptomatic People In Vivo: Measurements Suitable for Biomarker and Mendelian Randomization Studies

BACKGROUND

One strategy to reduce the burden of cardiovascular disease is the early detection and treatment of atherosclerosis. This has led to significant interest in studies of subclinical atherosclerosis, using different phenotypes, not all of which are accurate reflections of the presence of asymptomatic atherosclerotic plaques. The aim of part 2 of this series is to provide a review of the existing literature on purported measures of subclinical disease and recommendations concerning which tests may be appropriate in the prevention of incident cardiovascular disease.

METHODS

We conducted a critical review of measurements used to infer the presence of subclinical atherosclerosis in the major conduit arteries and focused on the predictive value of these tests for future cardiovascular events, independent of conventional cardiovascular risk factors, in asymptomatic people. The emphasis was on studies with >10 000 person-years of follow-up, with meta-analysis of results reporting adjusted hazard ratios (HRs) with 95% CIs. The arterial territories were limited to carotid, coronary, aorta, and lower limb arteries.

RESULTS

In the carotid arteries, the presence of plaque (8 studies) was independently associated with future stroke (pooled HR, 1.89 [1.04-3.44]) and cardiac events (7 studies), with a pooled HR, 1.77 (1.19-2.62). Increased coronary artery calcium (5 studies) was associated with the risk of coronary heart disease events, pooled HR, 1.54 (1.07-2.07) and increasing severity of calcification (by Agaston score) was associated with escalation of risk (13 studies). An ankle/brachial index (ABI) of <0.9, the pooled HR for cardiovascular death from 7 studies was 2.01 (1.43-2.81). There were insufficient studies of either, thoracic or aortic calcium, aortic diameter, or femoral plaque to synthesize the data based on consistent reporting of these measures.

CONCLUSIONS

The presence of carotid plaque, coronary artery calcium, or abnormal ankle pressures seems to be a valid indicator of the presence of subclinical atherosclerosis and may be considered for use in biomarker, Mendelian randomization and similar studies.

Validated spectrofluorimetric and resonance Rayleigh scattering methods for determining naftidrofuryl in varied pharmaceutical samples based on its interaction with erythrosin B

Naftidrofuryl is a vasodilator medication used for treating cerebral and peripheral vascular diseases. In this study, two spectroscopical techniques, spectrofluorimetric and resonance Rayleigh scattering (RRS), were utilized to quantify naftidrofuryl in its pharmaceutical samples. The developed methodologies in this study rely on a facile process of forming an association complex between erythrosine B reagent and naftidrofuryl under acidic conditions. The fluorimetric assay is based on the ability of naftidrofuryl to quench and decrease the native fluorescence intensity of the reagent when measured at λ emis . = 550 nm ( λ excit . = 526 nm). Under similar reaction conditions, the RRS method relies on the observed amplification in the RRS spectrum of the reagent at a wavelength of 577 nm following its interaction with naftidrofuryl. The methods exhibited linearity within the ranges 0.2-1.6 μg/ml (r2  = 0.999) and 0.1-1.4 μg/ml (r2  = 0.9994), with limit of quantitation values of 0.146 and 0.099 μg/ml, and limit of detection values of 0.048 and 0.032 μg/ml, for the fluorometric and the RRS methods, respectively. Moreover, the quenching between the dye and naftidrofuryl was studied using Stern-Volmer analysis, and the methodologies were experimentally optimized and validated. Additionally, acceptable recoveries were achieved when the procedures were applied to determine naftidrofuryl in pharmaceutical samples.

Association Between the Presence of Coronary Artery Disease or Peripheral Artery Disease and Left Ventricular Mass in Patients Who Have Undergone Coronary Computed Tomography Angiography

Background

Left ventricular mass (LVM) is a critical marker of future cardiovascular risk. We determined the association between LVM measured by coronary computed tomography angiography (CCTA) and the presence of coronary artery disease (CAD) or peripheral artery disease (PAD) in patients who had undergone CCTA for screening of CAD.

Methods

We enrolled 1,307 consecutive patients (66 ± 12 years old, 49% males) who underwent CCTA for screening of CAD at the Fukuoka University Hospital (FU-CCTA registry), and either were clinically suspected of having CAD or had at least one cardiovascular risk factor. Patients with coronary stenosis of ≥ 50% by CCTA were diagnosed as CAD. Patients with an ankle brachial pressure index < 0.9 or who had already been diagnosed with PAD were considered to have PAD. Left ventricular mass index (LVMI), left ventricular ejection fraction (LVEF), end-diastolic volume (EDV) and end-systolic volume (ESV) were measured. The patients were divided into CAD (-) and CAD (+) or PAD (-) and PAD (+) groups.

Results

The prevalences of CAD and PAD in all patients were 50% and 4.8%, respectively. Age, %males, %hypertension (HTN), %dyslipidemia (DL), %diabetes mellitus (DM), %smoking and %chronic kidney disease in the CAD (+) group were significantly higher than those in the CAD (-) group. Age, %males, %HTN, %DM and %smoking in the PAD (+) group were significantly higher than those in the PAD (-) group. CAD was independently associated with LVMI (odds ratio (OR): 1.01, 95% confidence interval (CI): 1.01 - 1.02, P < 0.01) in addition to age, male, HTN, DL, DM, and smoking. PAD was also independently associated with LVMI (OR: 1.01, 95% CI: 1.0 - 1.02, P = 0.018) in addition to age, DM, and smoking.

Conclusions

LVMI determined by CCTA may be useful for predicting atherosclerotic cardiovascular diseases including both CAD and PAD, although there were considerable differences between %CAD and %PAD in all patients.

Duplex ultrasound for surveillance of lower limb revascularisation

BACKGROUND

Lower extremity atherosclerotic disease (LEAD) - also known as peripheral arterial disease - refers to the obstruction or narrowing of the large arteries of the lower limbs, most commonly caused by atheromatous plaque. Although in many cases of less severe disease patients can be asymptomatic, the major clinical manifestations of LEAD are intermittent claudication (IC) and critical limb ischaemia, also known as chronic limb-threatening ischaemia (CLTI). Revascularisation procedures including angioplasty, stenting, and bypass grafting may be required for those in whom the disease is severe or does not improve with non-surgical interventions. Maintaining vessel patency after revascularisation remains a challenge for vascular surgeons, since approximately 30% of vein grafts may present with restenosis in the first year due to myointimal hyperplasia. Restenosis can also occur after angioplasty and stenting. Restenosis and occlusions that occur more than two years after the procedure are generally related to progression of the atherosclerosis. Surveillance programmes with duplex ultrasound (DUS) scanning as part of postoperative care may facilitate early diagnosis of restenosis and help avoid amputation in people who have undergone revascularisation.

OBJECTIVES

To assess the effects of DUS versus pulse palpation, arterial pressure index, angiography, or any combination of these, for surveillance of lower limb revascularisation in people with LEAD.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and LILACS databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 1 February 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that compared DUS surveillance after lower limb revascularisation versus clinical surveillance characterised by medical examination with pulse palpation, with or without any other objective test, such as arterial pressure index measures (e.g. ankle-brachial index (ABI) or toe brachial index (TBI)). Our primary outcomes were limb salvage rate, vessel or graft secondary patency, and adverse events resulting from DUS surveillance. Secondary outcomes were all-cause mortality, functional walking ability assessed by walking distance, clinical severity scales, quality of life (QoL), re-intervention rates, and functional walking ability assessed by any validated walking impairment questionnaire. We presented the outcomes at two time points: two years or less after the original revascularisation (short term) and more than two years after the original revascularisation (long term).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. We used the Cochrane RoB 1 tool to assess the risk of bias for RCTs and GRADE to assess the certainty of evidence. We performed meta-analysis when appropriate.

MAIN RESULTS

We included three studies (1092 participants) that compared DUS plus pulse palpation and arterial pressure index (ABI or TBI) versus pulse palpation and arterial pressure index (ABI or TBI) for surveillance of lower limb revascularisation with bypass. One study each was conducted in Sweden and Finland, and the third study was conducted in the UK and Europe. The studies did not report adverse events resulting from DUS surveillance, functional walking ability, or clinical severity scales. No study assessed surveillance with DUS scanning after angioplasty or stenting, or both. We downgraded the certainty of evidence for risk of bias and imprecision. Duplex ultrasound plus pulse palpation and arterial pressure index (ABI or TBI) versus pulse palpation plus arterial pressure index (ABI or TBI) (short-term time point) In the short term, DUS surveillance may lead to little or no difference in limb salvage rate (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.49 to 1.45; I² = 93%; 2 studies, 936 participants; low-certainty evidence) and vein graft secondary patency (RR 0.92, 95% CI 0.67 to 1.26; I² = 57%; 3 studies, 1092 participants; low-certainty evidence). DUS may lead to little or no difference in all-cause mortality (RR 1.11, 95% CI 0.70 to 1.74; 1 study, 594 participants; low-certainty evidence). There was no clear difference in QoL as assessed by the 36-item Short Form Health Survey (SF-36) physical score (mean difference (MD) 2 higher, 95% CI 2.59 lower to 6.59 higher; 1 study, 594 participants; low-certainty evidence); the SF-36 mental score (MD 3 higher, 95% CI 0.38 lower to 6.38 higher; 1 study, 594 participants; low-certainty evidence); or the EQ-5D utility score (MD 0.02 higher, 95% CI 0.03 lower to 0.07 higher; 1 study, 594 participants; low-certainty evidence). DUS may increase re-intervention rates when considered any therapeutic intervention (RR 1.38, 95% CI 1.05 to 1.81; 3 studies, 1092 participants; low-certainty evidence) or angiogram procedures (RR 1.53, 95% CI 1.12 to 2.08; 3 studies, 1092 participants; low-certainty evidence). Duplex ultrasound plus pulse palpation and arterial pressure index (ABI or TBI) versus pulse palpation plus arterial pressure index (ABI or TBI) (long-term time point) One study reported data after two years, but provided only vessel or graft secondary patency data. DUS may lead to little or no difference in vessel or graft secondary patency (RR 0.83, 95% CI 0.19 to 3.51; 1 study, 156 participants; low-certainty evidence). Other outcomes of interest were not reported at the long-term time point.

AUTHORS' CONCLUSIONS

Based on low certainty evidence, we found no clear difference between DUS and standard surveillance in preventing limb amputation, morbidity, and mortality after lower limb revascularisation. We found no studies on DUS surveillance after angioplasty or stenting (or both), only studies on bypass grafting. High-quality RCTs should be performed to better inform the best medical surveillance of lower limb revascularisation that may reduce the burden of peripheral arterial disease.

Interventions for motor rehabilitation in people with transtibial amputation due to peripheral arterial disease or diabetes

BACKGROUND

Amputation is described as the removal of an external part of the body by trauma, medical illness or surgery. Amputations caused by vascular diseases (dysvascular amputations) are increasingly frequent, commonly due to peripheral arterial disease (PAD), associated with an ageing population, and increased incidence of diabetes and atherosclerotic disease. Interventions for motor rehabilitation might work as a precursor to enhance the rehabilitation process and prosthetic use. Effective rehabilitation can improve mobility, allow people to take up activities again with minimum functional loss and may enhance the quality of life (QoL). Strength training is a commonly used technique for motor rehabilitation following transtibial (below-knee) amputation, aiming to increase muscular strength. Other interventions such as motor imaging (MI), virtual environments (VEs) and proprioceptive neuromuscular facilitation (PNF) may improve the rehabilitation process and, if these interventions can be performed at home, the overall expense of the rehabilitation process may decrease. Due to the increased prevalence, economic impact and long-term rehabilitation process in people with dysvascular amputations, a review investigating the effectiveness of motor rehabilitation interventions in people with dysvascular transtibial amputations is warranted.

OBJECTIVES

To evaluate the benefits and harms of interventions for motor rehabilitation in people with transtibial (below-knee) amputations resulting from peripheral arterial disease or diabetes (dysvascular causes).

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 9 January 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCT) in people with transtibial amputations resulting from PAD or diabetes (dysvascular causes) comparing interventions for motor rehabilitation such as strength training (including gait training), MI, VEs and PNF against each other.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. prosthesis use, and 2.

ADVERSE EVENTS

Our secondary outcomes were 3. mortality, 4. QoL, 5. mobility assessment and 6. phantom limb pain. We use GRADE to assess certainty of evidence for each outcome.

MAIN RESULTS

We included two RCTs with a combined total of 30 participants. One study evaluated MI combined with physical practice of walking versus physical practice of walking alone. One study compared two different gait training protocols. The two studies recruited people who already used prosthesis; therefore, we could not assess prosthesis use. The studies did not report mortality, QoL or phantom limb pain. There was a lack of blinding of participants and imprecision as a result of the small number of participants, which downgraded the certainty of the evidence. We identified no studies that compared VE or PNF with usual care or with each other. MI combined with physical practice of walking versus physical practice of walking (one RCT, eight participants) showed very low-certainty evidence of no difference in mobility assessment assessed using walking speed, step length, asymmetry of step length, asymmetry of the mean amount of support on the prosthetic side and on the non-amputee side and Timed Up-and-Go test. The study did not assess adverse events. One study compared two different gait training protocols (one RCT, 22 participants). The study used change scores to evaluate if the different gait training strategies led to a difference in improvement between baseline (day three) and post-intervention (day 10). There were no clear differences using velocity, Berg Balance Scale (BBS) or Amputee Mobility Predictor with PROsthesis (AMPPRO) in training approaches in functional outcome (very low-certainty evidence). There was very low-certainty evidence of little or no difference in adverse events comparing the two different gait training protocols.

AUTHORS' CONCLUSIONS

Overall, there is a paucity of research in the field of motor rehabilitation in dysvascular amputation. We identified very low-certainty evidence that gait training protocols showed little or no difference between the groups in mobility assessments and adverse events. MI combined with physical practice of walking versus physical practice of walking alone showed no clear difference in mobility assessment (very low-certainty evidence). The included studies did not report mortality, QoL, and phantom limb pain, and evaluated participants already using prosthesis, precluding the evaluation of prosthesis use. Due to the very low-certainty evidence available based on only two small trials, it remains unclear whether these interventions have an effect on the prosthesis use, adverse events, mobility assessment, mortality, QoL and phantom limb pain. Further well-designed studies that address interventions for motor rehabilitation in dysvascular transtibial amputation may be important to clarify this uncertainty.

2022 focused update of the 2017 Taiwan lipid guidelines for high risk patients: Coronary artery disease, peripheral artery disease and ischemic stroke

The previously published 2017 Taiwan Lipid Guidelines for High Risk Patients becomes the standard guidance of dyslipidemia management for patients with atherosclerotic cardiovascular disease (ASCVD) in Taiwan. New clinical trials of lipid lowering therapy were published successively after 2017. The study results changed the treatment concept of ASCVD. Therefore, an update focusing on the lipid treatment strategy for patients with ASCVD becomes necessary. In this focused update of the 2017 guideline, the treatment targets of low-density lipoprotein cholesterol (LDL-C) for patients with ASCVD were modified. The algorithm of LDL-C lowering therapy was revised. The recommendations in this focused update were made mainly based on the scientific evidence from recently published clinical trials and endorsed by the major medical societies in Taiwan.

Statins and statin intensity in peripheral artery disease

Background: Peripheral artery disease (PAD) affects more than 202 million people worldwide. Several studies have shown that patients with PAD are often undertreated, and that statin utilization is suboptimal. European and American guidelines highlight statins as the first-line lipid-lowering therapy to treat patients with PAD. Our objective with this meta-analysis was to further explore the impact of statins on lower extremities PAD endpoints and examine whether statin dose (high vs. low intensity) impacts outcomes. Patients and methods: We performed a systematic review and meta-analysis according to the PRISMA guidelines. Any study that presented a comparison of use of statins vs. no statins for PAD patients or studies comparing high vs. low intensity statins were considered to be potentially eligible. We excluded studies with only critical limb threatening ischemia (CLTI) patients. The Medline (PubMed) database was searched up to January 31, 2021. A random effects meta-analysis was performed. Results: In total, 39 studies and 275,670 patients were included in this meta-analysis. In total, 136,025 (49.34%) patients were on statins vs. 139,645 (50.66%) who were not on statins. Statin use was associated with a reduction in all cause-mortality by 42% (HR: 0.58, 95% CI: 0.49-0.67, p<0.01) and cardiovascular death by 43% (HR: 0.57, 95% CI: 0.40-0.74, p<0.01). Statin use was associated with an increase in amputation-free survival by 56% (HR: 0.44, 95% CI: 0.30-0.58, p<0.01). The risk of amputation and loss of patency were reduced by 35% (HR: 0.65, 95% CI: 0.41-0.89, p<0.01) and 46% (HR: 0.54, 95% CI: 0.34-0.74, p<0.01), respectively. Statin use was also associated with a reduction in the risk of major adverse cardiovascular events (MACE) by 35% (HR: 0.65, 95% CI: 0.51-0.80, p<0.01) and myocardial infarction rates by 41% (HR: 0.59, 95% CI: 0.33-0.86, p<0.01). Among patients treated with statins, the high-intensity treatment group was associated with a reduction in all cause-mortality by 36% (HR: 0.64, 95% CI: 0.54-0.74, p<0.01) compared to patients treated with low intensity statins. Conclusions: Statin treatment among patients with PAD was associated with a statistically significant reduction in all-cause mortality, cardiovascular mortality, MACE, risk for amputation, or loss of patency. Higher statin dose seems to be associated with improved outcomes.

Presence of asymptomatic Peripheral Arterial Disease in combination with common risk factors elevates the cardiovascular risk Substantially

Background and aims

This study evaluates the risks for adverse cardiovascular (CV) events in Asymptomatic Peripheral Arterial Disease (APAD) combined with different traditional CV risk factors.

Methods

A population-based observational study of 8000 subjects, identified 559 subjects as having APAD through ankle-brachial index (ABI) measurements and questionnaires regarding limb symptoms. This cohort and subgroups classified by presence of different traditional CV risk factors at baseline were assessed for 10 years on CV outcome. The recorded endpoints were all-cause mortality, CV mortality and non-fatal CV events.

Results

Before subdividing the APAD subjects, the CV mortality incidence was 28.5 deaths per 1000 person-years as compared to 8.7 deaths for references without APAD. For subjects with hypertension at baseline the CV mortality incidence was 35.4 when combined with APAD and 11.7 without. In women with hypertension but without other risk factors, presence of APAD increased the age-adjusted Hazard Ratio (HR) for fatal and non-fatal CV events by 1.86 [CI 1.54,2.24, p < 0.001].

Conclusions

ABI measurements should be considered an important indication for aggressive multifactorial risk factor reduction in populations with any other prevalent CV risk factor. In hypertension, diabetes mellitus and a smoking history, coexisting APAD contributes significantly to the increased age-adjusted CV risk.

Long-Term Exposures to Air Pollutants and Risk of Peripheral Arterial Occlusive Disease: A Nationwide Cohort Study in Taiwan

Air pollution is one of the most alarming environmental issues which causes multiple health hazards. An association between air pollution and cardiovascular diseases has been established through many prior studies. In this study, we aimed to evaluate the risk of long-term exposure to air pollution (PM_2.5, CO, and NO₂) and its association with the risk of developing peripheral arterial occlusive disease (PAOD). PAOD is a condition involving impairment of perfusion of blood in the distal parts of the aorta due to narrowing of the arteries (arterial stenosis) and has been reported as a risk factor for developing cardiovascular diseases. Furthermore, the risk of PAOD increases with age, and hence is a serious public health issue and a cause for concern, especially for an aging society such as Taiwan. Two national-scale databases from Taiwan, the national health insurance database (NHIRD) and the Taiwan air quality-monitoring database (TAQMD), were linked to conduct this cohort study between 2003 and 2013. Cox proportional hazards regression with time-dependent modeling was used to evaluate the hazard ratio (HR) for PAOD with respect to daily exposure to air pollutants. The concentrations of each of the pollutants of interest (PM_2.5, NO₂, and CO) were categorized into four categories according to the daily average concentration of air pollutants for every quarter of the year, Q1 to Q4 (Q4 = highest). The cumulative incidence of PAOD was examined by Kaplan–Meier analysis with two-tailed log-rank test. A total of 1,598 PAOD cases were identified during the 10-year follow-up period, along with 98,540 non-PAOD controls. In the multivariate analysis, after adjusting for age, gender, urbanization level, residential area, baseline comorbidities, and medications, the adjusted HRs were PM_2.5 = 1.14 (95% CI 1.13–1.16), NO₂ = 1.03 (95% CI 1.02–1.04), and CO = 2.35 (95% CI 1.95–2.84). Kaplan–Meier analysis showed that CO (P < 0.0001) and PM_2.5 (P < 0.0001) concentrations were strongly and positively associated with the cumulative incidence of PAOD during the follow-up period. Findings from this study established that prolonged exposure to air pollutants CO and PM_2.5 are significant factors that, among other well-known causes, may also play a potential role in PAOD pathogenesis.

Introducing multi-component cardiovascular health screening into existing Abdominal Aortic Aneurysm (AAA) screening programmes in the UK: a qualitative study of programme staff views

BACKGROUND

Cardiovascular disease is a major contributor to poor health in the UK and the leading cause of death in England. Peripheral arterial disease and high blood pressure are conditions that identify individuals at high cardiovascular disease risk, likely to benefit from cardiovascular risk management. Both conditions remain considerably underdiagnosed and untreated. The National Health Service abdominal aortic aneurysm (AAA) screening programmes represent an opportunity to screen for these conditions with potentially minimal additional effort or cost. We explored AAA screening programme staff views on the proposed introduction of such additional screening within AAA screening.

METHODS

Nine focus groups and seven follow-on interviews were undertaken with 38 AAA screening staff. Our study methods were oriented broadly towards a grounded theory methodology, and data were analysed using thematic analysis.

RESULTS

Three themes were identified: (i) 'Perceptions of patient experience and health-related outcomes', (ii) 'Opportunities and challenges for programme staff', and (iii) 'Maintaining and improving programme standards'. Staff talked about the high uptake of AAA screening, staff experience and skills in their role, and the programme's high quality standards as both opportunities and potential challenges linked to the proposed additions to AAA screening. While positive about the potential to improve patients' health outcomes, participants had questions about the practicalities of incorporating additional procedures within their time- and resource-constrained context, and how this may reconfigure work processes, roles and relationships.

CONCLUSIONS

The proposed additions to the programme require taking staff's views into account. Key areas that need to be addressed relate to ensuring follow-up support for patients, clarity around staff responsibilities, and availability of sufficient resources for the programme.

Implementation of supervised exercise therapy in a veteran population with symptomatic claudication

Background:

Real-world implementation of supervised exercise therapy (SET) referral for symptomatic intermittent claudication has been limited by poor provider awareness around reimbursement and low patient adherence owing to factors including limited center availability and long travel distances to sites.

Methods:

In this study, 76 of 77 consecutive male veteran patients with intermittent claudication managed at a single-center vascular specialty clinic were referred to SET prior to revascularization. Pre- and post-SET submaximal exercise treadmill testing was performed for assessment of exercise capacity in metabolic equivalents (METs).

Results:

In the 48.7% of subjects who completed 36 sessions of SET ( n = 37), the average improvement in METs was 60.3%, reflecting improvement from baseline average of 3.4 METs to 5.5 METs after SET. Another 14 patients pursued self-guided exercise therapy and 25 patients declined any participation in exercise therapy. Reasons for declining participation in SET included inadequate transportation, cost of copayment, and interference with full-time work schedules. There was a nonsignificant numeric trend toward improved change in ankle–brachial index in the combined SET and self-guided exercise groups compared to those that declined exercise therapy (0.011 ± 0.124 vs –0.040 ± 0.105, p = 0.156).

Conclusion:

High acceptance of referral to SET is possible, despite the limitations to implementation. Incorporation of novel pre- and post-SET submaximal exercise treadmill testing allows for assessment of change in exercise capacity and aids in risk stratification and management of intermittent claudication symptoms.

Associations of circulating biomarkers with the presence and severity of coronary, carotid and femoral arterial atherosclerosis

Aim. To identify and characterize the associations of the presence and severity of atherosclerosis of various localization with the blood level of biochemical parameters, as well as to assess the potential of their use as markers of metabolic disorders with increased atherogenic potential.

Material and methods. The study included 216 patients (men, 53%) aged 24-87 years (mean age, 61,5±10,73 years). All patients underwent coronary angiography, carotid (CA) and femoral arterial (FA) duplex ultrasound to assess the presence and severity of atherosclerosis. In blood serum/plasma, biochemical parameters were analyzed using standard methods.

Results. Based on the analysis of circulating biomarker profile, diagnostic complexes have been established that allow assessing atherosclerosis of different localization. According to the data obtained, the determinants of coronary and CA atherosclerosis are endothelial dysfunction (concentration of nitric oxide metabolites <36,0 μmol/L) and an increased level of creatinine (≥73,0 μmol/L). The specific markers associated with severe atherosclerosis of coronary and FAs (but not CA) were low high-density lipoprotein cholesterol (≤1,0/1,2 μmol/L for male/ female, respectively) and an increased C-reactive protein level (≥1,0 mg/l). Severe peripheral atherosclerosis (CA and FA involvement) was associated with hyperglycemia (glucose ≥6,1 μmol/L), while severe FA atherosclerosis — with hyperinsulinemia (insulin ≥14,0 μU/ml).

Conclusion. The analysis of associations of circulating biochemical parameters with atherosclerosis localization and severity revealed a number of metabolic markers associated with the increased atherogenic potential. It is possible to distinguish both universal parameters that are associated with atherosclerosis, regardless of its localization and/or severity, and specific biomarkers that characterize either the localization or the severity of atherosclerosis, or both.

Efficacy and Safety of Vorapaxar by Intensity of Background Lipid-Lowering Therapy in Patients With Peripheral Artery Disease: Insights From the TRA2P-TIMI 50 Trial

Background

Patients with peripheral artery disease are at increased risk of both major adverse cardiovascular events (MACEs) and limb events. The pathobiology of limb events is likely multifactorial. Observational studies suggest a benefit of statin therapy for reducing the risk of limb ischemic events while randomized trials demonstrate a benefit with more potent antithrombotic therapies, particularly those targeting thrombin. Whether the effects of these therapeutic pathways are independent and complementary is not known.

Methods and Results

The TRA 2°P‐TIMI 50 (Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events–Thrombolysis in Myocardial Infarction 50) trial demonstrated that vorapaxar significantly reduced MACEs and limb events. The purpose of the current analysis was to evaluate the association of statin use and intensity and the occurrence of MACEs and limb events in 5845 patients with symptomatic peripheral artery disease randomized in TRA 2°P‐TIMI 50 and then to understand whether statin use modified the benefits of vorapaxar for MACEs or limb ischemic events. We found that statin therapy was associated with significantly lower risk of MACEs (hazard ratio [HR], 0.77; 95% CI, 0.66–0.89; P<0.001) and limb ischemic events (HR, 0.73; 95% CI, 0.60–0.89; P=0.002). The benefit of vorapaxar for reducing MACEs and limb events was consistent regardless of background statin (P‐interaction=0.715 and 0.073, respectively). Event rates were lowest in patients receiving the combination of statin therapy and vorapaxar.

Conclusions

In conclusion, statin use and intensity is associated with significantly lower rates of MACEs and limb ischemic events. Thrombin inhibition with vorapaxar is effective regardless of background statin therapy. These results suggest that targeting both lipid and thrombotic risk in peripheral artery disease is necessary in order to optimize outcomes.

Characteristics of atherosclerosis in femoropopliteal artery and its clinical relevance

Atherosclerosis is a systemic disease with different faces. Despite identical or similar pathogenetic mechanisms, atherosclerotic lesions and their clinical manifestations vary in different parts of the vascular system. Peripheral arterial disease (PAD) represents one of the most frequent clinical manifestations of atherosclerosis with predominant location in the superficial femoral artery (SFA). Morphological characteristics of atherosclerotic plaques in peripheral arteries differ from lesions in the coronary and carotid arteries. Plaques in SFA have more fibrotic components, less lipids and inflammatory cells, which makes them more stable and less prone to rupture. Factors that determine the different structure of plaques in SFA compared to coronary arteries include hemodynamic forces, vasa vasorum and calcification. Low shear stress in SFA in the adductor canal is one of the factors which determines frequent atherosclerotic lesions in this region. Lower lipid content and fewer inflammatory cells explain higher stability of SFA plaques. The specific structure of SFA plaques may require preventive and therapeutic measures, which to some extent differ from prevention of coronary atherosclerosis and may include inhibition of fibrotic proliferation in SFA plaques and calcification. Revascularization of PAD differs from procedures used in coronary arteries and requires specific technical expertise and devices.

Dedicated photoacoustic imaging instrument for human periphery blood vessels: A new paradigm for understanding the vascular health

A novel photoacoustic imaging system based on a semi-ring transducer array is proposed to imageperipheralbloodvessels. The system's penetration depth is deep (~15 mm) with high spatial (~200 m) and temporal resolution. In a clinical study, volumetric photoacoustic data of limbs were obtained within the 50s (for a FOV of 15 cm4 cm) with the volunteers in the standing and sitting posture. Compared to the previous studies, our system has many advantages, including (1) Larger field of view; (2) Finer elevational and in-plane resolutions; (3) Enhanced 3D visualization of peripheralvascular networks; (4) Compact size and better portability. The 3D visualization and cross-sectional images of five healthy volunteers clearly show the vascular network and the system's ability to image submillimeter blood vessels. This high-resolution PA system has great potential for imaging human periphery vasculatures noninvasively in clinical research.

Clinical considerations after endovascular therapy of peripheral artery disease

Introduction: Patients with peripheral artery disease (PAD) are at higher risk for all-cause mortality, driven by increased cardiovascular mortality rates. In this manuscript we review the literature on guideline-recommended therapies and discuss the major clinical considerations after endovascular therapy of PAD.Areas covered: Current guidelines recommend smoking cessation, aspirin, statin, and renin-angiotensin system inhibitors in order to reduce the risk of cardiovascular and limb-related adverse events. Nonetheless, studies have shown that patients with PAD are undertreated with these important medical therapies. Additionally, there is lack in evidence regarding the most optimal follow up imaging approach for early detection of disease recurrence and re-intervention among patients undergoing endovascular therapy for PAD. We also describe the benefits of supervised walking exercise for patients with PAD that undergo revascularization procedures and are fit for such interventions.Expert opinion: Adherence to guideline recommended medical therapy is crucial for improved outcomes in PAD management. Systematic assessment of risk-reduction interventions could help increase adherence to clinically beneficial interventions and improve the overall prognosis of patients with PAD undergoing revascularization procedures. Additionally, optimization of current follow up protocols is needed, with the optimal goal to develop standardized cost-effective algorithms regarding early detection of disease recurrence and re-intervention.

Asymptomatic peripheral artery disease: Silent but deadly

Peripheral Artery Disease (PAD) is a manifestation of atherosclerosis characterized by diminished perfusion of the limb and a state of dysmetabolism. The asymptomatic PAD phenotype is a relatively recent classification. It is unknown how many people currently live with asymptomatic PAD because there are no universal screening recommendations for patients at risk for PAD. Patients with asymptomatic PAD suffer from a similar risk profile of morbidity and mortality as their counterparts with claudication. Despite this increased risk, there is a dearth of clinical investigations into therapies that specifically benefit the asymptomatic PAD population. At present, current pharmacotherapies that have been studied in PAD patient populations do not stratify by symptom status. We believe that further investigation of the impact of existing therapies in this unique population presents an opportunity to reduce morbidity and mortality due to PAD. This can only be achieved in combination with wide-spread adoption of screening for asymptomatic PAD.

Patterns of change in cardiovascular risk assessments and ankle brachial index among Puerto Rican adults

BACKGROUND

Puerto Rican adults have higher odds of peripheral artery disease (PAD) compared with Mexican Americans. Limited studies have examined relationships between clinical risk assessment scores and ABI measures in this population.

METHODS

Using 2004-2015 data from the Boston Puerto Rican Health Study (BPRHS) (n = 370-583), cross-sectional, 5-y change, and patterns of change in Framingham Risk Score (FRS) and allostatic load (AL) with ankle brachial index (ABI) at 5-y follow-up were assessed among Puerto Rican adults (45-75 y). FRS and AL were calculated at baseline, 2-y and 5-y follow-up. Multivariable linear regression models were used to examine cross-sectional and 5-y changes in FRS and AL with ABI at 5-y. Latent growth mixture modeling identified trajectories of FRS and AL over 5-y, and multivariable linear regression models were used to test associations between trajectory groups at 5-y.

RESULTS

Greater FRS at 5-y and increases in FRS from baseline were associated with lower ABI at 5-y (β = -0.149, P = 0.010; β = -0.171, P = 0.038, respectively). AL was not associated with ABI in cross-sectional or change analyses. Participants in low-ascending (vs. no change) FRS trajectory, and participants in moderate-ascending (vs. low-ascending) AL trajectory, had lower 5-y ABI (β = -0.025, P = 0.044; β = -0.016, P = 0.023, respectively).

CONCLUSIONS

FRS was a better overall predictor of ABI, compared with AL. Puerto Rican adults, an understudied population with higher FRS over 5 years, may benefit from intensive risk factor modification to reduce risk of PAD. Additional research examining relationships between FRS and AL and development of PAD is warranted.

The role of prognostic nutritional index in predicting amputation in patients with lower extremity peripheral artery disease

Introduction: Lower-extremity peripheral artery disease (PAD) can lead to a wide spectrum of symptoms that can progress from claudication to amputation. The prognostic nutritional index (PNI), which is calculated using the levels of albumin and lymphocyte, is an accepted indicator of immunological and nutritional status. In this study, the association between nutritional status determined using the PNI, and extremity amputation in patients with lower-extremity PAD was investigated.

Methods: Lower-extremity PAD patients who had been admitted to the cardiology clinic of the Dışkapı Yıldırım Beyazıt Training & Research Hospital with stage 2b or higher claudication, and who were technically unsuitable for revascularization or underwent unsuccessful revascularization procedure were enrolled in this retrospective study. Patients were grouped according to whether or not limb amputation had been performed previously. Potential factors were tested to detect independent predictors for amputation with logistic regression analysis.

Results: A study group was formed with 266 peripheral artery patients. The amputated group (39 patients) had a higher number of hypertensive (76.9% vs 57.7%; P = 0.032) and diabetic (92.3% vs 54.2%; P <0.001) patients than those in the non-amputated group (227 patients). The median PNI value of the amputated group was lower than that of the non-amputated group (31.8 vs 39.4; P <0.001). Multivariate logistic regression showed that the PNI (OR: 0.905, 95% CI: 0.859 – 0.954; P <0.001) was independently related with amputation.

Conclusion: Immune-nutritional status based on PNI was independently associated with limb amputation in patients with lower-extremity PAD.

Outcome of community- versus hospital-acquired intra-abdominal infections in intensive care unit: a retrospective study

Background

To compare patients hospitalised in the intensive care unit (ICU) after surgery for community-acquired intra-abdominal infection (CA-IAI) and hospital-acquired intra-abdominal infection (HA-IAI) in terms of mortality, severity and complications.

Methods

Retrospective study including all patients admitted to 2 ICUs within 48 h of undergoing surgery for peritonitis.

Results

Two hundred twenty-six patients were enrolled during the study period. Patients with CA-IAI had an increased 28-day mortality rate compared to those with HA-IAI (30% vs 15%, respectively (p = 0.009)). At 90 days, the mortality rates were 36.7 and 37.5% in the CA-IAI group and HA-IAI group, respectively, with a similar APACHE II score on admission (median: 21 [15–25] vs. 21 [15–24] respectively, p = 0.63). The patients with HA-IAI had prolonged ICU and hospital stays (median: 17 [7–36] vs. 6[3–12] days, p < 0.001 and 41 [24–66] vs. 17 [7–32] days, p = 0.001), and experienced more complications (reoperation and reintubation) than those with CA-IAI.

Conclusion

CA-IAI group had higher 28-day mortality rate than HA-IAI group. Mortality was similar at 90 days but those with HA-IAI had a prolonged ICU and hospital stay. In addition, they developed more complications.

Single nucleotide polymorphisms in LCAT may contribute to dyslipidaemia in HIV-infected individuals on HAART in a Ghanaian population

Highly active antiretroviral therapy (HAART) is known to cause lipid abnormalities such as dyslipidaemia in HIV-infected individuals. Yet, dyslipidaemia may not independently occur as it may be worsened by single nucleotide polymorphisms (SNPs) in lecithin cholesterol acyltransferase (LCAT) and lipoprotein lipase (LPL). This case–control study was conducted in three-selected hospitals in the Northern part of Ghana. The study constituted a total of 118 HIV-infected participants aged 19–71 years, who had been on HAART for 6–24 months. Dyslipidaemia was defined based on the NCEP-ATP III criteria. HIV-infected individuals on HAART with dyslipidaemia were classified as cases while those without dyslipidaemia were grouped as controls. Lipid profile was measured using an automatic clinical chemistry analyzer and genomic DNA was extracted for PCR (GeneAmp PCR System 2700). Overall, the prevalence of dyslipidaemia was 39.0% (46/118). High levels of low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), and reduced levels of high-density lipoprotein cholesterol (HDL-C) were observed in all cases. A total of 256 selected PCR amplicons comprising 137 LPL (exons 3, 5 and 6) and 119 LCAT (exons 1, 4, and 6) were sequenced in 46 samples (Inqaba Biotech). Six (6) clinically significant SNPs were identified in exons 1 and 4 for LCAT whereas 25 non-clinically significant SNPs were identified for LPL in exons 5 and 6. At position 97 for LCAT exon 1, there was a deletion of the nucleotide, ‘A’ in 32.5% (13/40) of the sampled population while 67.5% (27/40) of the sample population retained the nucleotide, ‘A’ which was significantly associated with dyslipidaemic outcomes in the study population (p = 0.0004). A total of 25 SNPs were identified in exons 5 and 6 of LPL; 22 were substitutions, and 3 were insertions. However, none of the 25 SNPs identified in LPL exon 5 and 6 were statistically significant. SNPs in LCAT may independently contribute to dyslipidaemia among Ghanaian HIV-infected individuals on HAART, thus, allowing genetic and/or functional differential diagnosis of dyslipidaemia and creating an opportunity for potentially preventive options.

Cost-effectiveness of Contemporary Statin Use Guidelines With or Without Coronary Artery Calcium Assessment in African American Individuals

Importance

Clinical and economic consequences of statin treatment guidelines supplemented by targeted coronary artery calcium (CAC) assessment have not been evaluated in African American individuals, who are at increased risk for atherosclerotic cardiovascular disease and less likely than non-African American individuals to receive statin therapy.

Objective

To evaluate the cost-effectiveness of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline without a recommendation for CAC assessment vs the 2018 ACC/AHA guideline recommendation for use of a non-0 CAC score measured on one occasion to target generic-formulation, moderate-intensity statin treatment in African American individuals at risk for atherosclerotic cardiovascular disease.

Design, Setting, and Participants

A microsimulation model was designed to estimate life expectancy, quality of life, costs, and health outcomes over a lifetime horizon. African American-specific data from 472 participants in the Jackson Heart Study (JHS) at intermediate risk for atherosclerotic cardiovascular disease and other US population-specific data on individuals from published sources were used. Data analysis was conducted from November 11, 2018, to November 1, 2019.

Main Outcomes and Measures

Lifetime costs and quality-adjusted life-years (QALYs), discounted at 3% annually.

Results

In a model-based economic evaluation informed in part by follow-up data, the analysis was focused on 472 individuals in the JHS at intermediate risk for atherosclerotic cardiovascular disease; mean (SD) age was 63 (6.7) years. The sample included 243 women (51.5%) and 229 men (48.5%). Of these, 178 of 304 participants (58.6%) who underwent CAC assessment had a non-0 CAC score. In the base-case scenario, implementation of 2013 ACC/AHA guidelines without CAC assessment provided a greater quality-adjusted life expectancy (0.0027 QALY) at a higher cost ($428.97) compared with the 2018 ACC/AHA guideline strategy with CAC assessment, yielding an incremental cost-effectiveness ratio of $158 325/QALY, which is considered to represent low-value care by the ACC/AHA definition. The 2018 ACC/AHA guideline strategy with CAC assessment provided greater quality-adjusted life expectancy at a lower cost compared with the 2013 ACC/AHA guidelines without CAC assessment when there was a strong patient preference to avoid use of daily medication therapy. In probability sensitivity analyses, the 2018 ACC/AHA guideline strategy with CAC assessment was cost-effective compared with the 2013 ACC/AHA guidelines without CAC assessment in 76% of simulations at a willingness-to-pay value of $100 000/QALY when there was a preference to lose 2 weeks of perfect health to avoid 1 decade of daily therapy.

Conclusions and Relevance

A CAC assessment-guided strategy for statin therapy appears to be cost-effective compared with initiating statin therapy in all African American individuals at intermediate risk for atherosclerotic cardiovascular disease and may provide greater quality-adjusted life expectancy at a lower cost than a non-CAC assessment-guided strategy when there is a strong patient preference to avoid the need for daily medication. Coronary artery calcium testing may play a role in shared decision-making regarding statin use.

Prediction and early detection of cardiovascular disease in South Asians with diabetes mellitus

BACKGROUND

Although diabetes mellitus (DM) is no longer considered "coronary heart disease risk equivalent", the risk remains sufficiently high, necessitating early recognition and management of cardiovascular disease (CVD) in these patients. Despite this understanding, the optimum strategy for prediction and early detection of CVD in DM remains debatable.

METHODS

Major societal guidelines for prediction and evaluation of CVD in subjects with or without DM were reviewed. Available evidence about various risk stratification strategies-their advantages, disadvantages and current role in clinical practice-were extensively reviewed. Special emphasis was placed on evidence from South Asian/Indian populations.

RESULTS

The inconsistency and variability inherent to the clinical risk algorithms, lack of consensus regarding the incremental value of subclinical atherosclerosis imaging and the lack of sufficient data to demonstrate the benefits of recognizing asymptomatic atherosclerotic disease are some of the reasons underlying prevailing uncertainty about the optimum approach for cardiovascular risk assessment in DM. These challenges notwithstanding, an evidence-based cardiovascular risk stratification strategy incorporating clinical risk algorithms, biomarkers, atherosclerosis imaging, and cardiac stress testing is proposed.

CONCLUSIONS

The proposed algorithm should help clinicians in optimizing cardiovascular evaluation and management of their patients with DM. However, this remains a dynamic field; further research into different risk assessment tools, esp. focusing on their impact on improving clinical outcomes, should help refine the evaluation strategy in future.

[Lower-limb peripheral arterial disease]

Peripheral arterial disease is a result of atheroma. This disease is frequent in subjects with vascular risk factors. This disease is also frequent in low income countries. The detection and the diagnosis of peripheral arterial disease is obtained by calculating the ankle brachial index. Patients with peripheral arterial disease are not always symptomatic thus explaining how this disease is under diagnosed. The symptoms can be absent, and especially in case of diabetes or in women. In case of peripheral arterial disease, atheroma often involves other arterial vascular networks especially the coronaries. An adapted treatment reduces the morbi-mortality linked to this disease. This treatment is based on the correction of the vascular risk factors and especially tobacco cessation, walking rehabilitation and drugs (antiplatelet agent, statin, renin angiotensin system blocker). In case of rest or critic ischemia, the first-line treatment is a revascularisation. In peripheral arterial disease, management of patients is often non optimal and therapeutic targets fairly often obtained.

Variations in the Management of Claudication in a Tertiary Care Center

BACKGROUND

Multiple societal guidelines recommend medical optimization and exercise therapy for patients with claudication prior to lower extremity revascularization (LER). However, the application of those guidelines in practice remains unknown. Our hypothesis is that vascular surgeons (VS) are more adherent to guidelines compared to non-VS treating claudication.

METHODS

The records of patients undergoing LER for claudication in a single center were reviewed, and adherence to guidelines prior to LER was assessed. Patients received conservative therapy if the impact of claudication on quality of life was documented, ankle-brachial index (ABI) was obtained, and patients were treated with at least 3 months of walking exercise and smoking cessation when indicated.

RESULTS

There were 187 patients treated for claudication (VS = 65, non-VS = 122). There were 161 patients who underwent endovascular intervention, 19 patients had an open revascularization, and 7 patients had a hybrid procedure. Patients treated by VS were younger and more likely to be African American. Patients treated by non-VS were more likely to have hyperlipidemia, coronary artery disease, smoke, and be on antiplatelet and statin medications. VS was more likely to assess pattern of symptoms with claudication and obtain ABIs compared to non-VS, although the mean ABIs were no different. VS was more likely to use walking exercises and smoking cessation when indicated before LER. Even though 70.8% and 31.1% of patients treated by VS and non-VS respectively were recommended walking exercises, only 33.8% and 18.0% were given a period of 3 months to benefit from it prior to LER. Conservative therapy was significantly higher among VS compared to non-VS but was overall low (VS = 12.3%, non-VS = 3.3%, P = 0.016). After a mean follow-up of 3.1 ± 1.3 years, there was no difference in mortality or major amputation.

CONCLUSIONS

Although adherence to guidelines in the medical management of vascular claudication prior to LER was higher among VS compared with non-VS, overall rates of adherence were low. Stricter institutional protocols and oversight across specialties are needed to reinforce the application of the established standards of care.

Statin therapy for reduction of cardiovascular and limb-related events in critical limb ischemia: A systematic review and meta-analysis

High-intensity statins are recommended for patients with peripheral artery disease (PAD). Critical limb ischemia (CLI) is the most advanced presentation of PAD. The benefit of statins in the CLI population is unclear based on the existent studies. Our objective was to perform a systematic review and meta-analysis regarding the efficacy of statin therapy in patients with CLI. PRISMA guidelines were followed. PubMed, EMBASE, and Cochrane CENTRAL databases were reviewed up to April 30, 2019. The primary outcomes included amputation rates and all-cause mortality. Secondary outcomes included primary patency rates, amputation-free survival and major adverse cardiac or cerebrovascular events (MACCE). Risk of bias was assessed with the Robins-I tool for observational studies. A random-effects model meta-analysis was performed. Heterogeneity was assessed with I2. Funnel plots and Egger’s test were used to assess publication bias. Nineteen studies including 26,985 patients with CLI were included in this systematic review. Among patients with known data on statin status, 12,292 (49.6%) were on statins versus 12,513 (50.4%) not on statins. Patients treated with statins were 25% less likely to undergo amputation (HR 0.75; 95% CI: 0.59–0.95; I2 = 79%) and 38% less likely to have a fatal event (HR 0.62; 95% CI: 0.52–0.75; I2 = 41.2%). Statin therapy was also associated with increased overall patency rates and lower incidence of MACCE. There was substantial heterogeneity in the analysis for amputation and amputation-free survival (I2 > 70%). In conclusion, statins are associated with decreased risk for amputation, mortality, and MACCE, as well as increased overall patency rates among patients with CLI. Future studies should assess whether other lipid-lowering medications in addition to high-intensity statins can further improve outcomes among patients with CLI. (PROSPERO registration number: CRD42019134160)

Patient perceptions of peripheral artery disease: A cross-sectional study of hospitalized adults

Patients with peripheral artery disease (PAD) have increased risk for complications of cardiovascular disease. Smoking cessation, physical activity, and adherence to treatment are critical for limiting the progression of this chronic disease and improving health-related quality of life in patients with PAD.The aim of the study was to explore patient perceptions of PAD and views on medication, tobacco use, and physical activity. This descriptive, cross-sectional study included patients with PAD admitted to a vascular surgery unit at a tertiary academic medical center (October 2017 to January 2018). Sociodemographic data and medical information were collected during hospitalization. Patients completed the Brief Illness Perception Questionnaire, Beliefs about Medicines Questionnaire, and Cigarette Dependence Scale. Additional questions examined physical activity. In total, 32 patients participated in the study. About half (16/30) were active smokers, whereas the remainder had smoked in the past. Only half of patients (16/32) considered smoking as contributing to PAD. Most patients (18/30) perceived PAD as a chronic problem, yet 8/30 (27%) considered PAD a rather acute illness. Patients reported significant cognitive and emotional consequences of PAD (mean 6.2 ± 1.8 and 8.3 ± 2.9, maximum score 10, respectively). They rated relatively low perceived personal control (mean 4.8 ± 2.8, maximum score 10) and weak beliefs about the necessity of medication (mean 12.5 ± 3.3, maximum score 25). Most patients (21/32) perceived physical activity as a protective factor for PAD. Patients perceive PAD as having significant impact on their life and report low levels of personal control in managing PAD. Understanding patient health beliefs may inform more tailored therapeutic education and health promoting interventions to limit disease progression.

Invasive screening for lower extremity peripheral artery disease: Killing two birds with one stone?

Objectives

There is substantial evidence that the majority of cases of lower extremity peripheral artery disease are undetected. As a result, there is great interest in the detection of lower extremity peripheral artery disease through routine screening. However, routine screening of lower extremity peripheral artery disease is still debated.

Methods

In our cross-sectional study, we included 200 consecutive patients with symptoms suggestive of angina who were undergoing coronary angiography. Irrespective of intermittent claudication, we subsequently performed peripheral angiography to detect lower extremity peripheral artery disease. The predictors of lower extremity peripheral artery disease were analyzed, and the diagnostic utility of these predictors and their combinations were determined. Additionally, the determinants of the amount of radio-opaque material used and peripheral fluoroscopy time were investigated.

Results

The overall prevalence of lower extremity peripheral disease was 16%. Being older than 65 years, having coronary artery disease and smoking history remained significant predictors after adjusting for other well-known parameters. Having the combination of age  ≥65 and smoking was associated with a positive predictive value of 50% (likelihood ratio 5.06), and having all of the predictors was associated with a positive predictive value of 100% (likelihood ratio >1000).

Conclusions

Routine screening for lower extremity peripheral disease patients undergoing coronary angiography may be useful in selected patients.

Prevalence and associated risk factors of peripheral artery disease in virologically suppressed HIV-infected individuals on antiretroviral therapy in Kwara state, Nigeria: a cross sectional study

Background

The association between HIV and cardiovascular disease (CVD) has been reported in several studies. However, there is paucity of information on the prevalence of subclinical disease as well as its associated risk factors in sub-Saharan African population. The aim of this study was to determine the prevalence and associated risk factors of peripheral artery disease (PAD) among virologically suppressed HIV-infected participants in Kwara State, Nigeria.

Methods

This study was conducted between July 2018 and December 2018. A total of 150 HIV-infected participants aged between 20 and 55 years and 50 HIV non-infected age-matched controls were randomly recruited in the study. Sociodemographic, anthropometric and clinical data were collected using a well-structured questionnaire. Ankle brachial index (ABI) was measured, PAD was defined as ABI of < 0.9. Cryopreserved serum was used to evaluate lipid profile parameters. Student’s t-test and Chi-square were used to compare continuous and categorical variables. Associations of CVD risk factors and clinical data, and lipid profile with low ABI were assessed using logistic regression analysis.

Results

The study participants had a mean age of 43.73 ± 8.74, majority were females (72.7%) with a mean duration on ART of 7.73 ± 3.52 years. Hypertension was present in 15.9%, diabetes 4%, family history of CVD 8.6% and metabolic syndrome 17.3% in the study group. The study participants recorded significantly lower mean values for ABI, HDL-C and significantly higher mean values of TG (P < 0.05) compared to the control group. The prevalence of low ABI (14.6%) was higher in the study group compared to the control group (2%). A significantly negative correlation between ABI and duration on ART (r = − 0.163, P = 0.041) and a positive correlation between viral load and TG were observed in the study group. TC (OR 1.784, P = 0.011), LDL-C (OR 1.824, P = 0.010) and CD4 cell count < 200 cells/mm³ (OR 2.635, P = 0.364) were associated with low ABI in the participants.

Conclusion

Viral suppression with combined antiretroviral therapy and long term treatment is associated with dyslipidaemia, with increased risk of PAD. Prevalence of PAD in virologically-suppressed individuals does not differ from the controls in the population studied.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7496-4) contains supplementary material, which is available to authorized users.

Oscillometric and Doppler Ankle Brachial Indexes as predictors of all-cause mortality in a Primary Care population

BACKGROUND

Doppler Ankle Brachial Index (ABI), the non-invasive reference standard for peripheral arterial disease (PAD) in Primary Care, has proved good capacity to predict all-cause mortality. However, the role of oscillometric ABI is uncertain. This study aims to evaluate the ability of oscillometric and Doppler ABI to predict all-cause mortality in a Primary Care population.

METHODS

Oscillometric and Doppler ABI were measured in 203 consecutive subjects with ≥1 cardiovascular risk factors or intermittent claudication. Pathologic ABI was defined when ABI was ≤0.9 or ≥1.4, and when the oscillometer was unable to record a value (oscillometric error). All-cause mortality was ascertained through examination of electronic medical records or telephone contact.

RESULTS

After analyzing 602.9 subjects/year, all-cause mortality was recorded in 17 (8.4%) patients. Kaplan-Meier survival curves for oscillometric (Log-Rank test χ2=66.02, P<0.001) and Doppler ABI (Log-Rank test χ2=42.30, P<0.001) showed that a pathologic ABI is associated with all-cause mortality. After adjusting for covariates, the hazard ratio in multivariable Cox regression were 4.52 (95% CI: 1.67-12.18, P=0.003) and 2.08 (95% CI: 0.83-5.18, P=0.117) for oscillometric and Doppler ABI models, respectively. When introducing oscillometric and Doppler ABI simultaneously in the Cox regression model, only oscillometric ABI was an independent predictor with a hazard ratio=7.90 (95% CI: 1.79-34.83, P=0.006). Regarding Doppler ABI, no significant differences were found in all-cause mortality between low ABI (≤0.9) and calcified ABI (≥1.4), (Log-Rank test χ2=0.98, P=0.322).

CONCLUSIONS

Oscillometric ABI predicted all-cause mortality in a Primary Care population even better than Doppler ABI, irrespective of cardiovascular risk factors. Oscillometric ABI, due to a high feasibility, could routinely identify high-risk patients to implement preventive measures.

Detecting Peripheral Arterial Disease in Primary Care: A Population Based Study

Background

Peripheral arterial disease (PAD) can progress silently without any clinical symptoms. Ankle-brachial index (ABI) is the recommended method used in primary care. We aimed to determine the prevalence of PAD and its related risk factors in primary care.

Methods

In this cross-sectional study, 250 participants aged ≥45 years were recruited randomly from the registered patients of family health center in a district of Izmir, Turkey. Patients’ demographic data, PAD symptoms, and PAD risk factors were obtained. The PAD group consisted of patients with ABI levels <0.9; the non-compressible artery (NCA) group consisted of patients with ABI levels >1.3.

Results

The prevalence of PAD was 17.6% (22.5% in women and 11.1% in men), while that of NCA was 15.2% (12.7% in women and 25.0% in men). About 27.3% and 54.5% of patients with PAD did not have claudication and problems with walking distance, respectively. Of the NCA patients, 15.8% had problems with walking distance and 39.5% had claudication. Regression analysis revealed two predictors of PAD (age ≥65 years: odds ratio [OR], 3.51; 95% confidence interval [CI], 1.65–7.47; claudication: OR, 3.41; 95% CI, 1.58–7.39) and three predictors of NCA (age <65 years: OR, 2.55; 95% CI, 1.01–6.45; male sex: OR, 2.40; 95% CI, 1.10–5.25; triglyceride [TG] >200 mg/dL: OR, 4.11; 95% CI, 1.58–10.67).

Conclusion

PAD had a prevalence of 17.6% and was associated with age ≥65 years and claudication. NCA had a prevalence of 15.2% and was associated with age <65 years, TG >200 mg/dL, and male sex.

Noninvasive Monitoring of Allogeneic Stem Cell Delivery with Dual-Modality Imaging-Visible Microcapsules in a Rabbit Model of Peripheral Arterial Disease

Stem cell therapies, although promising for treating peripheral arterial disease (PAD), often suffer from low engraftment rates and the inability to confirm the delivery success and track cell distribution and engraftment. Stem cell microencapsulation combined with imaging contrast agents may provide a means to simultaneously enhance cell survival and enable cell tracking with noninvasive imaging. Here, we have evaluated a novel MRI- and X-ray-visible microcapsule formulation for allogeneic mesenchymal stem cell (MSC) delivery and tracking in a large animal model. Bone marrow-derived MSCs from male New Zealand White rabbits were encapsulated using a modified cell encapsulation method to incorporate a dual-modality imaging contrast agent, perfluorooctyl bromide (PFOB). PFOB microcapsules (PFOBCaps) were then transplanted into the medial thigh of normal or PAD female rabbits. In vitro MSC viability remained high (79 ± 5% at 4 weeks of postencapsulation), and as few as two and ten PFOBCaps could be detected in phantoms using clinical C-arm CT and ¹⁹F MRI, respectively. Successful injections of PFOBCaps in the medial thigh of normal (n = 15) and PAD (n = 16) rabbits were demonstrated on C-arm CT at 1-14 days of postinjection. Using ¹⁹F MRI, transplanted PFOBCaps were clearly identified as “hot spots” and showed one-to-one correspondence to the radiopacities on C-arm CT. Concordance of ¹⁹F MRI and C-arm CT locations of PFOBCaps with postmortem locations was high (95%). Immunohistological analysis revealed high MSC survival in PFOBCaps (>56%) two weeks after transplantation while naked MSCs were no longer viable beyond three days after delivery. These findings demonstrate that PFOBCaps could maintain cell viability even in the ischemic tissue and provide a means to monitor cell delivery and track engraftment using clinical noninvasive imaging systems.

Prescription rate of anti-atherosclerotic drugs in German nursing homes and its impact on outcome

BACKGROUND

Peripheral arterial disease (PAD) is one of the major manifestations of general atherosclerosis and strongly associated with increased cardiovascular morbidity and mortality. Because only few epidemiologic studies are available concerning the prevalence of PAD in inhabitants ≥ 80 years of age, we screened inhabitants of nursing care homes in Germany for PAD and cardiovascular diseases and to assess the one year mortality.

PATIENTS AND METHODS

We conducted a prospective cohort study, screening inhabitants of 42 nursing homes for PAD. Demographic data, comorbidities, cardiovascular risk factors and daily medication were collected. PAD was defined as ankle-brachial index < 0.9. During a follow up period of one year, cardio- and cerebrovascular events and mortality were recorded, as well as the rate of falls and major amputation.

RESULTS

1,329 probands (391 men, 938 women) > 60 years were eligible for further analysis. The mean age was 84.1 years (range 61-107 years) and the prevalence of PAD was 31.5 % . Media sclerosis was found in up to 17 %, and an existing diagnosis of PAD (in case of pathological ABI) and undertreatment was common. Probands with PAD were less likely to be treated according to guideline recommendations (antiplatelet therapy, beta blockers, statins) than probands with coronary artery disease (CAD). The overall one-year mortality was 19.8 % (n = 236), significantly higher than for a gender and age matched German population (p < 0.001).

CONCLUSIONS

The current study shows a high prevalence of PAD in German nursing care homes. The one year mortality was not significantly different between probands with PAD and those with severe PAD (defined as an ABI of ≤ 0.5), whereas a media sclerosis was associated with an increased risk in probands with CAD in comparison to those without. Use of anti-diabetic agents and aspirin in monotherapy was associated with a reduced one-year mortality risk.

Measurement of Toe-Brachial Indices in People with Subnormal Toe Pressures Complexities and Revelations

BACKGROUND

Insufficient information exists about the nature of toe-brachial indices (TBIs) and how best to obtain them, yet their validity may be particularly important for the identification and management of peripheral artery disease and cardiovascular disease risk. We explore ways in which valid TBI measurements might be obtained.

METHODS

The TBI data were recorded from 97 people with subnormal toe pressures. Most people provided three TBI readings from each foot on six different occasions over a 6-month period. The foot with the lower baseline TBI was noted.

RESULTS

For most people, only small inconsistencies existed among the three readings taken from each foot on a single occasion, and there were no consistent differences based on sequence. However, for some people there were noticeable and unsystematic differences among the measures. Selecting any specific one of the three readings based on its sequential position, or averaging specific readings, did not yield TBIs that were unequivocally typical for a person, and taking the lowest reading of each set seemed to offer the most expedient solution in this context. That permitted baseline descriptive statistics to be produced for both the higher and lower pressure feet, between which there was a statistically significant TBI difference.

CONCLUSIONS

Accurate and consistent TBI readings cannot be assumed for people with subnormal toe pressures, and taking only a single reading or indiscriminately averaging readings seems inadvisable. Two readings and, if they are discrepant, additional readings, are recommended for each foot, ideally on several occasions, and careful consideration should be given to determine the most representative reading for each foot. Cuff sizes and other sources of inaccuracy or distortion should not be ignored, and standardized protocols for obtaining TBIs are recommended.