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Lipid Monitoring After Initiation of Lipid-Lowering Therapies: Return of Performance Measures? Curr Cardiol Rep 2021; 23:116. [PMID: 34269897 DOI: 10.1007/s11886-021-01545-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW The 2015 American College of Cardiology (ACC)/American Heart Association (AHA) Focused Update of Secondary Prevention Lipid Performance Measures removed low-density lipoprotein cholesterol (LDL-C) assessment as a performance measure. This review discusses the evidence supporting the importance of lipid monitoring in the secondary prevention of atherosclerotic cardiovascular disease (ASCVD). RECENT FINDINGS The 2018 AHA/ACC Multisociety cholesterol guideline (as did the 2013 guideline) recommends a lipid panel after initiating lipid-lowering therapy to monitor adherence and medication efficacy. The 2018 guideline also recommends adding nonstatin therapy in very-high-risk ASCVD patients with LDL-C ≥70 mg/dL despite maximally tolerated statin therapy. The removal of LDL-C monitoring as a performance measure is not consistent with the 2018 cholesterol guidelines. Given the importance of monitoring lipid-lowering medication efficacy and adherence and optimally reducing LDL-C in very-high-risk patients with additional evidence-based nonstatin therapy, LDL-C assessment after initiating lipid-lowering therapy should be reinstated as a performance measure for patients with ASCVD.
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Rivera-Caravaca JM, Camelo-Castillo A, Ramírez-Macías I, Gil-Pérez P, López-García C, Esteve-Pastor MA, Orenes-Piñero E, Tello-Montoliu A, Marín F. Antithrombotic Therapy in Patients with Peripheral Artery Disease: A Focused Review on Oral Anticoagulation. Int J Mol Sci 2021; 22:ijms22137113. [PMID: 34281167 PMCID: PMC8267774 DOI: 10.3390/ijms22137113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/25/2021] [Accepted: 06/26/2021] [Indexed: 12/24/2022] Open
Abstract
Peripheral artery disease (PAD) is a major cause of morbidity and mortality but it is usually underdiagnosed and undertreated. Patients with PAD present dysregulated procoagulant, anticoagulant, and fibrinolytic pathways leading to arterial and venous thrombosis. The risk of several ischemic-related complications could be mitigated with appropriate antithrombotic therapy, which plays a central role in all types of PAD. For years, antiplatelets have been indicated in patients with symptomatic PAD or those who have undergone revascularization. Unfortunately, a non-negligible proportion of patients with PAD will suffer from adverse events during the follow-up, even despite proper medical therapies for the prevention of PAD complications. Thus, there is room for improving clinical outcomes in these patients. Given the implication of both, primary and secondary hemostasis in arterial thrombosis and the pathophysiology of PAD, the combination of antiplatelets and anticoagulants has emerged as a potential antithrombotic alternative to antiplatelets alone. In this narrative review article, we have highlighted the most recent evidence about antithrombotic therapy in PAD patients, with a special focus on oral anticoagulation. Certainly, COMPASS and VOYAGER PAD trials have shown promising results. Thus, rivaroxaban in combination with aspirin seem to reduce cardiovascular outcomes with a similar bleeding risk compared to aspirin alone. Nevertheless, results from real-world studies are needed to confirm these observations, and other trials will provide novel evidence about the safety and efficacy of emerging anticoagulant agents.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L7 8TX, UK
- Correspondence: ; Tel.: +34-868-88-84-96
| | - Anny Camelo-Castillo
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - Inmaculada Ramírez-Macías
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - Pablo Gil-Pérez
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - Cecilia López-García
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - Esteban Orenes-Piñero
- Department of Biochemistry and Molecular Biology-A, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain;
| | - Antonio Tello-Montoliu
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
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Giannopoulos S, Armstrong EJ. Clinical considerations after endovascular therapy of peripheral artery disease. Expert Rev Cardiovasc Ther 2021; 19:369-378. [PMID: 33870848 DOI: 10.1080/14779072.2021.1914590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Santini L, Almeida Correia M, Oliveira PL, Puech-Leao P, Wolosker N, Cucato GG, Ritti-Dias RM. Functional and Cardiovascular Parameters in Peripheral Artery Disease Patients with Interarm Blood Pressure Difference. Ann Vasc Surg 2020; 70:355-361. [PMID: 32634564 DOI: 10.1016/j.avsg.2020.06.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 06/18/2020] [Accepted: 06/21/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND To analyze the impact of interarm blood pressure difference (IAD) on functional and cardiovascular parameters in patients with peripheral artery disease (PAD). METHODS Ninety-eight patients with PAD were recruited in this cross-sectional study. Patients with differences between the right and left arms of systolic and/or diastolic blood pressure ≥10 mm Hg were classified as IAD, whereas the remaining patients were classified as PAD control subjects. Functional parameters included were the 6-min walk test, short physical performance battery, walking impairment questionnaire (WIQ), and the walking estimated-limitation calculated by history. Systemic cardiovascular parameters included were arterial stiffness and heart rate variability. Local cardiovascular parameters assessed in both arms were brachial blood pressure and flow-mediated dilation. RESULTS Patients with IAD presented higher systolic blood pressure and pulse pressure compared with control patients (P < 0.01). The carotid femoral pulse wave velocity tended to be higher and flow-mediated dilation tended to be lower in PAD patients with IAD compared with control subjects (P < 0.09). Patients with IAD presented lower scores in short physical performance battery (P = 0.012), WIQ distance (P = 0.003), WIQ speed (P = 0.008), WIQ stair climbing (P = 0.034), and walking estimated-limitation calculated by history (P = 0.026) when compared with PAD control patients. CONCLUSIONS In patients with PAD, IAD is associated with lower physical function and impairments in cardiovascular parameters compared with PAD patients without IAD.
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Affiliation(s)
- Luiza Santini
- Graduate Program of Health Sciences, Instituto Israelita de Ensino e Pesquisa, São Paulo, São Paulo, Brazil
| | | | - Paulo L Oliveira
- Postgraduate Program in Rehabilitation Sciences, Universidde Nove de Julho, São Paulo, São Paulo, Brazil
| | - Pedro Puech-Leao
- Department of Vascular Surgery, Hospital das Clínicas da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Nelson Wolosker
- Graduate Program of Health Sciences, Instituto Israelita de Ensino e Pesquisa, São Paulo, São Paulo, Brazil
| | - Gabriel G Cucato
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle upon Tyne, UK
| | - Raphael M Ritti-Dias
- Postgraduate Program in Rehabilitation Sciences, Universidde Nove de Julho, São Paulo, São Paulo, Brazil.
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Jamee A, Aboyans V, Magne J, Elhendy M, Marie Preux P, Lacroix P. Epidemiology of peripheral artery disease in Palestine. VASA 2020; 49:323-329. [PMID: 32452724 DOI: 10.1024/0301-1526/a000871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Peripheral artery disease (PAD) is one of the most common manifestations of atherosclerosis affecting more than 200 million people globally but little is known about its epidemiology in Middle East populations, particularly in Arab countries. The present study was undertaken to assess the prevalence of PAD in the general population aged 40 years and more in Gaza-Palestine, and to determine the prevalence of its associated risk factors. Patients and methods: The study design was a cross-sectional with a stratified proportional sampling, involving the five governorates in Gaza Strip. We selected 1490 individuals aged age ≥ 40 years living in the area for more than 3 years. The questionnaire on lifestyle and cardiovascular risk factors was applied and the ankle-brachial index (ABI) was measured by Doppler examination in both legs in all participants. PAD was defined as an ABI ≤ 0.90. We excluded 92 participants (6 %) because of missing ABI or ABI > 1.40. Results: One-half of the 1398 participants had at least two associated cardiovascular risk factors, one-third were on aspirin and 15 % on statins. Overall, we found PAD in 191 (13.7 %) cases. This prevalence increased with age, and 18.7 % of adults older than 65 years had PAD. The prevalence was higher in females than in males (respectively 15.6 % vs 11.6 % p = 0.031). In the multivariate logistic regression model, significant associated factors with PAD in males were CAD (OR: 3.5; 95 % CI: 1.4-8.6), hypertension (OR: 2.8; 95 % CI: 1.3-6.1), and current smoking (OR: 2.7; 95 % CI: 1.1-6.6). In women, hypertension remains the main associated risk factor. Conclusions: Our study highlights the high prevalence of PAD in the Gazan community, mostly related to the high prevalence of cardiovascular risk factors and other cardiovascular conditions.
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Affiliation(s)
- Amal Jamee
- Inserm U 1094 & IRD, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, University of Limoges, Limoges, France.,Department of Cardiology, Ministry of Health, Palestine
| | - Victor Aboyans
- Inserm U 1094 & IRD, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, University of Limoges, Limoges, France.,Department of Cardiology, Dupuytren University Hospital, Limoges, France
| | - Julien Magne
- Inserm U 1094 & IRD, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, University of Limoges, Limoges, France.,Department of Cardiology, Dupuytren University Hospital, Limoges, France
| | - Mohammed Elhendy
- Holymed Advanced Diagnostic Laboratories, Ministry of Health, Palestine
| | - Pierre Marie Preux
- Inserm U 1094 & IRD, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, University of Limoges, Limoges, France
| | - Philippe Lacroix
- Inserm U 1094 & IRD, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, University of Limoges, Limoges, France.,Department of Thoracic and Vascular Surgery - Vascular Medicine, Dupuytren University Hospital, Limoges, France
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Kokkinidis DG, Armstrong EJ. Current developments in endovascular therapy of peripheral vascular disease. J Thorac Dis 2020; 12:1681-1694. [PMID: 32395311 PMCID: PMC7212127 DOI: 10.21037/jtd.2019.12.130] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
More than 200 million people worldwide have peripheral artery disease (PAD) or its most severe manifestation, critical limb ischemia (CLI). While endovascular treatment has become first line therapy in most cases, a number of challenges remain for optimal treatment of femoropopliteal (FP) or infrapopliteal (IP) disease, especially when these lesions are severely calcified, chronic total occlusions (CTOs) or in-stent restenosis (ISR). Continued evolution of technologies has significantly improved the outcomes for endovascular treatment. A number of new devices are in the pipeline right now, including new paclitaxel eluting stents and balloons, intravascular lithotripsy to treat severely calcified lesions, adventitial delivery of anti-restenotic agents to limit restenosis rates, and percutaneous femoro-popliteal bypass.
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Affiliation(s)
- Damianos G Kokkinidis
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Aurora, CO, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Aurora, CO, USA
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Imaeda S, Kuno T, Hirano K, Kodaira M, Anzai H, Numasawa Y. Risk of undiagnosed coronary artery disease associated with infrapopliteal artery occlusion from a multicenter study. Heart Vessels 2020; 35:307-311. [PMID: 31473802 DOI: 10.1007/s00380-019-01495-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 08/23/2019] [Indexed: 11/26/2022]
Abstract
Peripheral artery disease (PAD) is associated with high cardiovascular mortality. Which part of PAD with lower extremities is related to coronary artery disease (CAD) remains unknown. We hypothesized that PAD including infrapopliteal artery (IPA) occlusion was associated with CAD. A total of 260 patients who have no history of CAD or the anginal symptom, complain of the claudication or critical limb ischemia and underwent peripheral angiography were retrospectively analyzed. IPA occlusion was diagnosed with peripheral angiography, and CAD was diagnosed with the coronary angiography. A multivariate logistic regression analysis was performed to determine the predictors of silent CAD. Among them, a total of 146 patients (56.2%) had IPA occlusion. Baseline characteristics were significantly different between two groups as to the proportions of age, male, dyslipidemia (with vs. without IPA occlusion; 72.4 ± 10.8 vs. 69.1 ± 10.2; 62.3% vs. 75.4%; 38.6% vs. 52.6%, respectively, all comparisons P < 0.05). Notably, the prevalence of CAD was significantly higher in patients with IPA occlusion (50.7% vs. 34.2%, P = 0.008). On a multivariate analysis, IPA occlusion was an independent predictor for the presence of silent CAD (OR, 1.94; CI, 1.09-3.44, P = 0.024), but aortoiliac artery occlusion (OR, 1.16; CI, 0.53-2.56, P = 0.71) and femoropopliteal artery occlusion (OR, 1.02; CI, 0.57-1.83, P = 0.96) were not. IPA occlusion was associated with silent CAD. Vascular surgeons, interventional radiologists, as well as interventional cardiologists should recognize IPA occlusion as a risk factor of silent CAD.
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Affiliation(s)
- Shohei Imaeda
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Toshiki Kuno
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan.
- Department of Medicine, Icahn School of Medicine At Mount Sinai, Mount Sinai Beth Israel, First Avenue at 16th Street, New York, NY, 10003, USA.
| | - Keita Hirano
- Department of Nephrology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Masaki Kodaira
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Hitoshi Anzai
- Department of Cardiology, SUBARU Health Insurance Ota Memorial Hospital, Ota, Japan
| | - Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
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Wickström JE, Virtanen J, Aro E, Jalkanen J, Venermo M, Hakovirta H. Bilateral low systolic toe pressure and toe-brachial index are associated with long-term mortality in patients with peripheral artery disease. J Vasc Surg 2019; 70:1994-2004. [DOI: 10.1016/j.jvs.2019.03.073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 03/27/2019] [Indexed: 12/19/2022]
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Patel KK, Jones PG, Ellerbeck EF, Buchanan DM, Chan PS, Pacheco CM, Moneta G, Spertus JA, Smolderen KG. Underutilization of Evidence-Based Smoking Cessation Support Strategies Despite High Smoking Addiction Burden in Peripheral Artery Disease Specialty Care: Insights from the International PORTRAIT Registry. J Am Heart Assoc 2019; 7:e010076. [PMID: 30371269 PMCID: PMC6474973 DOI: 10.1161/jaha.118.010076] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background Smoking is the most important risk factor for peripheral artery disease (PAD). Smoking cessation is key in PAD management. We aimed to examine smoking rates and smoking cessation interventions offered to patients with PAD consulting a vascular specialty clinic; and assess changes in smoking behavior over the year following initial visit. Methods and Results A total of 1272 patients with PAD and new or worsening claudication were enrolled at 16 vascular specialty clinics (2011–2015, PORTRAIT (Patient‐Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry). Interviews collected smoking status and cessation interventions at baseline, 3, 6, and 12 months. Among smokers, transition state models analyzed smoking transitions at each time point and identified factors associated with quitting and relapse. On presentation, 474 (37.3%) patients were active, 660 (51.9%) former, and 138 (10.8%) never smokers. Among active smokers, only 16% were referred to cessation counseling and 11% were prescribed pharmacologic treatment. At 3 months, the probability of quitting smoking was 21%; among those continuing to smoke at 3 months, the probability of quitting during the next 9 months varied between 11% and 12% (P<0.001). The probability of relapse among initial quitters was 36%. At 12 months, 72% of all smokers continued to smoke. Conclusions More than one third of patients with claudication consulting a PAD provider are active smokers and few received evidence‐based cessation interventions. Patients appear to be most likely to quit early in their treatment course, but many quickly relapse and 72% of all patients smoking at baseline are still smoking at 12 months. Better strategies are needed to provide continuous cessation support. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT01419080.
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Affiliation(s)
- Krishna K. Patel
- Saint Luke's Mid America Heart InstituteUniversity of Missouri‐Kansas CityMO
| | - Philip G. Jones
- Saint Luke's Mid America Heart InstituteUniversity of Missouri‐Kansas CityMO
| | | | - Donna M. Buchanan
- Saint Luke's Mid America Heart InstituteUniversity of Missouri‐Kansas CityMO
| | - Paul S. Chan
- Saint Luke's Mid America Heart InstituteUniversity of Missouri‐Kansas CityMO
| | | | | | - John A. Spertus
- Saint Luke's Mid America Heart InstituteUniversity of Missouri‐Kansas CityMO
| | - Kim G. Smolderen
- Saint Luke's Mid America Heart InstituteUniversity of Missouri‐Kansas CityMO
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Analysis of Patients Undergoing Major Lower Extremity Amputation in the Vascular Quality Initiative. Ann Vasc Surg 2018; 46:75-82. [DOI: 10.1016/j.avsg.2017.07.034] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 12/15/2022]
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Systematic review and meta-analysis of duplex ultrasound surveillance for infrainguinal vein bypass grafts. J Vasc Surg 2017; 66:1885-1891.e8. [PMID: 29169544 DOI: 10.1016/j.jvs.2017.06.113] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 06/23/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Duplex ultrasound (DUS) surveillance of infrainguinal vein bypass grafts is widely practiced, but the evidence of its effectiveness compared with other methods of surveillance remains unclear. METHODS Following an a priori protocol developed by the guidelines committee from the Society for Vascular Surgery, this systematic review and meta-analysis included randomized and nonrandomized comparative studies that enrolled patients who underwent infrainguinal arterial reconstruction and received DUS surveillance for follow-up compared with any other method of surveillance. The search included MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature, and Scopus through November 2016. Outcomes of interest included all-cause mortality, limb viability, and graft patency reports. Meta-analysis was performed using the random-effects model. RESULTS We included 15 studies. Compared with ankle-brachial index and clinical examination, DUS surveillance was not associated with a significant change in primary, secondary, or assisted primary patency or mortality. DUS surveillance was associated with a nonstatistically significant reduction in amputation rate (odds ratio, 0.70 [95% confidence interval, 0.23-2.13]). The quality of evidence was low because of imprecision (small number of events and wide confidence intervals) and high risk of bias in the primary literature. CONCLUSIONS A recommendation for routine DUS surveillance of infrainguinal vein grafts remains dependent on low-quality evidence. Considering that DUS offers the opportunity of early intervention and because of its noninvasive nature and low cost, vascular surgeons may incorporate DUS as they individualize the follow-up of lower extremity vein grafts.
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Fabiani I, Calogero E, Pugliese NR, Di Stefano R, Nicastro I, Buttitta F, Nuti M, Violo C, Giannini D, Morgantini A, Conte L, Barletta V, Berchiolli R, Adami D, Ferrari M, Di Bello V. Critical Limb Ischemia: A Practical Up-To-Date Review. Angiology 2017; 69:465-474. [PMID: 29161885 DOI: 10.1177/0003319717739387] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Critical limb ischemia (CLI) is the most advanced form of peripheral artery disease. It is associated with significant morbidity and mortality and high management costs. It carries a high risk of amputation and local infection. Moreover, cardiovascular complications remain a major concern. Although it is a well-known entity and new technological and therapeutic advances have been made, this condition remains poorly addressed, with significantly heterogeneous management, especially in nonexperienced centers. This review, from a third-level dedicated inpatient and outpatient cardioangiology structure, aims to provide an updated summary on the topic of CLI of its complexity, encompassing epidemiological, social, economical and, in particular, diagnostic/imaging issues, together with potential therapeutic strategies (medical, endovascular, and surgical), including the evaluation of cardiovascular risk factors, the diagnosis, and treatment together with prognostic stratification.
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Affiliation(s)
- Iacopo Fabiani
- 1 Cardioangiology Universitary Departmental Section, Cardio Thoracic and Vascular Department, A.O.U.P., University of Pisa, Pisa, Italy
| | - Enrico Calogero
- 1 Cardioangiology Universitary Departmental Section, Cardio Thoracic and Vascular Department, A.O.U.P., University of Pisa, Pisa, Italy
| | - Nicola Riccardo Pugliese
- 1 Cardioangiology Universitary Departmental Section, Cardio Thoracic and Vascular Department, A.O.U.P., University of Pisa, Pisa, Italy
| | - Rossella Di Stefano
- 1 Cardioangiology Universitary Departmental Section, Cardio Thoracic and Vascular Department, A.O.U.P., University of Pisa, Pisa, Italy
| | - Irene Nicastro
- 1 Cardioangiology Universitary Departmental Section, Cardio Thoracic and Vascular Department, A.O.U.P., University of Pisa, Pisa, Italy
| | - Flavio Buttitta
- 1 Cardioangiology Universitary Departmental Section, Cardio Thoracic and Vascular Department, A.O.U.P., University of Pisa, Pisa, Italy
| | - Marco Nuti
- 1 Cardioangiology Universitary Departmental Section, Cardio Thoracic and Vascular Department, A.O.U.P., University of Pisa, Pisa, Italy
| | - Caterina Violo
- 1 Cardioangiology Universitary Departmental Section, Cardio Thoracic and Vascular Department, A.O.U.P., University of Pisa, Pisa, Italy
| | - Danilo Giannini
- 1 Cardioangiology Universitary Departmental Section, Cardio Thoracic and Vascular Department, A.O.U.P., University of Pisa, Pisa, Italy
| | - Alessandro Morgantini
- 1 Cardioangiology Universitary Departmental Section, Cardio Thoracic and Vascular Department, A.O.U.P., University of Pisa, Pisa, Italy
| | - Lorenzo Conte
- 1 Cardioangiology Universitary Departmental Section, Cardio Thoracic and Vascular Department, A.O.U.P., University of Pisa, Pisa, Italy
| | - Valentina Barletta
- 1 Cardioangiology Universitary Departmental Section, Cardio Thoracic and Vascular Department, A.O.U.P., University of Pisa, Pisa, Italy
| | - Raffaella Berchiolli
- 2 Vascular Surgery Operative Unit, Cardio Thoracic and Vascular Department, A.O.U.P., University of Pisa, Pisa, Italy
| | - Daniele Adami
- 2 Vascular Surgery Operative Unit, Cardio Thoracic and Vascular Department, A.O.U.P., University of Pisa, Pisa, Italy
| | - Mauro Ferrari
- 2 Vascular Surgery Operative Unit, Cardio Thoracic and Vascular Department, A.O.U.P., University of Pisa, Pisa, Italy
| | - Vitantonio Di Bello
- 1 Cardioangiology Universitary Departmental Section, Cardio Thoracic and Vascular Department, A.O.U.P., University of Pisa, Pisa, Italy
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Afzal N, Sohn S, Abram S, Scott CG, Chaudhry R, Liu H, Kullo IJ, Arruda-Olson AM. Mining peripheral arterial disease cases from narrative clinical notes using natural language processing. J Vasc Surg 2017; 65:1753-1761. [PMID: 28189359 PMCID: PMC5438905 DOI: 10.1016/j.jvs.2016.11.031] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 11/14/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Lower extremity peripheral arterial disease (PAD) is highly prevalent and affects millions of individuals worldwide. We developed a natural language processing (NLP) system for automated ascertainment of PAD cases from clinical narrative notes and compared the performance of the NLP algorithm with billing code algorithms, using ankle-brachial index test results as the gold standard. METHODS We compared the performance of the NLP algorithm to (1) results of gold standard ankle-brachial index; (2) previously validated algorithms based on relevant International Classification of Diseases, Ninth Revision diagnostic codes (simple model); and (3) a combination of International Classification of Diseases, Ninth Revision codes with procedural codes (full model). A dataset of 1569 patients with PAD and controls was randomly divided into training (n = 935) and testing (n = 634) subsets. RESULTS We iteratively refined the NLP algorithm in the training set including narrative note sections, note types, and service types, to maximize its accuracy. In the testing dataset, when compared with both simple and full models, the NLP algorithm had better accuracy (NLP, 91.8%; full model, 81.8%; simple model, 83%; P < .001), positive predictive value (NLP, 92.9%; full model, 74.3%; simple model, 79.9%; P < .001), and specificity (NLP, 92.5%; full model, 64.2%; simple model, 75.9%; P < .001). CONCLUSIONS A knowledge-driven NLP algorithm for automatic ascertainment of PAD cases from clinical notes had greater accuracy than billing code algorithms. Our findings highlight the potential of NLP tools for rapid and efficient ascertainment of PAD cases from electronic health records to facilitate clinical investigation and eventually improve care by clinical decision support.
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Affiliation(s)
- Naveed Afzal
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - Sunghwan Sohn
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - Sara Abram
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | | | - Rajeev Chaudhry
- Division of Primary Care Medicine, Knowledge Delivery Center and Center for Innovation, Mayo Clinic, Rochester, Minn
| | - Hongfang Liu
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - Iftikhar J Kullo
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
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Toe Pressure and Toe Brachial Index are Predictive of Cardiovascular Mortality, Overall Mortality, and Amputation Free Survival in Patients with Peripheral Artery Disease. Eur J Vasc Endovasc Surg 2017; 53:696-703. [PMID: 28292565 DOI: 10.1016/j.ejvs.2017.02.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 02/09/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE/BACKGROUND Peripheral haemodynamic parameters are used to assess the presence and severity of peripheral artery disease (PAD). The prognostic value of ankle brachial index (ABI) has been thoroughly delineated. Nonetheless, the relative usefulness of ankle pressure (AP), ABI, toe pressure (TP), and toe brachial index (TBI) in assessing patient outcome has not been investigated in a concurrent study setting. This study aimed to resolve the association of all four non-invasive haemodynamic parameters in clinically symptomatic patients with PAD with cardiovascular mortality, overall mortality, and amputation free survival (AFS). METHODS In total, 732 symptomatic patients with PAD admitted to the Department of Vascular Surgery for conventional angiography at Turku University Hospital, Turku, Finland, between January 2009 and August 2011 were reviewed retrospectively. Demographic factors, cardiovascular mortality, all-cause mortality, and above foot level amputations were obtained and assessed in relation to AP, ABI, TP, and TBI by means of Kaplan-Meier life tables and a multivariate Cox regression model. RESULTS The haemodynamic parameter that was associated with poor 36 month general outcome was TP < 30 mmHg. Univariate Cox regression analysis of stratified values showed that TP and TBI associated significantly with mortality. In multivariate analysis both TP and TBI were associated with a significant risk of death. For TP < 30 mmHg and TBI < 0.25 the risk of cardiovascular mortality was hazard ratio [HR] 2.84, 95% confidence interval [CI] 1.75-4.61 [p<.001]; HR 3.68, 95% CI 1.48-9.19 [p=.050], respectively; all-cause mortality (HR 2.05, 95% CI 1.44-2.92 [p<.001]; HR 2.53, 95% CI 1.35-4.74 [p=.040], respectively); and amputation or death (HR 2.13, 95% CI 1.52-2.98 [p<.001]; HR 2.46, 95% CI 1.38-4.40 [p=.050], respectively)... CONCLUSION Among non-invasive haemodynamic measurements and pressure indices both TP and TBI appear to be associated with cardiovascular and overall mortality and AFS for patients with PAD presenting symptoms of the disease.
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Determination and distribution of left ventricular size as measured by noncontrast CT in the Multi-Ethnic Study of Atherosclerosis. J Cardiovasc Comput Tomogr 2015; 9:113-9. [PMID: 25819193 DOI: 10.1016/j.jcct.2015.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 11/06/2014] [Accepted: 01/02/2015] [Indexed: 01/07/2023]
Abstract
BACKGROUND Left ventricular (LV) volume and mass have prognostic relevance. Overall size of the left ventricle as it appears in noncontrast CT is a composite of the ventricular volume and myocardial mass. We describe a method to estimate the LV size using a single cross-section in noncontrast CT and determined normal ranges on the basis of a large population cohort. METHODS The Multi-Ethnic Study of Atherosclerosis with 6814 participants from 4 ethnicities who were free of known cardiovascular disease and enrolled between 2000 and 2002 form the basis of our analysis. LV size was calculated from a single cross-sectional slice obtained by either nonenhanced electron beam or multidetector CT. LV size was adjusted to body surface area to obtain the LV size index, which was adjusted for age, sex, race or ethnicity, hypertension, hyperlipidemia, and diabetes. RESULTS There were significant differences in LV size index by race which were further influenced by age and sex. Higher values were noted in men in all ethnic groups across all age groups. Similarly, LV size index uniformly decreased with age across all ethnic and sex categories. Caucasians had the lowest and African Americans had the highest LV size index across all age and sex categories. In multivariate regression analyses adjusted for age, sex, race or ethnicity, hypertension, hyperlipidemia, smoking, and diabetes mellitus, the significant differences were noted between male vs female (median difference, 17.5 cc/m(2); P < .001), ethnic groups (Caucasian, reference group; Asian, 3.7 cc/m(2); African American, 8.3 cc/m(2); and Hispanic, 5.6 cc/m(2); P < .001), and age groups (45-54 years, reference group; 55-64 years, -5.2 cc/m(2); 65-74 years, -11.4 cc/m(2); and 74-84 years, -12.5 cc/m(2)). CONCLUSIONS This study provides normative values for LV size as determined from a single, nonenhanced CT cross-section and indexed to body surface area, and it demonstrates that the LV size index varies by age, sex, and ethnic background.
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Peripheral arterial occlusive disease (PAOD). PHLEBOLOGIE 2014. [DOI: 10.12687/phleb2241-6-2014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
SummaryLeg pain on exertion is the cardinal symptom of both arterial occlusive disease. Patients with PAOD complain of cramping pain in the calf, which disappears after standing still with a straight back for a few minutes. The diagnostic and therapeutic options are discussed.
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Danford CP, Navar-Boggan AM, Stafford J, McCarver C, Peterson ED, Wang TY. The feasibility and accuracy of evaluating lipid management performance metrics using an electronic health record. Am Heart J 2013; 166:701-8. [PMID: 24093850 DOI: 10.1016/j.ahj.2013.07.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 07/30/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Over the past decade, electronic health records (EHRs) have emerged as a potential tool to assess quality of care; however, the feasibility and accuracy of EHRs to assess adherence to lipid management performance measures have not been evaluated. METHODS We created a retrospective cohort of 3779 patients with coronary artery disease who were followed up in a cardiology clinic at an academic medical center using an EHR database. Of these 3779 patients, 300 randomly-selected charts were reviewed to identify reasons for failure to adhere to lipid management performance measures. RESULTS Based on the EHR, a low-density lipoprotein cholesterol measurement was obtained in 73% of patients within the past 3 years; of which, 34% had low-density lipoprotein cholesterol levels ≥100 mg/dL and statin therapy had been prescribed in 88%. Manual chart review revealed that many of these apparent failures were actually false positives, due to inaccurate capture of indications and contraindications to lipid measurement and statin prescription, patient/provider treatment preferences, and external data sources. CONCLUSIONS While it is possible to monitor adherence to lipid management performance measures using an EHR, the accuracy of this assessment is currently limited and may underestimate provider quality of care.
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Parmar GM, Lowman B, Combs BR, Taylor SM, Patterson MA, Passman MA, Jordan WD. Effect of lipid-modifying drug therapy on survival after abdominal aortic aneurysm repair. J Vasc Surg 2013; 58:355-63. [DOI: 10.1016/j.jvs.2013.01.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 12/12/2012] [Accepted: 01/15/2013] [Indexed: 12/01/2022]
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Subherwal S, Patel MR, Tang F, Smolderen KG, Jones WS, Tsai TT, Ting HH, Bhatt DL, Spertus JA, Chan PS. Socioeconomic disparities in the use of cardioprotective medications among patients with peripheral artery disease: an analysis of the American College of Cardiology's NCDR PINNACLE Registry. J Am Coll Cardiol 2013; 62:51-7. [PMID: 23643497 PMCID: PMC3912073 DOI: 10.1016/j.jacc.2013.04.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 04/17/2013] [Indexed: 01/13/2023]
Abstract
OBJECTIVES The aim of this paper was to examine disparities in the use of cardioprotective medications in the treatment of peripheral artery disease (PAD) by socioeconomic status (SES). BACKGROUND PAD is associated with increased cardiovascular risk and is more prevalent among those of lower SES. However, the use of guideline-recommended secondary preventive measures for the treatment of PAD across diverse income subgroups and the influence of practice site on potential treatment disparities by SES are unknown. METHODS Within the National Cardiovascular Disease Registry (NCDR) PINNACLE Registry, 62,690 patients with PAD were categorized into quintiles of SES, as defined by the median income of each patient's zip code. The association between SES and secondary preventive treatment with antiplatelet and statin medications was evaluated using sequential hierarchical modified Poison models, adjusting first for practice site and then for clinical variables. RESULTS Compared with the highest SES quintile (median income: >$60,868), PAD patients in the lowest SES quintile (median income: <$34,486) were treated less often with statins (72.5% vs. 85.8%; RR: 0.84; 95% CI: 0.83 to 0.86; p < 0.001) and antiplatelet therapy (79.0% vs. 84.6%; RR: 0.93; 95% CI: 0.91 to 0.94; p < 0.001). These differences were markedly attenuated after controlling for practice site variation: statins (adjusted RR: 0.97; 95% CI: 0.95 to 0.99; p = 0.003) and antiplatelet therapy (adjusted RR: 0.98; 95% CI: 0.97 to 1.00; p = 0.012). Additional adjustment for patients' clinical characteristics had minimal impact, with slight further attenuation with statins (adjusted RR: 1.00: 95% CI: 0.99 to 1.01; p = 0.772) and antiplatelet therapy (adjusted RR: 1.00; 95% CI: 0.99 to 1.01; p = 0.878). CONCLUSIONS Among PAD patients, the practice site at which patients received care largely explained the observed SES differences in treatment with guideline-recommended secondary preventive medications. Future efforts to reduce treatment disparities in these vulnerable populations should target systems improvement at practices serving high proportions of patients with low SES.
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Johner F, Thalhammer C, Jacomella V, Husmann M, Amann-Vesti B. Differences in cardiovascular risk factors between patients with acute limb ischemia and intermittent claudication. Angiology 2013; 65:497-500. [PMID: 23644258 DOI: 10.1177/0003319713487428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this retrospective study, cardiovascular risk factors of patients with acute limb ischemia (ALI) were compared with those of intermittent claudication (IC). Furthermore, the association of ALI with environmental temperature and/or hematocrit level was tested. A total of 436 patients treated for ALI and 832 patients with IC were included in the analysis. Diabetes (P = .0001), smoking (P < .0001), and hypertension (P < .0001) were significantly less prevalent in the patients with ALI. Patients with IC had a higher rate of coronary artery disease (P = .003), and patients with ALI had a higher rate of cerebrovascular disease (P < .0001). There was no association between the outside temperature or hematocrit level and the occurrence of ALI. The hypothesis of seasonal incidence of ALI could not be confirmed, and there was no association of ALI with the hematocrit level.
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Affiliation(s)
- Fabian Johner
- Clinic for Angiology, University Hospital Zurich, Switzerland
| | | | | | - Marc Husmann
- Clinic for Angiology, University Hospital Zurich, Switzerland
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Garimella PS, Hart PD, O'Hare A, DeLoach S, Herzog CA, Hirsch AT. Peripheral Artery Disease and CKD: A Focus on Peripheral Artery Disease as a Critical Component of CKD Care. Am J Kidney Dis 2012; 60:641-54. [DOI: 10.1053/j.ajkd.2012.02.340] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2011] [Accepted: 02/29/2012] [Indexed: 11/11/2022]
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Idiopathic midaortic syndrome: normalization of blood pressure on medication. Pediatr Nephrol 2012; 27:313-6. [PMID: 21986626 DOI: 10.1007/s00467-011-2023-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 09/09/2011] [Accepted: 09/09/2011] [Indexed: 10/16/2022]
Abstract
Midaortic syndrome (MAS) is a rare, idiopathic condition in children usually presenting with severe hypertension. We report a case of a 13-year-old girl who presented with severe hypertension (200/110 mmHg) associated with renal artery stenosis and normal renal function (creatinine clearance 110 ml/min/1.73m(2)). Percutaneous angioplasty (PTA) was first performed, but early recurrence of hypertension occurred. Subsequent imaging evaluation demonstrated association of aortic narrowing, proximal stenosis of the left renal artery, and wall thickening of superior mesenteric artery and right common carotid artery. Although previous large-vessel arteritis cannot be absolutely excluded, a diagnosis of idiopathic MAS was made, given the absence of any other clinical signs of inflammation (C-reactive protein <0.5 mg/dl; erythrocyte sedimentation rate 5 mm/h). Medical treatment was undertaken without repeat PTA or surgery. Blood pressure control was good, and antihypertensive therapy was stopped 4 years later. At age 22, the patient was still normotensive and receiving no antihypertensive therapy; normalization of Doppler velocities in the proximal left renal artery was confirmed. In the absence of renal dysfunction or target-organ damage, medical management of hypertension in MAS is feasible without intervention if blood pressure is well controlled on two antihypertensive agents.
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Vodnala D, Rajagopalan S, Brook RD. Medical Management of the Patient with Intermittent Claudication. Cardiol Clin 2011; 29:363-79. [DOI: 10.1016/j.ccl.2011.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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