Ankle-brachial index improves the classification of cardiovascular risk: PERART/ARTPER Study

Frequency of lower extremity artery disease in type 2 diabetic patients using pulse oximetry and the ankle-brachial index

Objectives: To determine the of undiagnosed lower extremity artery disease using the pulse oximetry in a type 2 diabetic population sample. Methods: Observational, cross-sectional, descriptive study that included 594 type 2 diabetic patients, with no previous history of lower extremity artery disease. Medical history, physical examination, determination of the ankle-brachial index (portable Doppler) and measurement of oxygen saturation in upper and lower extremities (pulse oximeter) were performed. Results: Frequency of lower extremity artery disease determined by ankle-brachial index was 18.4%. No significant correlations were detected between oxygen saturation and the ankle-brachial index except for the relationship between ankle-brachial index vs. oxygen saturation at 30 cm lower limb elevation vs. the supine position at no elevation (0 cm) in subjects under the age of 40. Pulse oximetry showed little diagnostic value in the screening of lower extremity artery disease. A relationship between lower extremity artery disease and age has been found. Its diagnosis was associated with a lower body mass index and lower systolic blood pressure in the lower extremities and higher in the upper extremities. Conclusions: We conclude that pulse oximetry is not useful in the screening for asymptomatic lower extremity artery disease in type 2 diabetics.

Cardiovascular risk assessment tools: A scoping review

OBJECTIVES

The objective of this review was to describe cardiovascular risk (CVR) assessment methods and to identify evidence-based practice recommendations when dealing with population at risk of developing cardiovascular diseases.

REVIEW METHODS AND DATA SOURCES

A literature review following the Arksey and O'Malley scoping review methodology was conducted. By using appropriate key terms, literature searches were conducted in PubMed, SciELO, Cochrane Library, Dialnet, ENFISPO, Medigraphic, ScienceDirect, Cuiden, and Lilacs databases. A complementary search on websites related to the area of interest was conducted. Articles published in English or Spanish in peer-review journals between 2010 and 2017. Critical appraisal for methodological quality was conducted. Data was extracted using ad-hoc tables and qualitatively synthesized.

RESULTS

After eliminating duplicates, 55325 records remained, and 1432 records were selected for screening. Out of these, 88 full-text articles were selected for eligibility criteria, and finally, 67 studies were selected for this review, and 25 studies were selected for evidence synthesis. In total, 23 CVR assessment tools have been identified, pioneered by the Framingham study. Qualitative findings were grouped into four thematic areas: assessment tools and scores, CVR indicators, comparative models, and evidence-based recommendations.

CONCLUSIONS

It is necessary to adapt the instruments to the epidemiological reality of the population. The most appropriate way to estimate CVR is to choose the assessment tool that best suits individual conditions, accompanied by a comprehensive assessment of the patient. More research is required to determine a single, adequate, and reliable tool.

Contribution of the ankle-brachial index to improve the prediction of coronary risk: The ARTPER cohort

BACKGROUND

The different cardiovascular risk prediction scales currently available are not sufficiently sensitive.

AIM

The aim of the present study was to analyze the contribution of the ankle-brachial index (ABI) added to the Framingham and REGICOR risk scales for the reclassification of cardiovascular risk after a 9-year follow up of a Mediterranean population with low cardiovascular risk.

DESIGN AND SETTING

A population-based prospective cohort study was performed in the province of Barcelona, Spain.

METHOD

A total of 3,786 subjects >49 years were recruited from 2006-2008. Baseline ABI was performed and cardiovascular risk was calculated with the Framingham and REGICOR scales. The participants were followed until November 2016 by telephone and review of the clinical history every 6 months to confirm the possible appearance of cardiovascular events.

RESULTS

2,716 individuals participated in the study. There were 126 incidental cases of first coronary events (5%) during follow up. The incidence of coronary events in patients with ABI <0.9 was 4-fold greater than that of subjects with a normal ABI (17.2/1,000 persons-year versus 4.8/1,000 persons-year). Improvement in the predictive capacity of REGICOR scale was observed on including ABI in the model, obtaining a net reclassification improvement of 7% (95% confidence interval 0%-13%) for REGICOR+ ABI. Framingham + ABI obtained a NRI of 4% (-2%-11%).

CONCLUSION

The results of the present study support the addition of the ABI as a tool to help in the reclassification of cardiovascular risk and to confirm the greater incidence of coronary events in patients with ABI < 0.9.

[The relevance of the ankle-arm index to the reclassification of cardiovascular risk in asymptomatic hypertensive middle-aged males]

BACKGROUND AND OBJECTIVE

The ankle-brachial index allows for the detection of subclinical cardiovascular disease and risk, by diagnosing peripheral arterial disease and arterial calcification. Asymptomatic hypertensive men, between 45-55 years and with the suspicion of low risk, could be an important population group to benefit from this technique. The aim of the study was to compare the frequency of abnormal ankle-brachial index (subclinical peripheral arterial disease and arterial calcification) between asymptomatic hypertensive and non-hypertensive men, of the same age and suspicion of low risk.

PATIENTS AND METHODS

Two hundred and forty-four asymptomatic men (122 hypertensive and 122 non-hypertensive), between 45 and 55 years and an REGICOR index<10, were voluntarily recruited using consecutive sampling. Complete anamnesis, physical examination, laboratory tests and ankle-brachial index determination were carried out on all patients.

RESULTS

We detected abnormal ankle-brachial index values in 9.8% (12 cases) of the hypertensive subjects and in 1.6% (2 cases) of non-hypertensive subjects (P=.006). In the multivariate analysis, hypertension was significantly associated with an abnormal ankle-brachial index (P<.026) (odds ratio [OR] 5.9, 95% confidence interval [95% CI] 1.2-28.3), smoking (P=.018) (OR 2.7; 95% CI 1.2-6.2) and abdominal obesity (P=.005) (OR 2.8; 95% CI 1.3-5.9).

CONCLUSIONS

The population group analyzed in this study might be considered as an overriding segment for detecting subclinical cardiovascular disease and risk with the ankle-brachial index. Further studies are needed to establish the prevalence of abnormal ankle-brachial index in this population in order to assess its efficiency.

Peripheral arterial disease, type 2 diabetes and postprandial lipidaemia: Is there a link?

Peripheral arterial disease, manifested as intermittent claudication or critical ischaemia, or identified by an ankle/brachial index < 0.9, is present in at least one in every four patients with type 2 diabetes mellitus. Several reasons exist for peripheral arterial disease in diabetes. In addition to hyperglycaemia, smoking and hypertension, the dyslipidaemia that accompanies type 2 diabetes and is characterised by increased triglyceride levels and reduced high-density lipoprotein cholesterol concentrations also seems to contribute to this association. Recent years have witnessed an increased interest in postprandial lipidaemia, as a result of various prospective studies showing that non-fasting triglycerides predict the onset of arteriosclerotic cardiovascular disease better than fasting measurements do. Additionally, the use of certain specific postprandial particle markers, such as apolipoprotein B-48, makes it easier and more simple to approach the postprandial phenomenon. Despite this, only a few studies have evaluated the role of postprandial triglycerides in the development of peripheral arterial disease and type 2 diabetes. The purpose of this review is to examine the epidemiology and risk factors of peripheral arterial disease in type 2 diabetes, focusing on the role of postprandial triglycerides and particles.

Task force on: 'Early markers of atherosclerosis: influence of age and sex'

Atherosclerosis and its complications are the most important causes of death all over the world, especially in Western countries. Diet habits, modern stress life, smoking, sedentary way of life and an involvement of genetic pattern of individuals lead to a sure degeneration of quality of life increasing the risk of atherosclerosis development. For this reason, the main purpose of actual medicine is to identify all the markers that could allow the physicians to evaluate the first moments of the development of this dangerous pathological process. The aim is to reduce the speed of its evolution, trying to delay indefinitely the risk coming from the morphological alterations of the vessels. 'Endothelium function' could allow physicians to detect the first moment of the natural history of atherosclerosis process. Its impairment is the first step in the degeneration of vascular structures. Many methods [flow-mediated vasodilatation (FMD); antero-posterior abdominal aorta diameter (APAO); intima-media thickness of the common carotid artery (CCA-IMT); arterial stiffness; and so on] try to evaluate its function, but many limitations come from general population characteristics. A standardization of the methods should take into account individuals' peculiarities. Two elements, not modifiable, should be taken into account for vascular evaluation: age and sex. The aim of this review is to outline the linkage among age, sex and instrumental evaluation of patients considered for a noninvasive assessment of their cardiovascular risk profile.

Concordance between automated oscillometric measurement of ankle-brachial index and traditional measurement by eco-Doppler in patients without peripheral artery disease

AIM

To evaluate the concordance between automated oscillometric measurement (WatchBP® Office ABI) of the ankle- brachial index (ABI) and the traditional measurement by eco-Doppler in a Spanish population without peripheral artery disease attended in primary care.

METHODS

The ABI was determined by both methods in a general population aged ≥ 18 years, from the RICARTO study. The intraclass correlation coefficient was calculated to assess the concordance between both techniques and the Bland-Altman plot was determined to analyze the agreement between them.

RESULTS

A total of 322 subjects (mean age 47.7 ± 16.0 years; 54.3% women) were included in the study. With regard to cardiovascular risk factors, 70.5% of subjects had dyslipidemia, 26.7% hypertension, 24.8% obesity, 8.4% diabetes and 25.5% were smokers. Mean ABI measured by eco-Doppler and the automated method were 1.17 ± 0.1 and 1.2 ± 0.1, respectively (mean differences - 0.03 ± 0.09; p < 0.001). The Pearson correlation coefficient and the intraclass correlation coefficient were in both cases 0.70.

CONCLUSIONS

The automated oscillometric measurement of ABI is a reliable and useful alternative to conventional eco-Doppler determination in the general population without peripheral artery disease attended in primary care.

Estimating the risk of peripheral artery disease using different population strategies

OBJECTIVE

The objective of this study is to compare the clinical performance of different strategies, REASON, PREVALENT, Inter-Society Consensus (ISC), and the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines, in the selection of candidates for peripheral artery disease (PAD) screening using ankle-brachial index (ABI).

METHOD

Our work is a population-based cross-sectional study conducted in Extremadura (Spain) in 2007-2009. Participants were ≥50years old and free of cardiovascular disease. ABI and cardiovascular risk factors were measured.

RESULT

In total, 1288 individuals (53% women), with a mean age of 63years (standard deviation (SD) 9) were included. The prevalence of ABI <0.9 was 4.9%. REASON risk score identified 53% of the sample to screen with sensitivity of 87.3%, quite similar to that identified in ISC and ACC/AHA strategies (both 90.5%), and specificity of 48.3%, higher than that of the ISC (30.9%) and ACC/AHA (31.1%) strategies. Although the Youden index was 0.4 for both REASON and PREVALENT risk scores, the latter's sensitivity was 60.3%, almost 30 points less than all other strategies.

CONCLUSION

REASON risk score was the strategy with the highest clinical performance and efficiency, with sensitivity of 87.3% and specificity higher than that of the ISC and ACC/AHA strategies. Although very specific, the PREVALENT strategy had low sensitivity making it difficult to be implemented as a screening tool.

Prevalence of low ankle brachial index and relationship with cardiovascular risk factors in a Western urban population in Turkey

We determined the prevalence of peripheral arterial disease (PAD) and associated risk factors in an urban population age ≥30 years in Turkey and assessed the impact of incorporating ankle brachial index (ABI) measurement with coronary heart disease risk calculations to the risk reclassification of individuals. The sample was drawn from 4600 participants of Balcova Heart Study. The prevalence of low ABI (<0.9) was 6.3%. Current smoking (odds ratio [OR]: 5.07, 95% confidence interval [CI]: 1.85-13.88), cardiovascular disease history (OR: 6.83, 95% CI: 3.00-15.53), hypertension (OR: 2.58, 95% CI: 1.06-6.33), diabetes (OR: 3.25, 95% CI: 1.51-6.98), and high waist circumference (OR: 2.24, 95% CI: 1.02-4.94) were positively associated with prevalent PAD. When ABI measurement was taken into account, 3.5% of low or intermediate risk patients were reclassified as high risk. Screening individuals who have one of these risk factors with ABI can help reclassifying individuals toward the high-risk category.

[Criteria for referral between levels of care of patients with peripheral vascular disease. SEMFYC-SEACV consensus document]

Coordination between care levels is essential to increase the efficiency of the Health System; vascular disease has an important role in this respects, as it includes frequent, serious and vulnerable conditions. Consensus documents are an essential tool to obtain these aims. This document is not expected to replace the Clinical Guidelines, but tries to establish the basis of the shared management of the patient with vascular disease (peripheral arterial disease, diabetic foot, and chronic venous insufficiency) in three ways: to determine the profile of the patient who should receive priority follow-up at every level; to establish the skills that every professional must have, and to set and to prioritise the referral criteria in both directions.

Prevalence and clinical characteristics of peripheral arterial disease in the study population Hermex

INTRODUCTION AND OBJECTIVES

To estimate the prevalence of peripheral arterial disease as measured on ankle-brachial index and evaluate the associated risk, clinical, and diagnostic factors.

METHODS

Cross-sectional study conducted in a random population-based sample of 2833 individuals aged 25 to 79 years from Don Benito health area (Badajoz). Peripheral arterial disease was considered for ankle-brachial index<0.90. To identify symptomatic disease we used the Edinburgh questionnaire. The current screening recommendations, changes to other categories of estimated coronary risk associated with index measurements, and the association with risk factors were assessed.

RESULTS

The prevalence of peripheral arterial disease was 3.7% (95% confidence interval, 3.0%-4.5%), 5.0% (3.9%-6.3%) in men and 2.6% (1.8%-3.5%) in women (P=.001). The cumulative prevalence in those aged 50, 60 and 70 years were 6.2%, 9.1%, and 13.1% respectively. The disease was symptomatic in 13.3% (6.8%-19.8%) of cases and 29.6% of asymptomatic patients were not detected as recommended for high-risk groups. The use of ankle-brachial index increased the number of individuals with high coronary risk by 32.7%. Peripheral arterial disease was positively associated with age, smoking, hypercholesterolemia, sedentary lifestyle, microalbuminuria and history of cardiovascular disease, and negatively with alcohol consumption.

CONCLUSIONS

The use of ankle-brachial index for peripheral arterial disease diagnosis is advisable because of the low prevalence of symptomatic cases and the associated change in estimated coronary risk. Screening groups should be adapted to the Spanish population. Smoking and hypercholesterolemia are major associated risk factors.

[Update on ischemic heart disease]

This article contains a review of the main developments reported in 2011 on the pathophysiology, prevention, prognosis and treatment of chronic coronary artery disease and acute coronary syndrome, with or without ST-segment elevation. It also discusses the recommendations of the latest clinical practice guidelines.

Screening for coronary artery disease in patients with type 2 diabetes mellitus: An evidence-based review

Coronary artery disease (CAD) is the leading cause of morbidity and mortality in patients with diabetes. CAD is often asymptomatic in these patients, until the onset of myocardial infarction or sudden cardiac death. Consequently, proper screening and diagnosis of CAD is crucial for the prevention and early treatment of coronary events. This review deals with selection of the sub group of patients who have type 2 diabetes, who are at high risk for developing CAD and need to be screened for the same. The various diagnostic modalities which can be used in the screening process for enhancing risk stratification and management are also discussed.