[Ankle brachial index and cardiovascular risk]

The ARTICO study: identification of patients at high risk of vascular recurrence after a first non-cardioembolic stroke

BACKGROUND

About 20% of patients with a first ischaemic stroke will experience a new vascular event within the first year. The atherosclerotic burden, an indicator of the extension of atherosclerosis in a patient, has been associated with the risk of new cardiovascular events in the general population. However, no predictive models reliably identify groups at a high risk of recurrence. The ARTICO study prospectively analysed the predictive value for the risk of recurrence of specific atherosclerotic markers.

METHODS

The multicentre ARTICO study included 620 consecutive independent patients older than 60 years suffering from a first non-cardioembolic stroke. We analysed classical stroke risk factors; duplex study of supraaortic trunk including intima-media thickness (IMT) measurement; quantification of internal carotid (ICA) stenosis; number, morphology and surface characteristics of carotid plaques; ankle brachial index (ABI); and the presence of microalbuminuria. Patients were followed up at 6 and 12 months after inclusion. The primary end-point was death or major cardiovascular events.

RESULTS

Any vascular event or death at 12 months occurred in 78 (13.8%) patients. In 40 (7.1%) of these the vascular event was a stroke recurrence. Weight, history of diabetes mellitus, history of symptomatic PAD, ABI <0.9 and significant ICA stenosis (>50%) were associated with a higher risk of vascular events on follow-up in the bivariate analysis. In the final Cox regression analysis, body mass index (BMI), systolic blood pressure, history of diabetes mellitus, symptomatic PAD (HR, 2.76; 95% CI, 1.10-6.95; p=0.03), and particularly patients with both ICA stenosis >50% and PAD (HR 4.52; 95% CI, 2.14-9.53; p<0.001) were independently associated with an increased risk of vascular events. Neither isolated ICA stenosis >50% nor isolated abnormal ABI remained associated with an increased risk of recurrence in comparison with the whole population.

CONCLUSIONS

Symptomatic PAD identifies a high risk group of vascular recurrence after a first non-cardioembolic stroke. The associated increased risk was particularly high in patients with both ICA stenosis and either symptomatic or asymptomatic PAD. Neither asymptomatic PAD alone nor isolated ICA stenosis >50% were associated with an increased risk of recurrence in this particularly high-risk group of non-cardioembolic stroke.

[Peripheral arterial disease and cardiovascular risk factors among patients infected with human immunodeficiency virus: a comparison between hospital out-patients and patients in a prison]

INTRODUCTION

Cardiovascular disease among human immunodeficiency virus (HIV) infected patients is more frequent than in the general population. Peripheral arterial disease measured by ankle-brachial index (ABI) and cardiovascular risk factors (CVRF) is not well known in all groups of HIV-infected patients.

METHODS

Transversal study of HIV-infected patients >45 years, seen as outpatients in hospital (HO) in 2008 and patients institutionalized in a prison in 2009. Cardiovascular risk factors, information on the HIV infection and healthy lifestyles were evaluated. ABI was measured at rest and was considered pathological when a value ≤ 0.9 or ≥ 1.3 was obtained.

RESULTS

We included 71 patients (mean age of 50.6 ± 6.9 years, 86% male), 32 HO and 39 in prison. The most prevalent CVRF was smoking (80.2%) followed by an altered lipid profile (63.3%). The evolution time of HIV infection was 13.1 ± 7.1 years. 74.6% of patients didn't follow a heart-healthy diet and 25% were sedentary. The ABI was low in 7 cases (9.8%) and ≥ 1.3 in one. Patients in prison were younger, the rate of smokers and of individuals with low HDL were higher, the time of evolution of the HIV infections was longer and they were less adherent to a heart-healthy diet than in HO, reaching in all cases statistical significance (P<.05).

CONCLUSIONS

In our study there is a high prevalence of altered ABI. The most common CVRF is smoking, followed by the alteration of lipids. Patients in prison are more likely to be smokers, to have low HDL and they are less adherence to a heart-healthy diet.

An analysis of the relationship between ankle-brachial index and estimated glomerular filtration rate in type 2 diabetes

We investigated the relationship between peripheral arterial disease (PAD) and renal function in patients with type 2 diabetes mellitus (T2DM). We enrolled 2057 hospitalized patients with T2DM and measured kidney function and ankle-brachial index (ABI). The estimated glomerular filtration rate (eGFR) was derived using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and ABI was grouped as low (<0.9), low-normal (0.9-1.09), normal (1.1-1.3), and high (>1.3). Logistic regression was used to evaluate the associations of eGFR with ABI. Generally speaking, the ABI was negatively correlated with systolic blood pressure, fasting C-peptide, total cholesterol, and low-density lipoprotein cholesterol while positively correlated with body mass index (P < .05 to <.01). Only a low ABI was positively correlated with eGFR (P < .01). In addition to the association of the ABI with cardiovascular events, stroke, and PAD, ABI may also predict the change in renal function in patients with T2DM.

Additive value of diabetes and peripheral arterial disease in the risk stratification of patients admitted after an acute coronary syndrome: a subanalysis of the PAMISCA Study

BACKGROUND

There is an increasing interest in the use of non-invasive methods for the detection of subclinical atherosclerosis to better identify patients with high risk of cardiovascular events The presence of diabetes mellitus (DM) and peripheral arterial disease (PAD) is associated with increased risk of events but their value in the acute coronary syndrome (ACS) patient has not been ascertained.

METHODS

We performed a subanalysis of the PAMISCA study, designed to investigate the prevalence of PAD in patients admitted to Spanish hospitals with a diagnosis of an ACS.

RESULTS

A total of 1410 patients were analysed (71.4% men, age 66 +/- 11.9 years, 35% DM). The prevalence of PAD was higher in DM vs. no-DM (41.5% vs. 30.6% respectively, p < 0.001). Patients with PAD and DM had more in-hospital cardiac complications such as atrial fibrillation/flutter, recurrent myocardial ischaemia and heart failure and a trend towards higher in-hospital mortality (p = 0.08). Non-DM patients with PAD and DM without PAD shared similar cardiac complications and the group without neither PAD nor DM had the best prognosis. In patients without PAD, DM was an independent predictor of three-vessel coronary disease (OR 1.6; 95% CI: 1.1-2.5, p < 0.05) after adjustment by age, sex, low density lipoproteins (LDL), smoking and the previous myocardial infarction. However, in PAD patients, DM failed to be an independent risk factor in the multivariate analysis (OR 1.0; 95% CI 0.6-1.6, p < 0.05).

CONCLUSIONS

The concurrence of DM and PAD helps identify patients with an adverse risk profile.

Peripheral arterial disease in HIV patients older than 50 years of age

Our objective was to analyze the prevalence of peripheral arterial disease (PAD) in HIV patients at risk and to compare them with the general population. All HIV patients older than 50 years who attended our unit from October 2005-July 2006 and all persons attending for an annual medical checkup at an employees' insurance association during the same period were invited to participate in the study. Of the latter (n = 407), a person of the same sex and age (+/-5 years) was included for each HIV patient. PAD was assessed by the ankle-brachial index (ABI) in all subjects, and all completed the Edinburgh questionnaire. Ninety-nine HIV patients and 99 persons from the general population of the same age and sex were included in the study. The HIV patients had a greater prevalence of dyslipidemia, diabetes, and PAD, which was symptomatic in five of them and in one subject from the general population. Patients with HIV infection older than 50 had a high prevalence of PAD, and as it was asymptomatic in half the cases, an ABI may be performed in this population to actively look for PAD. Control of cardiovascular risk factors and the use of such drugs as platelet antiaggregation agents should therefore be optimized in this population.

[Ankle-brachial index in patients with diabetes mellitus: prevalence and risk factors]

INTRODUCTION

Diabetic patients have a high cardiovascular morbidity and mortality rate. Ankle brachial index (ABI) is an available, straightforward and reproducible method for the detection of peripheral vascular disease and for improving risk stratification in this population. The objective of our study was to evaluate the prevalence of a low and a pathological ABI in type 2 diabetics older than 60 years and to study the risk factors associated with its development.

PATIENTS AND METHODS

1,360 subjects between 60 and 79 years, 213 of them diabetics, without symptoms of intermittent claudication and who gave their consent to have an ABI measurement in their primary care center were included in the study. Cardiovascular risk factors were evaluated in all participants. An ABI < 0.9 was considered low and a value < 0.9, >or= 1.4 or non-compressible was considered pathological.

RESULTS

Prevalence of a low ABI in subjects with or without diabetes was 11.3% and 4.3% and prevalence of a pathological ABI was 18.8% and 7%, respectively. Factor associated with a low or pathological ABI were gender, age, duration of diabetes, the type of antidiabetic treatment and the presence of vascular disease in another vascular bed. After multivariate adjustment, only age (OR: 1.15; 95% CI: 1.04-1.27) and duration of diabetes (OR: 1.05; 95% CI: 1.01-1.10) continue being significant. The prevalence of a pathological ABI did not differ between diabetics without vascular disease and non-diabetics with previous cardiovascular disease.

CONCLUSION

The prevalence of a low or pathological ABI is elevated in diabetic subjects and relates with age, duration of diabetes and the presence of vascular disease in another vascular bed.

Asymptomatic cerebrovascular disease and systemic diagnosis in stroke, atherothrombosis as a disease of the vascular tree

Atherosclerosis is a chronic vascular disease of true epidemic proportions. It is the first cause of death in developed countries and responsible for one quarter of documented deaths worldwide. Arteriosclerotic vascular disease is a systemic process which affects different organs; principally the heart, brain, and peripheral artery system. Despite well-documented differences, all manifestations of the disease share the same risk factors; albeit with varying degrees of impact. The concept of asymptomatic cerebrovascular disease is an important one for clinicians who treat stroke patients. The development of new neuroimaging and vascular evaluation techniques has enabled the presence of apparently silent lesions to be detected and their progress monitored in follow-up. Ultrasonography techniques enable the identification of atheromatous disease. Asymptomatic involvement of the cerebral parenchyma consists of ischemia, leukoaraiosis, and silent hemorrhage and can be detected using the available radiological techniques such as cranial CT, magnetic resonance, or gradient echo magnetic resonance imaging. From the point of view of prevention, it is of considerable importance to identify diagnostic markers for arteriosclerosis in asymptomatic patients in some, if not all, vascular territories. In view of the natural history of this disease and the impact it has on society, there is an increasing need to identify and understand the risk factors or vascular disease risk markers, so that the stratification of risk of an individual patient or in a specific population can be established, appropriate cerebrovascular assessments conducted, and appropriate therapeutic intervention initiated.