Atrial fibrillation does not affect ankle-brachial index measured using the Doppler method

Low Ankle-Brachial Index Is Associated With Stroke Recurrence in Ischemic Stroke Patients With Atrial Fibrillation

Introduction: Cardioembolic stroke (CE) has poor outcomes and high recurrence rates. A low ankle-brachial index (ABI <0.9) is associated with atrial fibrillation (AF) and poor stroke outcomes. We investigated whether a low ABI is associated with stroke recurrence, major adverse cardiovascular events (MACE), and mortality in patients with CE and whether this association is affected by AF.

Methods: We enrolled patients with CE who underwent ABI measurements during hospitalization. Recurrent stroke was defined based on newly developed neurologic symptoms with relevant lesions 7 days after the index stroke. MACE comprised stroke recurrence, myocardial infarction, or death.

Results: Of 775 patients, 427 (55.1%) were AF patients and 348 (44.9%) were non-AF patients. Patients were followed up for a median of 33.6 (IQR, 18.0–51.6) months. In total, 194 (25.0%) patients experienced MACE, including 77 (9.9%) patients with stroke recurrence and 101 (13.0%) patients with mortality, during the study period. Multivariable Cox regression analysis showed that an ABI <0.9 was independently associated with MACE (AF patients: hazard ratio [HR] = 2.327, 95% confidence interval [CI] = 1.371–3.949, non-AF patients: HR = 3.116, 95% CI = 1.465–6.629) and mortality (AF patients: HR = 2.659, 95% CI = 1.483–4.767, non-AF patients: HR = 3.645, 95% CI = 1.623–8.187). Stroke recurrence was independently associated with an ABI <0.9 in AF patients (HR = 3.559, 95% CI = 1.570–8.066), but not in non-AF patients (HR = 1.186, 95% CI = 0.156–8.989).

Conclusions: We found that a low ABI is associated with stroke recurrence, MACE, and mortality in patients with CE. In particular, the association between ABI and recurrent stroke is only present in AF patients. A low ABI may be a useful prognostic marker in patients with CE, especially in AF patients.

Peripheral artery disease and clinical outcomes in patients with atrial fibrillation: A systematic review and meta-analysis

Background

Atrial fibrillation (AF) is the most common cardiac rhythm disturbance and leads to morbidity and mortality. Peripheral artery disease (PAD) is associated with atherosclerotic risk factors and always classified as a vascular disease and deemed to be a bad complication of AF. In patients with AF, the risk and prognostic value of PAD have not been estimated comprehensively.

Hypothesis

PAD is associated with all‐cause mortality, cardiovascular (CV) mortality, and other outcomes in patients with AF.

Methods

We searched PubMed, Embase, and Cochrane Library databases for prospective studies published before April 2021 that provided outcomes data on PAD in confirmed patients with AF. Heterogeneity was estimated using the I² statistic. The fixed‐effects model was used for low to moderate heterogeneity studies, and the random‐effects model was used for high heterogeneity studies.

Results

Eight prospective studies (Newcastle‐Ottawa score range, 7–8) with 39 654 patients were enrolled. We found a significant association between PAD and all‐cause mortality (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.25–1.62; p < .001), CV mortality (HR, 1.64; 95% CI, 1.32–2.05; p < .001) and MACE (HR, 1.75; 95% CI, 1.38–2.22; p < .001) in patients with AF. No significant relationship was found in major bleeding (HR, 1.22; 95% CI, 0.95–1.57; p = 0.118), myocardial infarction (MI) (HR, 2.07; 95% CI, 1.17–3.67; p = .038), and stroke (HR, 1.14; 95% CI, 0.87–1.50, p = 0.351).

Conclusions

PAD is associated with an increased risk of all‐cause mortality, CV mortality, and MACE in patients with AF. However, no significant association was found with major bleeding, MI, and stroke.

The Impact of Hypertension and Atrial Fibrillation on Cognitive Decline and Subclinical Atherosclerosis

BACKGROUND

Assessment of cognitive impairment and the presence of subclinical atherosclerosis are very important especially in patients with cardiovascular risk factors.

METHODS

We included 155 hypertensive patients (84 with AF versus 71 without AF) to identify the premature cognitive impairment, the earliest signs of subclinical atherosclerosis and onset of myocardial dysfunction and to evaluate the type of anticoagulation used, the importance of CHA₂DS₂-VASc score (3), age (65 years) in hypertensive patients with AF.

RESULTS

Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment Scale (MoCA), Left Ventricular Ejection Fraction (LVEF) were significantly decreased, and Activities of Daily Living Score (ADL), Geriatric Depression Scale(GDS-15), and intima-media thickness (IMT) were significantly increased in hypertensive patients with AF vs. without AF (p < 0.05). MMSE was significantly decreased, ADL and IMT were significant increased in patients with AF and CHA₂DS₂-VASc>3 and non-vitamin K antagonists oral anticoagulants therapy (NOACs)(p < 0.05). Patients with age >65 with AF had higher rates of cognitive impairment (MMSE significant decrease) and a larger IMT (significant increase) versus patients with AF and age <65 (p < 0.05).

CONCLUSIONS

Cognitive impairment is encountered in hypertensive patients having AF. Our conclusions suggest a direct link between cognitive impairment, depression, hypertension, AF, age, CHA₂DS₂-VASc score, type of anticoagulants used, LVEF, cognitive parameters, and IMT. We acknowledge the importance of identifying and preventing cognitive changes.

Atrial fibrillation influences automatic oscillometric ankle-brachial index measurement

INTRODUCTION

Repeated measurements of ankle-brachial index (ABI) using Doppler method were shown to be accurate during atrial fibrillation. Oscillometric devices are effective in ABI measurement, but their accuracy during atrial fibrillation is unknown. The purpose of the study was to investigate whether atrial fibrillation influences ABI obtained with the automatic oscillometric method.

MATERIAL AND METHODS

Ninety-nine patients with atrial fibrillation (mean age: 66.6 +(SD = 11) years, M/F - 63/36) who underwent electrical cardioversion were investigated (198 lower extremities). The ABI measurements using oscillometric and Doppler methods were performed on both lower extremities before and after procedure.

RESULTS

The ABI measured using the oscillometric method on both lower limbs did not change after cardioversion (1.21 (IQR: 1.13-1.27) vs. 1.22 (IQR: 1.14-1.26), p = 0.664, respectively). The ABI measured before and after cardioversion using Doppler and oscillometric methods showed a significant difference (1.14 (IQR: 1.07-1.22) vs. 1.21 (IQR: 1.13-1.27), p < 0.001 and 1.18 (IQR: 1.09-1.13) vs. 1.22 (IQR: 1.14-1.26), p < 0.001 respectively). Both methods showed a weak correlation before (r = 0.35, p < 0.001) and no correlation after cardioversion (r = 0.12, p = 0.07). The Bland-Altman plot showed poor agreement between measurements performed with the Doppler and oscillometric methods in sinus rhythm and during atrial fibrillation.

CONCLUSIONS

The automated oscillometric method of ABI measurements should not replace the reference Doppler method in patients with atrial fibrillation. More research related to the oscillometric measurements is needed in subjects with peripheral artery disease and atrial fibrillation.

Ankle Brachial Index Predicts for Difficulties in Performing Microvascular Anastomosis

PURPOSE

In reconstructive microsurgery, severe arteriosclerosis is a known predictor for free flap failure because of problems with the vascular anastomosis. We investigated whether the ankle brachial index (ABI) could be a suitable preoperative measurement for the prediction of compromise regarding vascular anastomosis in patients undergoing microsurgical reconstruction.

MATERIAL AND METHODS

We conducted a prospective cohort study of patients who had undergone reconstructive microvascular surgery in a tertiary care center from 2015 to 2017. The ABI was preoperatively assessed by dividing the systolic blood pressure measured at the ankle by the brachial systolic blood pressure. Results from 0.9 to 1.3 are within the physiologic range. Values less than 0.9 indicate moderate to severe arteriosclerosis, and those greater than 1.3 indicate the major form of arteriosclerosis with complete calcification of the tunica media. The ABI value correlated with the ease of the anastomosis (rated from 1 [very straightforward] through 5 [very difficult]), gross examination findings (intraluminal plaque [yes vs no]), and the necessity of plaque removal before anastomosis (yes vs no). In addition, cross-sectional specimens were obtained from the arteries and veins of the donor and recipient sites intraoperatively. The specimens were rated histologically for the arteries and veins using an ordinal scale. Histologic evaluation was performed to confirm and objectify the results from the ABI. Statistical analysis was performed using SPSS software, version 24.0 (IBM Corp, Armonk, NY) and t tests, analysis of variance, and χ² tests.

RESULTS

The sample included 41 patients with a mean age of 56.7 years; 59% were men. The mean ABI was 1.06. The mean ease of anastomosis was 1.8. The mean ABI was associated with the ease of anastomosis. A pathologic ABI was significantly related to problems with the arterial anastomosis (P = .004) and increased arteriosclerosis in the arteries from the donor (P = .047) and recipient (P = .036) sites.

CONCLUSIONS

A pathologic ABI was associated with increased difficulty with the microvascular anastomosis.

The impact of atrial fibrillation on accuracy of oscillometric blood pressure measurement: effect of ventricular rate

This study evaluated the impact of ventricular rate (VR) in atrial fibrillation (AF) patients with oscillometric BP measurements. This study included 138 patients with AF and 112 patients with sinus rhythm (SR) who underwent coronary angiography. Left arm BP was measured three times with an oscillometric device, and the average was recorded as the final oscillometric value. At the same time, the average of three intra-aortic BP readings was used as invasive values. Delta BP was the difference between intra-aortic and oscillometric BP. Meanwhile, the BP percentage difference (PD-BP) was calculated with the following formula: PD-BP = (delta BP/intra-aortic BP) × 100%. Based on the VR, four subgroups of AF and SR patients, <80, 80-99, 100-120, and >120 bpm, were created, and the mean PD-BP for both systolic blood pressure (SBP) and diastolic blood pressure (DBP) was significantly higher in the AF group than in the SR group. Moreover, the mean PD-SBP values gradually increased as VR increased in both groups. More importantly, the difference in PD-SBP between the AF and SR groups increased as VR increased: when VR was <80 bpm, the levels were similar (-2.0 ± 3.5 vs. -1.4 ± 2.7 mm Hg, NS), but these values in AF patients were significantly higher when VR was 80-99 bpm (-3.7 ± 5.0 vs. -1.8 ± 2.3 mm Hg, p < 0.05), 100-120 bpm (-6.1 ± 4.3 vs. -2.3 ± 1.9 mm Hg, p < 0.05) and >120 bpm (-7.8 ± 4.9 vs. -2.9 ± 1.7 mm Hg, p < 0.05). The accuracy of oscillometric BP measurements are dependent on the ventricular rate in AF patients even after three measurements, and a higher ventricular rate may result in larger underestimations of oscillometric BP.

The association of endothelin-1 gene polymorphism and its plasma levels with hypertension and coronary atherosclerosis

INTRODUCTION

Endothelin-1 (ET-1) is the most potent among all vasoconstrictors, and its association with cardiovascular diseases has been reported before. Our aim was to investigate the association of ET-1 plasma level and its gene polymorphisms (rs5370 and rs10478694) with hypertension and coronary atherosclerosis (CA).

MATERIAL AND METHODS

This study was carried out on 128 women and 132 men, who were divided into 4 groups: hypertensive without atherosclerosis (H+A-); hypertensive with atherosclerosis (H+A+); non-hypertensive with atherosclerosis (H-A+); and non-hypertensive without atherosclerosis (control group). Endothelin-1 plasma levels were measured by ELISA, and gene polymorphisms were detected by polymerase chain reaction - restriction fragment length polymorphism (PCR-RFLP) methods. Coronary artery diseases (CAD) were then defined based on angiography data.

RESULTS

The ET-1 plasma level was significantly higher in the H+A+ group in comparison with the other groups, especially H+A-. Comparing people with CA and those without it, the highest frequency level of the T allele of rs5370 was found in people with CA. Significantly higher frequencies of the 3A allele were detected in hypertensive patients in comparison with non-hypertensive individuals, when analyzing rs10478694.

CONCLUSIONS

Endothelin-1 plasma level shows a direct association with the risk of CA development. The T allele of rs5370 can be regarded as a risk factor for CA development. The 3A allele of rs10478694 can be associated with the risk of hypertension; therefore, it can be concluded that ET-1 and its gene polymorphisms play an important role in CA development and hypertension observed in the south-eastern populations of Iran.