Pulse pressure and subclinical peripheral artery disease

Association Between Genetic Variation in Blood Pressure and Increased Lifetime Risk of Peripheral Artery Disease

[Figure: see text].

Prevalence of peripheral artery disease (PAD) and factors associated: An epidemiological analysis from the population-based Screening PRE-diabetes and type 2 DIAbetes (SPREDIA-2) study

AIM

To describe the prevalence of Peripheral Artery Disease (PAD) in a random population sample and to evaluate its relationship with Mediterranean diet and with other potential cardiovascular risk factors such as serum uric acid and pulse pressure in individuals ranged 45 to 74 years.

METHODS

Cross-sectional analysis of 1568 subjects (mean age 6.5 years, 43% males), randomly selected from the population. A fasting blood sample was obtained to determine glucose, lipids, and HbA1C levels. An oral glucose tolerance test was performed in non-diabetic subjects. PAD was evaluated by ankle-brachial index and/or having a prior diagnosis.

RESULTS

PAD prevalence was 3.81% (95% CI, 2.97-4.87) for all participants. In men, PAD prevalence was significantly higher than in women [5.17% (95% CI, 3.74-7.11) vs. 2.78% (95% CI, 1.89-4.07); p = 0.014]. Serum uric acid in the upper quartile was associated with the highest odds ratio (OR) of PAD (for uric acid > 6.1 mg/dl, OR = 4.31; 95% CI, 1.49-12.44). The remaining variables more strongly associated with PAD were: Heart rate >90 bpm (OR = 4.16; 95%CI, 1.62-10.65), pulse pressure in the upper quartile (≥ 54 mmHg) (OR = 3.82; 95%CI, 1.50-9.71), adherence to Mediterranean diet (OR = 2.73; 95% CI, 1.48-5.04), and former smoker status (OR = 2.04; 95%CI, 1.00-4.16).

CONCLUSIONS

Our results show the existence of a low prevalence of peripheral artery disease in a population aged 45-74 years. Serum uric acid, pulse pressure and heart rate >90 bpm were strongly associated with peripheral artery disease. The direct association between Mediterranean diet and peripheral artery disease that we have found should be evaluated through a follow-up study under clinical practice conditions.

Twenty-Year Predictors of Peripheral Arterial Disease Compared With Coronary Heart Disease in the Scottish Heart Health Extended Cohort (SHHEC)

BACKGROUND

Coronary heart disease and peripheral arterial disease (PAD) affect different vascular territories. Supplementing baseline findings with assays from stored serum, we compared their 20-year predictors.

METHODS AND RESULTS

We randomly recruited 15 737 disease-free men and women aged 30 to 75 years across Scotland between 1984 and 1995 and followed them through 2009 for death and hospital diagnoses. Of these, 3098 developed coronary heart disease (19.7%), and 499 PAD (3.2%). Hazard ratios for 45 variables in the Cox model were adjusted for age and sex and for factors in the 2007 ASSIGN cardiovascular risk score. Forty-four of them were entered into parsimonious predictive models, tested by c-statistics and net reclassification improvements. Many hazard ratios diminished with adjustment and parsimonious modeling, leaving significant survivors. The hazard ratios were mostly higher in PAD. New parsimonious models increased the c-statistic and net reclassification improvements over ASSIGN variables alone but varied in their components and ranking. Coronary heart disease and PAD shared 7 of the 9 factors from ASSIGN: age, sex, family history, socioeconomic status, diabetes mellitus, tobacco smoking, and systolic blood pressure (but neither total nor high-density lipoprotein cholesterol); plus 4 new ones: NT-pro-BNP, cotinine, high-sensitivity C-reactive protein, and cystatin-C. The highest ranked hazard ratios for continuous factors in coronary heart disease were those for age, total cholesterol, high-sensitivity troponin, NT-pro-BNP, cotinine, apolipoprotein A, and waist circumference (plus 10 more); in PAD they were age, high-sensitivity C-reactive protein, systolic blood pressure, expired carbon monoxide, cotinine, socioeconomic status, and lipoprotein (a) (plus 5 more).

CONCLUSIONS

The mixture of shared with disparate determinants for arterial disease in the heart and the legs implies nonidentical pathogenesis: cholesterol dominant in the former, and inflammation (high-sensitivity C-reactive protein, diabetes mellitus, smoking) in the latter.

Incidence of Peripheral Arterial Disease and Its Association with Pulse Pressure: A Prospective Cohort Study

BACKGROUND

The association of pulse pressure and peripheral arterial disease (PAD) has seldom been examined using a prospective design. This study aimed to investigate the association of pulse pressure with PAD incidence in an elderly general population.

METHODS

We utilized data from a cohort conducted in Beijing with additionally 2-year follow-up time. PAD was defined as an ankle brachial index value <0.9 in either leg. Cox proportional hazard regression model was used to quantify the magnitude of pulse pressure on PAD incidence.

RESULTS

During a 2-year follow-up time, 357 of 4,201 (8.5%) participants developed PAD with 105 (6.9%) men and 252 (9.4%) women, respectively. After adjusting for baseline age, sex, body mass index, hypertension, diabetes, total cholesterol, and high-density lipoprotein cholesterol, and smoking, the hazard ratio and 95% confidence interval for people with pulse pressure greater than 60 mmHg was 2.20 (1.53, 3.15) compared with those whose pulse pressure was less than 40 mmHg. A linear trend was observed for the association of pulse pressure with PAD.

CONCLUSION

Higher pulse pressure was associated with higher PAD incidence.

Pulse Pressure and Upstroke Time Are Useful Parameters for the Diagnosis of Peripheral Artery Disease in Patients With Normal Ankle Brachial Index

Background

Some peripheral artery disease (PAD) patients have normal ankle brachial index (ABI) (0.9 - 1.4), although ABI is a useful parameter for the diagnosis of PAD. We investigated whether other parameters of ABI report sheet are useful to detect these patients.

Methods

We initially enrolled 3,912 patients (7,824 limbs) who underwent ABI for the first time. Subjects who have normal ABI were divided into the PAD group (n = 136) and the non-PAD group (n = 240) by lower extremity ultrasonography. We investigated blood pressures (BP) (systolic (SBP), diastolic (DBP), mean (mBP) and pulse pressure (PP)), heart rate, upstroke time (UT), and %mean arterial pressure (%MAP).

Results

SBP, mBP, PP, UT, and %MAP in the PAD group were significantly higher. A multivariate analysis showed that mBP, DBP, PP, UT and %MAP were independently associated with the presence of PAD (mBP: odds ratio (OR) 2.30, 95% confidence interval (CI) 1.22 - 4.37, P = 0.010; DBP: OR 0.52, 95% CI 0.28 - 0.97, P = 0.039; PP: OR 1.30, 95% CI 0.69 - 2.46, P = 0.041; UT: OR 3.40, 95% CI 2.03 - 5.83, P < 0.001; %MAP: OR 1.77, 95% CI 1.05 - 2.98, P = 0.031). Maximal area under the curve (AUC) of BPs for associating PAD was PP. The cut-off value of PP was 53.0 mm Hg (sensitivity 0.500, specificity 0.721, AUC 0.628, 95% CI 0.569 - 0.687).

Conclusions

The present study demonstrated that BPs are associated with PAD in patients with normal ABI. The measurement of BPs could provide additional information for the diagnosis of PAD.

A Prediction Model for the Peripheral Arterial Disease Using NHANES Data

We aim to build models for peripheral arterial disease (PAD) risk prediction and seek to validate these models in 2 different surveys in the US general population. Model building survey was based on the National Health and Nutrition Examination Surveys (NHANES, 1999-2002). Potential predicting variables included race, gender, age, smoking status, total cholesterol (TC), body mass index, high-density lipoprotein (HDL), ratio of TC to HDL, diabetes status, HbA1c, hypertension status, and pulse pressure. The PAD was diagnosed as ankle brachial index <0.9. We used multiple logistic regression method for the prediction model construction. The final predictive variables were chosen based on the likelihood ratio test. Model internal validation was done by the bootstrap method. The NHANES 2003-2004 survey was used for model external validation. Age, race, sex, pulse pressure, the ratio of TC to HDL, and smoking status were selected in the final prediction model. The odds ratio (OR) and 95% confidence interval (CI) for age with 10 years increase was 2.00 (1.72, 2.33), whereas that of pulse pressure for 10 mm Hg increase was 1.19 (1.10, 1.28). The OR of PAD was 1.11 (95% CI: 1.02, 1.21) for 1 unit increase in the TC to HDL ratio and was 1.61 (95% CI: 1.40, 1.85) for people who were currently smoking compared with those who were not. The respective area under receiver operating characteristics (AUC) of the final model from the training survey and validation survey were 0.82 (0.82, 0.83) and 0.76 (0.72, 0.79) indicating good model calibrations. Our model, to some extent, has a moderate usefulness for PAD risk prediction in the general US population.

The Relationship Between High Pulse Pressure and Low Ankle-Brachial Index. Potential Utility in Screening for Peripheral Artery Disease in Population-Based Studies

INTRODUCTION

The ankle-brachial index (ABI) is a reliable screening procedure for peripheral artery disease detection. However, ABI testing is time-consuming and requires trained personnel, which may preclude its routine use in population-based surveys. Preliminary data suggest a relationship between ABI values and pulse pressure (PP) levels.

AIM

To assess whether PP calculation might help to detect persons who need ABI screening in population-based studies.

METHODS

All Atahualpa residents aged ≥60 years were identified during a door-to-door survey and invited to undergo ABI testing. Non-consented persons and those with ABI ≥1.4 were excluded. Using generalized linear and logistic regression models adjusted for demographics and cardiovascular risk factors, as well as receiver operator characteristics curve analysis, we evaluated the association between PP values and ABI, as well as the reliability of PP to identify candidates for ABI testing.

RESULTS

Out of 239 participants (mean age 70 ± 8 years, 62 % women), 46 (19 %) had an ABI ≤0.9 and 136 (57 %) had PP >65 mmHg, with a negative relationship between them (R = -0.386, p < 0.0001). A PP >65 mmHg was associated with an ABI ≤ 0.9 in the logistic regression model (OR 3.46, 95 % CI 1.07-11.2, p = 0.038). Continuous PP levels also correlated negatively with ABI (β -0.0014, 95 % CI -0.0024 to -0.0004, p = 0.005). The sensitivity of a PP >65 mmHg to predict a low ABI was 85 %, and the specificity was 50 %. In contrast, the sensitivity of blood pressure ≥140/90 mmHg was 27 % and the specificity was 10 %. The area under the curve for the predictive value of a PP >65 mmHg was 0.673 (95 % CI 0.609-0.736), and that of a blood pressure ≥140/90 mmHg was 0.371 (95 % CI 0.30-0.443), with a significant difference between them (p < 0.0001).

CONCLUSIONS

PP calculation may be a simple tool to detect candidates for ABI testing in population-based studies.

Prevalence, correlates, and prognosis of peripheral artery disease in rural ecuador-rationale, protocol, and phase I results of a population-based survey: an atahualpa project-ancillary study

Background. Little is known on the prevalence of peripheral artery disease (PAD) in developing countries. Study design. Population-based study in Atahualpa. In Phase I, the Edinburgh claudication questionnaire (ECQ) was used for detection of suspected symptomatic PAD; persons with a negative ECQ but a pulse pressure ≥65 mmHg were suspected of asymptomatic PAD. In Phase II, the ankle-brachial index will be used to test reliability of screening instruments and to determine PAD prevalence. In Phase III, participants will be followed up to estimate the relevance of PAD as a predictor of vascular outcomes. Results. During Phase I, 665 Atahualpa residents aged ≥40 years were enrolled (mean age: 59.5 ± 12.6 years, 58% women). A poor cardiovascular health status was noticed in 464 (70%) persons of which 27 (4%) had a stroke and 14 (2%) had ischemic heart disease. Forty-four subjects (7%) had suspected symptomatic PAD and 170 (26%) had suspected asymptomatic PAD. Individuals with suspected PAD were older, more often women, and had a worse cardiovascular profile than those with nonsuspected PAD. Conclusions. Prevalence of suspected PAD in this underserved population is high. Subsequent phases of this study will determine whether prompt detection of PAD is useful to reduce the incidence of catastrophic vascular diseases in the region.

Ankle-brachial blood pressure index predicts cardiovascular events and mortality in Japanese patients with chronic kidney disease not on dialysis

The ankle-brachial blood pressure index (ABPI) has been recognized to have a predictive value for cardiovascular (CV) events and mortality in general or dialysis populations. However, the associations between ABPI and those outcomes have not been fully investigated in predialysis patients. The present study aimed to clarify the relationships between ABPI and both CV events and mortality in Japanese chronic kidney disease (CKD) patients not on dialysis. In this prospective observational study, we enrolled 320 patients with CKD stages 3-5 who were not on dialysis. At baseline, ABPI was examined and a low ABPI was defined as <0.9. CV events and all-cause deaths were examined in each patient. A Cox proportional hazards model was applied to determine the risk factors for CV events, as well as for mortality from CV and all causes. The median follow-up period was 30 months. CV events occurred in 56 patients and all-cause deaths occurred in 48, including 20 CV deaths. Multivariate analysis showed that age and low ABPI were risk factors for CV events. It was demonstrated that age, a history of cerebrovascular disease and low ABPI were determined as independent risk factors for CV mortality. In addition, age, body mass index and low ABPI were independently associated with all-cause mortality. In patients with CKD, low ABPI during the predialysis period is independently associated with poor survival and CV events, suggesting the usefulness of measuring ABPI for predicting CV events and patient survival in CKD.