Functional status and mobility among elderly women with lower extremity arterial disease: the Study of Osteoporotic Fractures

Addressing Psychosocial Care Needs in Women with Peripheral Artery Disease

PURPOSE OF REVIEW

Peripheral artery disease (PAD) is a growing global epidemic. Women with PAD are at elevated risk of experiencing psychosocial stressors that influence the diagnosis, management, and course of their illness due to unique sex- and gender-based factors.

RECENT FINDINGS

We review existing evidence for increased psychosocial risk in women with PAD with a focus on mood disorders, chronic stress, pain experiences, substance use disorders, health behaviors and illness perceptions, and healthcare access. We discuss how these factors exacerbate PAD symptomatology and lead to adverse outcomes. Existing gaps in women's vascular care are reviewed and potential solutions to bridge these gaps through psychosocial care integration are proposed. Current care paradigms for women's vascular care do not adequately screen for and address psychosocial comorbidities. Clinician education, integration of evidence-based psychological care strategies, implementation of workflows for the management of individuals with PAD and mental health comorbidities, reform to reimbursement structures, and further advocacy are needed in this space. This review provides a construct for integrated behavioral health care for women with PAD and advocates for further integration of care.

Peripheral Arterial Diseases and Diabetes Mellitus: Associations With Quality of Health Measures in Patients Undergoing Percutaneous Vascular Interventions

BACKGROUND

Peripheral arterial disease (PAD) is more prevalent and severe in patients with diabetes mellitus (DM) compared with those without DM. Peripheral vascular intervention (PVI) is often used in patients failing conservative management. The association of PVI with health status in diabetic patients has yet to be determined.

METHODS

We analyzed the clinical response to PVI in DM (n = 203, 52 %) compared with non-DM patients (n = 183, 48 %), using the Peripheral Arterial Questionnaire (PAQ) for patients during baseline and a maximum 6 months after PVI. We used the PAQ summary score, which summarized the patients' level of physical and social function, patient symptoms, and overall quality of life. This represented the PAD-related Quality of Health (QOH). Our score range is between 0 (lowest health quality) and 100 (highest health quality).

RESULTS

Compared with non-DM patients, those with DM were more likely to have a history of prior PVI, an increased prevalence of PAD risk factors, and significantly lower QOH scores at baseline (32.7 ± 20 vs 37.5 ± 20.6, p = 0.02). After adjustment for baseline confounding, neither the baseline, the change, nor the final summary scores were significantly different between groups, suggesting similar symptomatic and functional improvement in non-DM and DM patients post-PVI.

CONCLUSIONS

Following PVI, PAD-specific health status showed a similar improvement in patients with and without DM, illustrating that use of this strategy among patients with multiple comorbidities or diffuse PAD as useful.

Spatial Reorganization of Liquid Crystalline Domains of Red Blood Cells in Type 2 Diabetic Patients with Peripheral Artery Disease

In this work, we will investigate if red blood cell (RBC) membrane fluidity, influenced by several hyperglycemia-induced pathways, could provide a complementary index of HbA1c to monitor the development of type 2 diabetes mellitus (T2DM)-related macroangiopathic complications such as Peripheral Artery Disease (PAD). The contextual liquid crystalline (LC) domain spatial organization in the membrane was analysed to investigate the phase dynamics of the transition. Twenty-seven patients with long-duration T2DM were recruited and classified in DM, including 12 non-PAD patients, and DM + PAD, including 15 patients in any stage of PAD. Mean values of RBC generalized polarization (GP), representative of membrane fluidity, together with spatial organization of LC domains were compared between the two groups; p-values < 0.05 were considered statistically significant. Although comparable for anthropometric characteristics, duration of diabetes, and HbA1c, RBC membranes of PAD patients were found to be significantly more fluid (GP: 0.501 ± 0.026) than non-PAD patients (GP: 0.519 ± 0.007). These alterations were shown to be triggered by changes in both LC microdomain composition and distribution. We found a decrease in Feret diameter from 0.245 ± 0.281 μm in DM to 0.183 ± 0.124 μm in DM + PAD, and an increase in circularity. Altered RBC membrane fluidity is correlated to a spatial reconfiguration of LC domains, which, by possibly altering metabolic function, are associated with the development of T2DM-related macroangiopathic complications.

Spatial uncertainty and environment-health association: An empirical study of osteoporosis among "old residents" in public housing estates across a hilly environment

BACKGROUND

Built environment can influence physical conditions of older adults (e.g. osteoporosis). However, traditional methods using 2-dimensional circular buffer as a spatial structure to measure neighbourhood effect may create bias in health estimation, especially for the hilly and compact environment across low-income neighbourhoods (e.g. public housing estates).

METHODS

We evaluated the environmental influences on self-reported osteoporosis among "old residents" (age≥65) in Hong Kong (n = 2077). Twelve public housing estates across hilly neighbourhoods in Hong Kong were selected as study sites. A cross-validated approach was developed to evaluate four spatial structures (2D circular, 2D service area, 3D circular, 3D service area). To determine problems of spatial uncertainty, we compared odds ratios (OR) and differences in effect sizes from models using different spatial structures. When all adjusted models achieve significant results based on 95% confidence intervals (CI) and with all positive/negative ORs, this study reported to have reached "a result with consistency". Results from the 3D service area were then used to explain the environment-health relationship.

RESULTS

Different spatial structures can yield different results. Particularly, circular buffers overestimated environmental effects on self-reported osteoporosis. Overestimated measures were related to walkability and accessibility but not greenery. Specifically, results from the 3D service area showed that more public space and health facilities within a walkable distance (500 m) from a location of subject's residence were negatively associated with self-reported osteoporosis (adjusted ORs: 0.44 [0.29, 0.66]; 0.94 [0.90, 0.99]). However, more major transport facilities at the immediate distance from residence (200 m) was positively associated with self-reported osteoporosis (adjusted OR: 1.11 [1.01, 1.23]).

CONCLUSIONS

Physical conditions (e.g. osteoporosis) of older adults living in a hilly neighbourhood could be driven by walking behaviours. It is necessary to include local terrain and road network to define a walkable neighbourhood for environment-health estimations to minimize spatial bias.

Connecting the past to the present: A historical review of exercise training for peripheral artery disease

Peripheral artery disease (PAD), a prevalent manifestation of atherosclerosis, is associated with increased cardiovascular morbidity and mortality as well as decreased functional ability. Exercise training for PAD is acknowledged to be a highly effective treatment, which improves walking ability and cardiovascular risk. The historical development of this treatment has not been the focus of a report. Therefore, we present a historical review of research on exercise training for PAD. Overall, this body of knowledge has provided strong evidence of the efficacy of supervised exercise training (SET) to improve walking ability for patients with claudication due to PAD. SET, using intermittent bouts of walking exercise to moderate claudication pain on a treadmill, is considered the most efficacious mode of exercise to improve walking ability in patients with claudication. This compelling evidence published over the past 60 years was evaluated by the Centers for Medicare & Medicaid Services in 2017, which culminated in a national coverage determination for SET to improve symptomatic PAD. Future directions include determining optimal delivery strategies for SET and further elucidation of the mechanisms of improvement in walking ability resulting from SET. In addition, alternative forms of exercise should be evaluated and effective home- and community-based exercise interventions should be assessed. There is an enormous need to increase the inclusion of women and racial and ethnic minority groups in studies. It is to be hoped that researchers will continue with new innovative research and persistence in the treatment of claudication due to PAD.

Sex Differences in Peripheral Artery Disease

Peripheral artery disease (PAD) is a prevalent condition that confers substantial morbidity and mortality and remains underdiagnosed as well as undertreated in the overall population. Although PAD prevalence is similar or higher in women compared with men, associations of traditional and nontraditional risk factors with PAD and clinical manifestations of PAD differ by sex and may contribute to delayed or lack of diagnosis in women. Such sex-based differences in the manifestation of PAD may arise from sexual dimorphism in the vascular substrate in health as well as sex variation in the responses to vascular stressors. Despite the availability of proven therapies for improving symptoms and reducing risk of ischemic cardiovascular and limb events among patients with diagnosed PAD, important sex differences in treatment and outcomes have been observed. We provide an overview of current knowledge regarding sex differences in the epidemiology, pathophysiology, clinical presentation, and management of PAD.

The current burden of diabetic foot disease

Neuropathy and ischaemia are two great pathologies of the diabetic foot which lead to the characteristic features of foot ulceration (neuropathic and ischaemic) and Charcot neuroarthropathy. These can be complicated by infection and eventually may result in amputation (minor or major) and increased mortality. All of these features contribute to considerable clinical and economic burden. Peripheral nerves in the lower limbs are susceptible to different types of damage in patients with diabetes leading to distinctive syndromes. These include symmetrical sensory neuropathy associated with autonomic neuropathy, which advances gradually, and acutely painful neuropathies and mononeuropathies which have a rather acute presentation but usually recover. Ischaemia in the form of peripheral arterial disease is an important contributor to the burden of the diabetic foot. The incidence of atherosclerotic disease is raised in patients with diabetes and its natural history is accelerated. Diabetes causes severe and diffuse disease below-the knee. The lifetime risk of developing a diabetic foot ulcer is between 19% and 34%. Recurrence is common after initial healing; approximately 40% of patients have a recurrence within 1 year after ulcer healing, almost 60% within 3 years, and 65% within 5 years. Charcot neuroarthropathy is characterised by bone and joint destruction on the background of a neuropathy. Its prevalence in diabetes varies from 0.1% to 8%. Infection develops in 50%-60% of ulcers and is the principal pathology that damages diabetic feet. Approximately 20% of moderate or severe diabetic foot infections result in lower extremity amputations. The incidence of osteomyelitis is about 20% of diabetic foot ulcers. Every 20 s a lower limb is amputated due to complications of diabetes. Of all the lower extremity amputations in persons with diabetes, 85% are preceded by a foot ulcer. The mortality at 5 years for an individual with a diabetic foot ulcer is 2.5 times as high as the risk for an individual with diabetes who does not have a foot ulcer. The economic burden exacted on health care systems is considerable and includes direct and indirect costs, with loss of personal earnings and burden to carers. The diabetic foot is a significant contributor to the global burden of disability and reduces the quality of life. It remains a considerable public health problem.

Diagnostic Accuracy of Color Doppler and Calcium Scoring versus Dual-Energy Computed Tomography Angiography in the Assessment of Peripheral Arterial Diseases of Lower Limb

Objectives

Peripheral arterial disease (PAD) leads to narrowing and hardening of arteries which leads to increased risk of lower extremity amputation. Hence, the accuracy of non-invasive diagnostic methods such as calcium scoring and color Doppler needs to be assessed in comparison to the gold standard dual-energy computed tomography (DECT) angiography. This study aims to evaluate the accuracy of color Doppler and calcium scoring when compared to DECT angiography in the assessment of PAD of the lower limb. It is a cross- sectional retrospective study.

Material and Methods

The study included 55 patients aged between 40 and 70 years. All the patients with symptoms suggestive of PAD underwent color Doppler study of lower limb arterial system. Afterward, the patient underwent CT angiography. The first plain images were taken for calcium scoring following which contrast was given and further images were taken.

Results

As compared to CT angiography assessment, Doppler assessment was 88.1% sensitive but only 69.2% specific with diagnostic accuracy of 83.6%. For angiographically detected atheromatous changes, color Doppler had sensitivity and specificity of 86.2% and 76.9%. The derived cutoff value >149.1 of calcium score in lower limb arteries was in 100% agreement with CT angiography detected PAD, whereas, for atheromatous changes, total calcium score at a cutoff value of >842.2 had sensitivity and specificity of 75.9% and 80.8%.

Conclusion

Calcium scoring as compared to color Doppler has a higher diagnostic efficacy for the detection of DECT angiography confirmed PAD, whereas calcium score lacks adequate sensitivity at projected cutoff in the evaluation of atheromatous changes.

Microvascular Disease Increases Amputation in Patients With Peripheral Artery Disease

It is estimated that >2 million patients are living with an amputation in the United States. Peripheral artery disease (PAD) and diabetes mellitus account for the majority of nontraumatic amputations. The standard measurement to diagnose PAD is the ankle-brachial index, which integrates all occlusive disease in the limb to create a summary value of limb artery occlusive disease. Despite its accuracy, ankle-brachial index fails to well predict limb outcomes. There is an emerging body of literature that implicates microvascular disease (MVD; ie, retinopathy, nephropathy, neuropathy) as a systemic phenomenon where diagnosis of MVD in one capillary bed implicates microvascular dysfunction systemically. MVD independently associates with lower limb outcomes, regardless of diabetic or PAD status. The presence of PAD and concomitant MVD phenotype reveal a synergistic, rather than simply additive, effect. The higher risk of amputation in patients with MVD, PAD, and concomitant MVD and PAD should prompt aggressive foot surveillance and diagnosis of both conditions to maintain ambulation and prevent amputation in older patients.

Atherogenic Index of Plasma: A Potential Biomarker for Clinical Diagnosis of Diabetic Foot Osteomyelitis

Background: Osteomyelitis of the diabetic foot is a costly health problem worldwide. Early and accurate diagnosis of the disease in patients with diabetic foot infections is needed urgently and will have an important role in diabetic foot management. Methods: This was a case-control study of subjects with diabetic foot ulcers admitted to Beijing Shijitan Hospital from September 2015 to April 2018. We compared differences in the atherogenic index of plasma (AIP) in patients with or without osteomyelitis. Results: The mean AIP of 165 patients with osteomyelitis was 0.23 ± 0.24, which was significantly higher than the mean AIP of patients without osteomyelitis. Higher AIP values were associated with a considerably higher risk of osteomyelitis with an odds ratio of 1.81 (95% confidence interval [CI] 0.71-4.61), 4.70 (1.88-11.75), 5.03 (2.06-12.25) and 1.74 (1.33-2.28). Moreover, at a cut-off of 0.184, the AIP value showed a sensitivity of 84.3% and a specificity of 83.1% in the discriminatory identification of diabetic foot osteomyelitis. Conclusions: Elevated AIP was significantly associated with diabetic foot osteomyelitis, supporting the use of this index as a biomarker for the diagnosis in clinical practice.

Ankle-brachial index and physical function in older individuals: The Atherosclerosis Risk in Communities (ARIC) study

BACKGROUND AND AIMS

Most prior studies investigating the association of lower extremity peripheral artery disease (PAD) with physical function were small or analyzed selected populations (e.g., patients at vascular clinics or persons with reduced function), leaving particular uncertainty regarding the association in the general community.

METHODS

Among 5262 ARIC participants (age 71-90 years during 2011-2013), we assessed the cross-sectional association of ankle-brachial index (ABI) with the Short Physical Performance Battery (SPPB) score (0-12), its individual components (chair stands, standing balance, and gait speed) (0-4 points each), and grip strength after accounting for potential confounders, including a history of coronary disease, stroke, or heart failure.

RESULTS

There were 411 participants (7.8%) with low ABI ≤0.90 and 469 (8.9%) participants with borderline low ABI 0.91-1.00. Both ABI ≤0.90 and 0.91-1.00 were independently associated with poor physical function (SPPB score ≤6) compared to ABI 1.11-1.20 (adjusted odds ratio 2.10 [95% CI 1.55-2.84] and 1.86 [1.38-2.51], respectively). The patterns were largely consistent across subgroups by clinical conditions (e.g., leg pain or other cardiovascular diseases), in every SPPB component, and for grip strength. ABI >1.3 (472 participants [9.0%]), indicative of non-compressible pedal arteries, was related to lower physical function as well but did not necessarily reach significance.

CONCLUSIONS

In community-dwelling older adults, low and borderline low ABI suggestive of PAD were independently associated with poorer systemic physical function compared to those with normal ABI. Clinical attention to PAD as a potential contributor to poor physical function is warranted in community-dwelling older adults.

Factors associated with lower extremity atherosclerotic disease in Chinese patients with type 2 diabetes mellitus: A case-control study

Early detection and treatment of lower extremity atherosclerotic disease (LEAD), and controlling its risk factors are critical in preventing amputation and death in diabetic patients. This study aimed to investigate the factors associated with LEAD in Chinese diabetic patients.In this case-control study, patients with type 2 diabetes mellitus (T2DM) (N = 1289) were divided into 2 groups according to the ultrasonic Doppler examination: with (LEAD+, n = 737) and without (LEAD-, n = 552) LEAD. In subgroup analysis, the LEAD+ group was divided based on the diameter of lower-extremity arteries: LEAD+A (1%-49% reduction) and LEAD+B (≥50% reduction). Clinical and demographic data of patients were analyzed.Compared with the LEAD- group, serum creatinine levels were significantly increased (P < 0.001), whereas glomerular filtration rate (GFR) was significantly decreased (P < 0.001) in the LEAD+ group. Multivariate analysis results showed that GFR (odds ratio [OR] 0.991, 95% confidence interval [CI] 0.986-0.997, P = 0.003), diabetes duration (OR 1.055, 95% CI 1.026-1.084, P < 0.001), age (OR 1.123, 95% CI 1.104-1.142, P < 0.001), and uric acid (OR 1.002, 95% CI 1.000-1.004, P = 0.031) were independently associated with LEAD in patients with T2DM. Furthermore, multivariate analysis showed that age (OR 1.078, 95% CI 1.048-1.109, P < 0.001) and GFR (OR 0.985, 95% CI 0.975-0.994, P = 0.002) were independently associated with the severity of arterial lesions in patients with T2DM and LEAD.The risk factors of LEAD in Chinese patients with T2DM include age, course of disease, uric acid, and GFR. Patients with T2DM, high uric acid levels, and declined GFR could be listed in the high-risk group for LEAD.

Mandate for Creation of a National Peripheral Arterial Disease Public Awareness Program: An Opportunity to Improve Cardiovascular Health

Background: There has been increasing recognition of the detrimental effect of peripheral arterial disease (PAD) on the health of Americans, and yet there is no common national program of public PAD education designed to diminish this effect.

Format: To heighten awareness of this problem, a 2-day PAD Public Education Strategy Meeting was recently attended by representatives of 17 professional societies and public health associations whose missions support the prevention, diagnosis, treatment, and rehabilitation of vascular diseases. This Public Education Strategy Meeting was intended to provide the rationale and structure to create a national PAD public awareness campaign to diminish the health effect of PAD and to improve cardiovascular outcomes in the United States. This document (1) provides the rationale for creation of a national PAD public education program; (2) reviews the development and success of national hypertension, hypercholesterolemia, and Women’s Heart Health public education programs as models of educational efficacy; (3) elucidates how the work of many vascular professionals has led to a national consensus for creation of a national PAD public educational program; (4) provides an overview of the National Heart, Lung, and Blood Institute PAD education meeting; and (5) outlines the “next steps” required to accomplish these goals.

Outcome: This meeting achieved consensus that we share responsibility for developing accurate, unified messages to promote PAD awareness and improved care. Participants agreed

Peripheral arterial disease symptom subtype and walking impairment

Walking impairment is common in patients with peripheral arterial disease (PAD). The purpose of this study was to compare specific leg symptoms and walking impairment in a racially diverse cohort of patients with PAD. Patients who were receiving care at the Michael E DeBakey Veterans Affairs Medical Center or in the Harris County Hospital District were screened for PAD, which was diagnosed in the office setting by blood pressure measurements that were used to calculate the ankle-brachial index (a level <0.90 was defined as disease). To define leg symptoms, we asked patients to complete the San Diego Claudication Questionnaire. Based on the questionnaire results, leg symptoms were categorized as: asymptomatic, atypical, and intermittent claudication. The patients also completed the Walking Impairment Questionnaire. Among 403 patients screened (136 Caucasians, 136 African Americans and 131 Latinos), 67 were found to have PAD (18 Caucasians, 31 African Americans and 18 Latinos). The mean age of the cohort was 63.8 years (standard deviation (SD) 7.3). Walking distance, speed and stair climbing scores were lower (p < 0.0001) for patients with PAD and leg pain on exertion or at rest when compared with patients with PAD without leg symptoms or with symptoms of intermittent claudication. For patients with PAD and leg pain on exertion and at rest, the walking distance score was 27.1 ± SD 37.7 compared with 41.0 ± 38.4 for those with asymptomatic disease who were inactive, and with 38.5 ± 42.7 for those with intermittent claudication ( p = 0.02).

In an ethnically diverse primary care clinic population, patients with PAD and leg pain on exertion and at rest had greater compromise in their walking ability when compared with patients with intermittent claudication. The reasons for the significant impairment in walking among patients with PAD and these atypical leg symptoms may stem from coexisting illnesses or other as yet undefined factors. Future research should focus on methods to improve daily walking in patients with PAD and atypical leg symptoms.

Cost-effectiveness of exercise training to improve claudication symptoms in patients with peripheral arterial disease

Exercise rehabilitation is a proven, yet poorly available, treatment for intermittent claudication, the primary symptom of peripheral arterial disease (PAD). Exercise rehabilitation is effective, non-invasive, and associated with minimal cardiovascular risk in appropriate patients. Percutaneous transluminal angioplasty (PTA), especially of the iliac segment, is an alternative effective treatment for claudication. There are, however, minimal data currently available to compare the cost-effectiveness of these two interventions. We compared the cost-effectiveness of 3- and 6-month exercise programs with that of iliac PTA without stenting, using the incremental cost-effectiveness ratio [ICER 1/4 (Cost2 Cost1)=(Effectiveness2 Effectiveness1)]. The ICER represented the price of an additional meter walked derived from each treatment based on conservative models of success of each procedure and specific care assumptions. PTA and exercise efficacy data were derived from a literature review and exercise costs were modeled per the current CPT code 93668. Effectiveness was defined as absolute claudication distance (ACD) at 3 and 6 months. Three treatment alternatives were assessed: (1) no treatment, (2) PTA, and (3) exercise rehabilitation. At 3 months, PTA was more effective than exercise therapy and resulted in an additional 38 meters at an additional cost of $6719, for an ICER of $177=meter. At 6 months, however, exercise was more effective than PTA, resulting in an additional 137 meters walked, and costs less ($61 less per meter gained). In conclusion, exercise rehabilitation at 6 months is more effective and costs less than PTA, and is therefore cost-saving. The cost-effectiveness and availability of claudication treatments has national implications for future PAD care; however, data to inform these care choices can best be obtained in prospective clinical trials.

The mandate for creation of a national peripheral arterial disease public awareness program: an opportunity to improve cardiovascular health

There has been increasing recognition of the detrimental impact of peripheral arterial disease (PAD) on the health of Americans, and yet there is no common national program of public PAD education designed to diminish this impact. To heighten awareness of this problem, a 2-day PAD Public Education Strategy Meeting was recently attended by representatives of 17 professional societies and public health associations whose missions support the prevention, diagnosis, treatment, and rehabilitation of vascular diseases. This Public Education Strategy Meeting was intended to provide the rationale and structure to create a national PAD public awareness campaign to diminish the health impact of PAD, and to improve cardiovascular outcomes in the USA. This paper: (1) provides the rationale for creation of a national PAD public education program; (2) reviews the development and success of national hypertension, hypercholesterolemia, and Women’s Heart Health public education programs as models of educational efficacy; (3) elucidates how the work of many vascular professionals has led to a national consensus for creation of a national PAD public educational program; (4) provides an overview of the National Heart, Lung and Blood Institute PAD education meeting; and (5) outlines the ‘next steps’ required to accomplish these goals. This meeting achieved consensus that we share responsibility for developing accurate, unified messages to promote PAD awareness and improved care. Participants agreed that the creation of such messages should be linked to plans to disseminate them to all Americans at risk. A consensus was reached that such messages, when commonly created and offered to the public, are most likely to achieve the rewards in better health that all Americans deserve. The Vascular Disease Foundation, a not-for-profit foundation whose mission includes public education regarding the prevention, diagnosis, treatment, and rehabilitation of PAD, will devote its resources to guide a new coalition in this process and to create a national PAD awareness campaign. During 2003 and 2004, the coalition will create the organizational underpinnings and timeline for what will undoubtedly be a multi-year effort. In conclusion, participants of the Public Education Strategy Meeting agreed to create a broad coalition to develop a national PAD public awareness program, with the objectives to develop and disseminate public education messages on PAD. A successful national PAD education program will contribute to the creation of a broader mandate to improve global cardiovascular health in the USA.

Advances in our understanding of the influence of gender on patient outcomes with peripheral arterial disease co-occurring with diabetes

Peripheral arterial disease is an important predictor of cardiovascular morbidity and mortality. Patients with peripheral arterial disease are at a higher risk of myocardial infarction and stroke. The well-known coronary artery disease risk factors such as diabetes, hypertension, smoking and dyslipidemia are also risk factors for peripheral arterial disease. Hyperglycemia is an important mediator in the pathogenesis of this disease in diabetics, more so in women. The morbidity and poor outcomes associated with peripheral arterial disease in women are emerging. Women are more likely to present at an older age are often asymptomatic and have poorer outcomes with revascularization. Women experience specific sex-related challenges in the various diagnostic methods which could lead to a delay in diagnosis. This is a group which needs close attention and aggressive risk factor modification.

Hip Osteoarthritis and the Risk of All-Cause and Disease-Specific Mortality in Older Women: A Population-Based Cohort Study

OBJECTIVE

To determine the risk of all-cause and disease-specific mortality among older women with hip osteoarthritis (OA) and to identify mediators in the causal pathway.

METHODS

Data were from the Study of Osteoporotic Fractures, a US population-based cohort study of 9,704 white women age ≥65 years. The analytic sample included women with hip radiographs at baseline (n = 7,889) and year 8 (n = 5,749). Mortality was confirmed through October 2013 by death certificates and hospital discharge summaries. Radiographic hip OA (RHOA) was defined as a Croft grade of ≥2 in at least 1 hip (definite joint space narrowing or osteophytes plus 1 other radiographic feature).

RESULTS

The mean ± SD followup time was 16.1 ± 6.2 years. The baseline and year 8 prevalence of RHOA were 8.0% and 11.0%, respectively. The cumulative incidence (proportion of deaths during the study period) was 67.7% for all-cause mortality, 26.3% for cardiovascular disease (CVD) mortality, 11.7% for cancer mortality, 1.9% for gastrointestinal disease mortality, and 27.8% for all other mortality causes. RHOA was associated with an increased risk of all-cause mortality (hazard ratio 1.14 [95% confidence interval 1.05-1.24]) and CVD mortality (hazard ratio 1.24 [95% confidence interval 1.09-1.41]) adjusted for age, body mass index, education, smoking, health status, diabetes, and stroke. These associations were partially explained by the mediating variable of physical function.

CONCLUSION

RHOA was associated with an increased risk of all-cause and CVD mortality among older white women followed up for 16 years. Dissemination of evidence-based physical activity and self-management interventions for hip OA in community and clinical settings can improve physical function and might also contribute to lower mortality.

Effect of physical activity assessment on prognostication for peripheral artery disease and mortality

OBJECTIVE

To examine whether a simple question about the performance of regular vigorous activity is associated with peripheral artery disease (PAD) and mortality.

METHODS

A total of 1288 individuals undergoing nonemergency coronary angiography were assessed for participation in regular vigorous activity by questionnaire. Data on demographic characteristics, ankle-brachial indexes, and cardiovascular outcomes were prospectively collected.

RESULTS

Compared with those who denied participation in regular vigorous activity, those who reported participation were less likely to have PAD (odds ratio, 0.58; 95% CI, 0.39-0.86), had higher ankle-brachial indexes, had better Walking Impairment Questionnaire scores (P<.001), and experienced reduced all-cause mortality rates (hazard ratio, 0.48; 95% CI, 0.31-0.74). When added to the Framingham Risk Score, the response improved the net reclassification index for all-cause (32.6%) and cardiovascular (32.0%) mortality.

CONCLUSION

Among at-risk individuals, regular vigorous activity is associated with decreased PAD and all-cause mortality. Simple and readily available, a single yes/no query about participation in regular vigorous exercise could be used to improve risk stratification.

Diabetic women are poor responders to exercise rehabilitation in the treatment of claudication

BACKGROUND

It is not clear whether subgroups of patients with peripheral artery disease (PAD) and claudication respond more favorably to exercise rehabilitation than others. We determined whether sex and diabetes were factors associated with the response to exercise rehabilitation in patients with claudication.

METHODS

Eighty patients were randomized to home-based and supervised exercise programs, and 60 finished with complete exercise intervention data. Exercise consisted of intermittent walking to near maximal claudication pain for 3 months. Primary outcome measures included claudication onset time (COT) and peak walking time. Patients were partitioned into diabetic and nondiabetic groups and then further partitioned by sex to form four groups.

RESULTS

Overall, exercise adherence was high (84%), and there was no significant difference (P > .05) in the amount of exercise completed among the four groups. All groups had significant improvements (P < .05) in COT and peak walking time after exercise rehabilitation, except for diabetic women (P > .05). Only 37% of women with diabetes had an increase in COT compared with 100% of men with diabetes (P < .01), and their risk ratio for nonresponse was 9.2 (P < .0001).

CONCLUSIONS

Women with PAD and claudication, particularly those with diabetes, represent a vulnerable subgroup of patients who respond poorly to a program of exercise rehabilitation. Diabetic women with PAD and claudication may need a greater dose of exercise or another intervention separate from or in combination with exercise to elicit improvements in claudication measures that are similar to nondiabetic women and to diabetic and nondiabetic men.

The impact of sex on angioplasty and primary stenting for femoropopliteal occlusive disease: results of the DURABILITY II trial

BACKGROUND

This study investigates the impact of sex on angioplasty and primary stenting for the treatment of claudicants with femoropopliteal occlusive disease (FPOD).

METHODS

Two hundred eighty-seven patients enrolled in the Safety and Effectiveness Study of EverFlex Stent to Treat Symptomatic Femoral-popliteal Atherosclerosis (DURABILITY II) trial (a prospective, nonrandomized, core laboratory audited, and independently adjudicated investigational device exemption trial) were stratified by sex (190 men and 97 women) and reviewed.

RESULTS

Women presented with FPOD at an older age than men (71.3 ± 11.2 vs. 65.9 ± 9.9 years; P < 0.001). Men were more likely to be hyperlipidemic (89.5% vs. 79.4%; P = 0.030). No other statistically significant differences were observed with regard to periprocedural comorbidities and demographics. Clinically, women presented more often with severe claudication (64.9% vs. 51.1%; P = 0.033) as compared with men that had more moderate claudication (44.2% vs. 29.9%; P = 0.022). The incidence of rest pain and tissue loss was low and did not vary between sexes. Angiographically, women had smaller reference vessels (4.4 ± 0.8 mm vs. 5.0 ± 0.9 mm; P < 0.001). Longer lesions (91.6 ± 46.8 mm vs. 87.8 ± 43.9 mm) and higher primary (79.0% vs. 76.5%), primary-assisted (90.6% vs. 85.1%), and secondary patency (90.6% vs. 85.7%) rates in women did not achieve statistical significance (P = NS). Mean percent stenosis and occlusion rates were similar between groups, but men were more likely to have severe calcification (47.9% vs. 34.0%; P = 0.020). Inter-Society Consensus for the Management of Peripheral Arterial Disease II classifications were similar between groups. The target lesion revascularization, major adverse event, and mortality rates were similar between groups. At baseline, the absolute claudication distance was 0.29 miles for men, while women only reached 0.14 miles (P < 0.0001). Walking improvement questionnaire scores were also compared; women had significantly lower scores at baseline and at 1 year.

CONCLUSIONS

Despite presenting with FPOD at a later age, with more severe claudication, a shorter absolute claudication distance, and smaller vessels than men, women achieved equal patency rates using angioplasty and primary stenting with similar target lesion revascularization, major adverse event, and mortality rates. Despite these findings, women subjectively have worse symptoms at baseline and at 1 year.

Differences in presentation of symptoms between women and men with intermittent claudication

Background

More women than men have PAD with exception for the stage intermittent claudication (IC). The purpose of this study was to evaluate differences in disease characteristics between men and women when using current diagnostic criteria for making the diagnosis IC, defined as ABI < 0.9 and walking problems.

Study Design

Cohort study

Methods

5040 elderly (median age 71) subjects participated in a point-prevalence study 2004. They had their ABI measured and filled out questionnaires covering medical history, current medication, PAD symptoms and walking ability. The prevalence of IC was 6.5% for women and 7.2% for men (P = 0.09). A subset of subjects with IC (N = 56) was followed up four years later with the same procedures. They also performed additional tests aiming to determine all factors influencing walking ability.

Results

Men with IC had more concomitant cardiovascular disease and a more profound smoking history than women. Women, on the other hand, reported a lower walking speed (P < 0.01) and more joint problems (P = 0.018). In the follow up cohort ABI, walking ability and amount of atherosclerosis were similar among the sexes, but women more often reported atypical IC symptoms.

Conclusion

Sex differences in the description of IC symptoms may influence diagnosis even if objective features of PAD are similar. This may influence accuracy of prevalence estimates and selection to treatment.

Outcome of lower extremity revascularization for peripheral artery occlusive disease: is there a difference between men and women?

The incidence of peripheral arterial occlusive disease (PAD) increases with age. Women represent a growing percentage of the elderly population who present with PAD. While speculation exists that gender affects outcome after revascularization procedures, the literature is confusing and often conflicting. This review compares outcomes by gender after open surgical and endovascular lower extremity revascularization (LER) procedures including: demographic differences, patency rates, limb salvage rates, long-term survival, perioperative complications and 30-day mortality. This review summarizes the existing data and discusses current influences on outcome after LER.

Cancer therapy associated bone loss: implications for hip fractures in mid-life women with breast cancer

PURPOSE

Aromatase inhibitors (AIs) have been recently associated with hip fractures. We present a case series of breast cancer survivors and a systematic review of bone health care in breast cancer.

EXPERIMENTAL DESIGN

We completed clinical assessments and bone density testing (BMD) of hip fractures from January 2005 to December 2008. Prefracture and 12-month functional status was obtained. Systematic review included case reports and review of MEDLINE, PubMed, EMBASE, and Food and Drug Administration Adverse Event Reporting System (FDA AERS) from January 1998 to December 2008 (search terms: breast cancer, bone loss, osteopenia, osteoporosis, malignancy, cancer treatment, menopause, adriamycin, cytoxan, tamoxifen, and AIs).

RESULTS

Median age was 53.5 years; five women had osteopenia, one osteoporosis. Five cases were ER (+), and received surgery, XRT chemotherapy, and anastrozole. Functional decline was noted at 12 months, with difficulty in performing heavy housekeeping, climbing stairs, and shopping. The FDA AERS database included 228 cases of fractures associated with breast cancer therapy; 77/228 (29.4%) were hip or femur fractures. Among mid-life women under the age of 64 years there were 78 fractures; 15/228 (19%) were hip and femur fractures. AIs were the most common drug class associated with fractures (n = 149, 65%).

CONCLUSIONS

Cancer treatment induced bone loss results in hip fractures among mid-life women with breast cancer. Hip fractures occur at younger ages and higher BMD than expected for patients in this age group without breast cancer. Hip fractures result in considerable functional decline. Greater awareness of this adverse drug effect is needed.

Validation of the Chinese version of the Walking Impairment Questionnaire in patients with both peripheral arterial disease and type 2 diabetes mellitus

The aim of present study is to translate and validate a Chinese version of the WIQ in patients with PAD and T2DM. A cross-sectional survey was conducted. After translation, a convenience sample of 59 patients with PAD and T2DM completed the Chinese WIQ, the Chinese SF-36 and the 6MWT. The ICC and Cronbach's alpha were calculated to determine the reliability and internal consistency, respectively.Validity was evaluated by correlation coefficients between WIQ, SF-36 and 6MWD. The internal consistency determined by Cronbach's alpha was 0.93. Test-retest reliability expressed by ICC was 0.93. Significant correlations were observed between WIQ, SF-36 and 6MWD (ρ (s) =0.27 ∼0.88, p < 0.01).The Chinese version of the WIQ has satisfactory reliability and validity and can be used to assess walking ability in type 2 diabetic PAD patients.

Gender differences in daily ambulatory activity patterns in patients with intermittent claudication

OBJECTIVES

To compare the pattern of daily ambulatory activity in men and women with intermittent claudication, and to determine whether calf muscle hemoglobin oxygen saturation (StO2) is associated with daily ambulatory activity.

METHODS

Forty men and 41 women with peripheral arterial disease limited by intermittent claudication were assessed on their community-based ambulatory activity patterns for 1 week with an ankle-mounted step activity monitor and on calf muscle StO2 during a treadmill test.

RESULTS

Women had lower adjusted daily maximal cadence (mean±SE) for 5 continuous minutes of ambulation (26.2±1.2 strides/min vs 31.0±1.2 strides/min; P=.009), for 1 minute of ambulation (43.1±0.9 strides/min vs 47.2±0.9 strides/min; P=.004), and for intermittent ambulation determined by the peak activity index (26.3±1.2 strides/min vs 31.0±1.2 strides/min; P=.009). Women also had lower adjusted time to minimum calf muscle StO2 during exercise (P=.048), which was positively associated with maximal cadence for 5 continuous minutes (r=0.51; P<.01), maximal cadence for 1 minute (r=0.42; P<.05), and peak activity index (r=0.44; P<.05). These associations were not significant in men.

CONCLUSION

Women with intermittent claudication ambulate slower in the community setting than men, particularly for short continuous durations of up to 5 minutes and during intermittent ambulation at peak cadences. Furthermore, the daily ambulatory cadences of women are correlated with their calf muscle StO2 during exercise, as women who walk slower in the community setting reach their minimum calf muscle StO2 sooner than those who walk at faster paces. Women with intermittent claudication should be encouraged to not only walk more on a daily basis, but to do so at a pace that is faster than their preferred speed.

Functional decline after incident wrist fractures--Study of Osteoporotic Fractures: prospective cohort study

OBJECTIVE

To study the effect of an incident wrist fracture on functional status in women enrolled in the Study of Osteoporotic Fractures.

DESIGN

Prospective cohort study.

SETTING

Baltimore, Minneapolis, Portland, and the Monongahela valley in Pennsylvania, USA PARTICIPANTS: 6107 women aged 65 years and older without previous wrist or hip fracture recruited from the community between September 1986 and October 1988.

MAIN OUTCOME MEASURE

Clinically important functional decline, defined as a functional deterioration of 5 points in five activities of daily living each scored from 0 to 3 (equivalent to one standard deviation decrease in functional ability).

RESULTS

Over a mean follow-up of 7.6 years, 268 women had an incident wrist fracture and 41 (15%) of these developed clinically important functional decline. Compared with women without wrist fractures, those with incident wrist fractures had greater annual functional decline after adjustment for age, body mass index, and health status. Occurrence of a wrist fracture increased the odds of having a clinically important functional decline by 48% (odds ratio 1.48, 95% confidence interval 1.04 to 2.12), even after adjustment for age, body mass index, health status, baseline functional status, lifestyle factors, comorbidities, and neuromuscular function.

CONCLUSIONS

Wrist fractures contribute to clinically important functional decline in older women.

Gender and ethnic differences in arterial compliance in patients with intermittent claudication

OBJECTIVE

To assess the gender and ethnic differences in arterial compliance in patients with intermittent claudication.

METHODS

A total of 114 patients participated, including 38 Caucasian men, 32 Caucasian women, 16 African American men, and 28 African American women. Patients were assessed on large artery elasticity index (LAEI), small artery elasticity index (SAEI), age, weight, body mass index, ankle-brachial index (ABI), smoking status, and metabolic syndrome components.

RESULTS

Group differences were found for LAEI (P = .042), SAEI (P = .019), body mass index (P = .020), prevalence of elevated fasting glucose (P = .001), and prevalence of abdominal obesity (P = .025). Significant covariates for LAEI included age (P = .0002) and elevated triglycerides (P = .0719). LAEI (units = 10 mL x mm Hg) adjusted for age and triglycerides was 39% lower (P = .0005) in African Americans (11.4 +/- .90; mean +/- SE) than in Caucasians (15.8 +/- 0.72), whereas no significant difference (P = .7904) existed between men (13.8 +/- 0.81) and women (13.5 +/- 0.79). Significant covariates for SAEI included age (P = .0001), abdominal obesity (P = .0030), and elevated blood pressure (P = .0067). SAEI (units = 100 mL x mm Hg) adjusted for age, abdominal obesity, and elevated blood pressure was 32% lower (P = .0007) in African-Americans (2.8 +/- 0.3) than in Caucasians 4.1 +/- 0.2), and was 18% lower (P = .0442) in women (3.1 +/- 0.2) than in men (3.8 +/- 0.2).

CONCLUSION

African American patients with intermittent claudication have more impaired macrovascular and microvascular function than Caucasian patients, and women have more impaired microvascular function than men. These ethnic and gender differences in arterial compliance are evident even though ABI was similar among groups, suggesting that arterial compliance provides unique information to quantify vascular impairment in patients with intermittent claudication.

Sex differences in calf muscle hemoglobin oxygen saturation in patients with intermittent claudication

PURPOSES

We tested the hypotheses that women have greater impairment in calf muscle hemoglobin oxygen saturation (StO(2)) in response to exercise than men, and that the sex-related difference in calf muscle StO(2) would partially explain the shorter claudication distances of women.

METHODS

The study comprised 27 men and 24 women with peripheral arterial disease limited by intermittent claudication. Patients were characterized on calf muscle StO(2) before, during, and after a graded treadmill test, as well as on demographic and cardiovascular risk factors, ankle-brachial index (ABI), ischemic window, initial claudication distance (ICD), and absolute claudication distance (ACD).

RESULTS

Women had a 45% lower ACD than men (296 +/- 268 m vs 539 +/- 288 m; P = .001) during the treadmill test. Calf muscle StO(2) declined more rapidly during exercise in women than in men; the time to reach minimum StO(2) occurred 54% sooner in women (226 +/- 241 vs 491 +/- 426 seconds; P = .010). The recovery time for calf muscle StO(2) to reach the resting value after treadmill exercise was prolonged in women (383 +/- 365 vs 201 +/- 206 seconds; P = .036). Predictors of ACD included the time from start of exercise to minimum calf muscle StO(2), the average rate of decline in StO(2) from rest to minimum StO(2) value, the recovery half-time of StO(2), and ABI (R(2) = 0.70; P < .001). The ACD of women remained lower after adjusting for ABI (mean difference, 209 m; P = .003), but was no longer significantly lower (mean difference, 72 m; P = .132) after further adjustment for the StO(2) variables for the three calf muscles.

CONCLUSION

In patients limited by intermittent claudication, women have lower ACD and greater impairment in calf muscle StO(2) during and after exercise than men, the exercise-mediated changes in calf muscle StO(2) are predictive of ACD, and women have similar ACD as men after adjusting for calf StO(2) and ABI measures.

Coronary artery calcium and physical function in older adults: the Cardiovascular Health Study

BACKGROUND

In older adults without clinical cardiovascular disease, coronary artery calcium (CAC) is associated with other subclinical vascular diseases, which, in turn, predict physical dysfunction. However, the association between CAC and physical function is unstudied.

METHODS

In 387 older community-dwellers from the Cardiovascular Health Study without clinical cardiovascular diseases (mean age +/- standard deviation = 78.7 +/- 3.7, 35% men, 22% African Americans), CAC was measured using electron beam tomography, and physical performance was assessed by usual pace gait speed, chair stand, and tandem stand. Differences in physical performance across CAC quartiles were investigated in the whole cohort and by gender. Associations with gait speed (m/s) were assessed in multivariable models using both the continuous form of CAC score (log(CAC)) and quartiles of CAC, adjusting for demographics and comorbidities.

RESULTS

No differences in physical performance were observed across CAC quartiles in the whole group. In gender-stratified analyses, a significant association was shown among women, who had progressively lower gait speed across CAC quartiles: Those with CAC > 220 walked more than 0.1 m/s slower than those with CAC < 35 (age-adjusted ptrend =.017). After multivariable adjustment, the association remained statistically significant for women in both linear (log(CAC) and gait speed, p =.025) and logistic models: Each of the top three CAC quartiles (35-220, 221-659, and > or = 660) had a more than twofold odds of walking slower than 1 m/s, compared to the lowest CAC quartile (< 35; p =.021).

CONCLUSIONS

In this sample of older community-dwellers without overt cardiovascular disease, CAC was inversely related to gait speed in women, but not in men.

Diabetes-related microvascular and macrovascular diseases in the physical therapy setting

Physical therapists commonly treat people with diabetes for a wide variety of diabetes-associated impairments, including those from diabetes-related vascular disease. Diabetes is associated with both microvascular and macrovascular diseases affecting several organs, including muscle, skin, heart, brain, and kidneys. A common etiology links the different types of diabetes-associated vascular disease. Common risk factors for vascular disease in people with diabetes, specifically type 2 diabetes, include hyperglycemia, insulin resistance, dyslipidemia, hypertension, tobacco use, and obesity. Mechanisms for vascular disease in diabetes include the pathologic effects of advanced glycation end product accumulation, impaired vasodilatory response attributable to nitric oxide inhibition, smooth muscle cell dysfunction, overproduction of endothelial growth factors, chronic inflammation, hemodynamic dysregulation, impaired fibrinolytic ability, and enhanced platelet aggregation. It is becoming increasingly important for physical therapists to be aware of diabetes-related vascular complications as more patients present with insulin resistance and diabetes. The opportunities for effective physical therapy interventions (such as exercise) are significant.

Incident physical disability in people with lower extremity peripheral arterial disease: the role of cardiovascular disease

OBJECTIVES

To evaluate the risk of incident physical disability and the decline in gait speed over a 6-year follow-up associated with a low ankle-arm index (AAI) in older adults.

DESIGN

Observational cohort study.

SETTING

Forsyth County, North Carolina; Sacramento County, California; Washington County, Maryland; and Allegheny County, Pennsylvania.

PARTICIPANTS

Four thousand seven hundred five older adults, 58% women and 17.6% black, participating in the Cardiovascular Health Study.

MEASUREMENTS

AAI was measured in 1992/93 (baseline). Self-reported mobility, activity of daily living (ADL), and instrumental activity of daily living (IADL) disability and gait speed were recorded at baseline and at 1-year intervals over 6 years of follow-up. Mobility disability was defined as any difficulty walking half a mile and ADL and IADL disability was defined as any difficulty with 11 specific ADL and IADL tasks. Individuals with mobility, ADL, or IADL disability at baseline were excluded from the respective incident disability analyses.

RESULTS

Lower baseline AAI values were associated with increased risk of mobility disability and ADL/IADL disability. Clinical cardiovascular disease (CVD), diabetes mellitus, and interim CVD events partially explained these associations for mobility disability and clinical CVD and diabetes mellitus partially explained these associations for ADL and IADL disability. Individuals with an AAI less than 0.9 had on average a mean decrease in gait speed of 0.02 m/s per year, or a decline of 0.12 m/s over the 6-year follow-up. Prevalent CVD partly explained this decrease but interim CVD events did not further attenuate it.

CONCLUSION

Low AAI serves as marker of future disability risk. Reduction of disability risk in patients with a low AAI should consider cardiovascular comorbidity and the prevention of additional disabling CVD events.

Does Lower-Extremity Arterial Disease Predict Future Falling Among Older Men and Women?

The purpose of this study was to determine whether lower-extremity peripheral arterial disease (PAD) is an independent risk factor for falls among older persons. Men and women 55 years old and older participated. Subjects with PAD (n = 86) were identified from a noninvasive vascular laboratory and a general medicine practice. Randomly selected controls without PAD (n = 82) were identified from the same medicine practice. Subjects were categorized into PAD (ankle brachial index, <0.90) or controls (ankle brachial index, 0.90 to 1.50). Subjects underwent a comprehensive baseline evaluation for fall risk. Prospective fall data were obtained using monthly mail-in postcards and structured telephone interviews over a mean follow-up of 9.6 ± 2.9 months. Two independent investigators blinded to PAD status reviewed each fall incident for its eligibility. A total of 37 subjects (22%) had at least 1 eligible fall. In an unadjusted Cox regression model, the relative risk of falling was lower among PAD subjects than among controls (relative risk, 0.54; 95% confidence interval, 0.28 to 1.06). After adjustment for age, gender, history of frequent falls in the last year, number of comorbidities, and balance and gait abnormalities, PAD was significantly associated with a lower risk of falling (relative risk, 0.43; 95% confidence interval, 0.21 to 0.87) as compared with controls. PAD is associated with a lower risk of falling as compared with persons without PAD among older men and women. Future study is needed to determine whether reduced levels of physical activity among patients with PAD account for the lower rate of falling observed here.

Arterial vascular disease in women

BACKGROUND

Arterial disease in women will become a major issue in the near future.

METHODS

A systemic review of existing literature was retrospectively conducted to collect information on the three most common entities of vascular disease: carotid atherosclerotic, abdominal aortic aneurismal, and lower extremity arterial occlusive disease.

RESULTS

Vascular disease is either underdiagnosed or undertreated in women. Whether regarding cerebrovascular disease, aortic aneurysmal disease, or atherosclerosis affecting the lower extremities, natural history, clinical and physiologic patterns are different in women vs men. Current biomedical devices create challenges in endovascular procedures performed in women. Furthermore, indications for treatment of vascular disease are derived from large studies where women are often underrepresented; and, thus, may not be applicable in female vascular patients.

CONCLUSIONS

Better understanding of the gender differences in vascular disease with focused randomized trials, biomedical research, and identification of gender specific medical and social risk factors will improve the clinical outcomes in female patients.

Prevalence and Risk Factors of Peripheral Arterial Disease in a Selected Thai Population

Peripheral arterial disease (PAD) is a condition with high mortality, but it is amenable to secondary prevention. Data on its prevalence in Thailand are scarce. To study the prevalence of PAD in a middle-class, urban Thai population, a cross-sectional study was conducted at the Electric Generating Authority of Thailand's head plant, Nonthaburi, in 2002 and 2003 on all surviving and contactable employees and former employees who had participated in the first cardiovascular risk factors survey in 1985. Participants completed a structured questionnaire detailing their medical history, and they underwent a physical examination. A diagnosis of PAD was made when the ankle-brachial index (ABI) was < 0.9. Ankle-brachial index data were available for 98% of participants in the survey; 75% were men, and participants' ages ranged from 52 to 73 years. The overall prevalence of PAD was 5.2%. The age-standardized prevalence of PAD was 4% in men and 9% in women. Multiple logistic regression analysis found hypertension (OR = 1.7), female gender (OR = 1.9), current smoking (OR = 3.0), current alcohol drinking (OR = 0.41), and overweight (body mass index [BMI] > 25 kg/m 2, OR = 0.54) to be significant (P < .05) predictors of PAD. The prevalence of PAD in urban, middle-class Thais was similar to that in the population in developed countries.

The relationship between ankle-brachial index and leisure-time physical activity in patients with intermittent claudication

The purpose of the study was to examine the relationship between ankle-brachial index (ABI) and leisure-time physical activity (LTPA) in patients with peripheral arterial disease limited by intermittent claudication. Patients included 342 sedentary men and women between the ages of 45 and 85 with intermittent claudication confirmed by a resting ABI of less than 0.90. Patients were categorized into either a low ABI group (ABI <0.50; n=84), a middle ABI group (ABI = 0.50 to 0.69; n=164), or a high ABI group (ABI = 0.70 to 0.89; n=94). The Minnesota LTPA questionnaire was used to estimate physical activity patterns, and a treadmill test, 6- minute walk test, and Walking Impairment Questionnaire were used to measure ambulatory function. A progressive decrease (p=0.030) in the total LTPA was observed among the high ABI (180 +/-131 kcal/day; mean +/- SD), middle ABI (138 +/-127 kcal/day), and low ABI (110 +/-89 kcal/day) groups. Progressive decrements in LTPA spent at moderate intensity (p=0.016) and high intensity (p=0.009), as well as the mean intensity of LTPA (p=0.024) were observed among the three respective ABI groups. Group differences in the LTPA measurements were no longer present (p>0.05) after adjusting for group differences in the absolute claudication distance during a treadmill test, and the 6-minute walk distance. The decline in total daily LTPA with progressively lower ABI in patients with intermittent claudication was due to their decreased participation in physical activities requiring moderate and high intensities. In addition, group differences in the LTPA measurements were explained by differences in ambulatory function.

Managing abnormal blood lipids: a collaborative approach

Current data and guidelines recommend treating abnormal blood lipids (ABL) to goal. This is a complex process and requires involvement from various healthcare professionals with a wide range of expertise. The model of a multidisciplinary case management approach for patients with ABL is well documented and described. This collaborative approach encompasses primary and secondary prevention across the lifespan, incorporates nutritional and exercise management as a significant component, defines the importance and indications for pharmacological therapy, and emphasizes the importance of adherence. Use of this collaborative approach for the treatment of ABL ultimately will improve cardiovascular and cerebrovascular morbidity and mortality.