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McBane RD, Murphree DH, Liedl D, Lopez-Jimenez F, Arruda-Olson A, Scott CG, Prodduturi N, Nowakowski SE, Rooke TW, Casanegra AI, Wysokinski WE, Houghton DE, Muthusamy K, Wennberg PW. Artificial intelligence of arterial Doppler waveforms to predict major adverse outcomes among patients with diabetes mellitus. J Vasc Surg 2024; 80:251-259.e3. [PMID: 38417709 DOI: 10.1016/j.jvs.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/12/2024] [Accepted: 02/19/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVE Patients with diabetes mellitus (DM) are at increased risk for peripheral artery disease (PAD) and its complications. Arterial calcification and non-compressibility may limit test interpretation in this population. Developing tools capable of identifying PAD and predicting major adverse cardiac event (MACE) and limb event (MALE) outcomes among patients with DM would be clinically useful. Deep neural network analysis of resting Doppler arterial waveforms was used to detect PAD among patients with DM and to identify those at greatest risk for major adverse outcome events. METHODS Consecutive patients with DM undergoing lower limb arterial testing (April 1, 2015-December 30, 2020) were randomly allocated to training, validation, and testing subsets (60%, 20%, and 20%). Deep neural networks were trained on resting posterior tibial arterial Doppler waveforms to predict all-cause mortality, MACE, and MALE at 5 years using quartiles based on the distribution of the prediction score. RESULTS Among 11,384 total patients, 4211 patients with DM met study criteria (mean age, 68.6 ± 11.9 years; 32.0% female). After allocating the training and validation subsets, the final test subset included 856 patients. During follow-up, there were 262 deaths, 319 MACE, and 99 MALE. Patients in the upper quartile of prediction based on deep neural network analysis of the posterior tibial artery waveform provided independent prediction of death (hazard ratio [HR], 3.58; 95% confidence interval [CI], 2.31-5.56), MACE (HR, 2.06; 95% CI, 1.49-2.91), and MALE (HR, 13.50; 95% CI, 5.83-31.27). CONCLUSIONS An artificial intelligence enabled analysis of a resting Doppler arterial waveform permits identification of major adverse outcomes including all-cause mortality, MACE, and MALE among patients with DM.
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Affiliation(s)
- Robert D McBane
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN.
| | - Dennis H Murphree
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN
| | - David Liedl
- Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Francisco Lopez-Jimenez
- Cardiovascular Department, Mayo Clinic, Rochester, MN; Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN
| | | | | | - Naresh Prodduturi
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | | - Thom W Rooke
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Ana I Casanegra
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Waldemar E Wysokinski
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Damon E Houghton
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | | | - Paul W Wennberg
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
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Martin SS, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Barone Gibbs B, Beaton AZ, Boehme AK, Commodore-Mensah Y, Currie ME, Elkind MSV, Evenson KR, Generoso G, Heard DG, Hiremath S, Johansen MC, Kalani R, Kazi DS, Ko D, Liu J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Perman SM, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Tsao CW, Urbut SM, Van Spall HGC, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Palaniappan LP. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation 2024; 149:e347-e913. [PMID: 38264914 DOI: 10.1161/cir.0000000000001209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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3
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de Barros E Silva PGM, do Nascimento CT, Pedrosa RP, Nakazone MA, do Nascimento MU, de Araújo Melo L, Júnior OLS, Zimmermann SL, de Melo RMV, Bergo RR, Precoma DB, Tramujas L, Lima EG, Dantas JMM, do Amaral Baruzzi AC, Flumignan RLG, de Oliveira Paiva MSM, Gowdak LHW, de Carvalho PN, de Figueiredo Neto JA, Silvestre OM, Fioranelli A, Vieira RD'O, Horak ACP, Miyada DHK, Kojima FCS, de Oliveira JS, de Oliveira Silva L, Pavanello R, Ramacciotti E, Lopes RD. Primary results of the brazilian registry of atherothrombotic disease (NEAT). Sci Rep 2024; 14:4222. [PMID: 38378735 PMCID: PMC10879483 DOI: 10.1038/s41598-024-54516-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 02/13/2024] [Indexed: 02/22/2024] Open
Abstract
There is limited contemporary prospective real-world evidence of patients with chronic arterial disease in Latin America. The Network to control atherothrombosis (NEAT) registry is a national prospective observational study of patients with known coronary (CAD) and/or peripheral arterial disease (PAD) in Brazil. A total of 2,005 patients were enrolled among 25 sites from September 2020 to March 2022. Patient characteristics, medications and laboratorial data were collected. Primary objective was to assess the proportion of patients who, at the initial visit, were in accordance with good medical practices (domains) for reducing cardiovascular risk in atherothrombotic disease. From the total of patients enrolled, 2 were excluded since they did not meet eligibility criteria. Among the 2,003 subjects included in the analysis, 55.6% had isolated CAD, 28.7% exclusive PAD and 15.7% had both diagnoses. Overall mean age was 66.3 (± 10.5) years and 65.7% were male patients. Regarding evidence-based therapies (EBTs), 4% were not using any antithrombotic drug and only 1.5% were using vascular dose of rivaroxaban (2.5 mg bid). Only 0.3% of the patients satisfied all the domains of secondary prevention, including prescription of EBTs and targets of body-mass index, blood pressure, LDL-cholesterol, and adherence of lifestyle recommendations. The main barrier for prescription of EBTs was medical judgement. Our findings highlight that the contemporary practice does not reflect a comprehensive approach for secondary prevention and had very low incorporation of new therapies in Brazil. Large-scale populational interventions addressing these gaps are warranted to improve the use of evidence-based therapies and reduce the burden of atherothrombotic disease.ClinicalTrials.gov NCT04677725.
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Affiliation(s)
- Pedro G M de Barros E Silva
- HCor Research Institute, 250 Abilio Soares Street, São Paulo, SP, 04.005-909, Brazil.
- Brazilian Clinical Research Institute, São Paulo, Brazil.
- Hospital Samaritano Paulista, São Paulo, Brazil.
- Centro Universitário São Camilo, São Paulo, Brazil.
| | | | - Rodrigo Pinto Pedrosa
- Procape - Pronto Socorro Cardiológico de Pernambuco - Universidade de Pernambuco, Recife, Brazil
| | | | | | | | | | - Sérgio Luiz Zimmermann
- Clínica Procardio e Hospital Santa Isabel e Universidade Regional de Blumenau, Santa Catarina, Brazil
| | | | | | | | - Lucas Tramujas
- HCor Research Institute, 250 Abilio Soares Street, São Paulo, SP, 04.005-909, Brazil
| | | | | | | | | | | | | | | | | | - Odilson Marcos Silvestre
- Universidade Federal Do Acre, Acre, Brazil
- Centro de Pesquisa Clínica Silvestre Santé, Acre, Brazil
| | | | | | | | | | | | | | | | - Ricardo Pavanello
- HCor Research Institute, 250 Abilio Soares Street, São Paulo, SP, 04.005-909, Brazil
| | | | - Renato D Lopes
- Brazilian Clinical Research Institute, São Paulo, Brazil
- Duke University Medical Center, Durham, NC, USA
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Desai U, Babcock A, Wang Y, Akbarnejad H, Lemus Wirtz E, Laliberte F, Lefebvre P, Kharat A. Real-World Incidence of Adverse Clinical Outcomes Among People With Coronary Artery Disease and/or Peripheral Artery Disease in Relation to Vascular Risk in the United States. Am J Cardiol 2023; 208:44-52. [PMID: 37812866 DOI: 10.1016/j.amjcard.2023.08.110] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 10/11/2023]
Abstract
Presence of polyvascular disease, diabetes, heart failure, or renal insufficiency in patients with chronic coronary artery disease (CAD) and peripheral artery disease (PAD) are associated with increased risks of adverse events, including major adverse cardiovascular events (MACEs) and major adverse limb events (MALEs). In this retrospective observational study using administrative claims data from Optum's deidentified Clinformatics Data Mart Database from January 2016 to September 2021, we described the incidence rates of MACEs, MALEs, and major thrombotic vascular events in patients with CAD or PAD stratified by the presence of risk factors (i.e., polyvascular disease, diabetes, heart failure, or renal insufficiency). A total of 1,435,241 patients (77% CAD and 34% PAD) met the inclusion and exclusion criteria. Patients with 0 risk factors were deemed the low-risk group (47%; n = 681,333) and patients with ≥1 risk factor were deemed the high-risk group (53%; n = 753,908). The mean age was 71.8 and 73.6 years, and 42% and 44% were female in the low- and high-risk groups, respectively. Compared with the low-risk group, the high-risk group had a 72% higher hazard of developing MACEs (adjusted hazard ratio 1.72, 95% confidence interval 1.70 to 1.74), 82% higher hazard of developing major thrombotic vascular events (1.82, 1.80 to 1.84), and 146% higher hazard of developing MALEs (2.46, 2.39 to 2.53) (all p <0.001). In conclusion, in patients with CAD or PAD, the presence of 1 or more risk factors was associated with higher risks of MACEs, MALEs, and major thrombotic vascular events, underscoring the need to improve management of underlying diseases in this population.
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Affiliation(s)
- Urvi Desai
- Analysis Group, Inc., Boston, Massachusetts.
| | - Aram Babcock
- Janssen Scientific Affairs, LLC, Titusville, New Jersey
| | - Yao Wang
- Analysis Group, Inc., Boston, Massachusetts
| | | | | | | | | | - Akshay Kharat
- Janssen Scientific Affairs, LLC, Titusville, New Jersey
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Tonnesen PT, Olesen KKW, Thrane PG, Gyldenkerne C, Peters CD, Buus NH, Maeng M. Absence of Coronary Artery Disease is a Strong Negative Predictor of Major Adverse Cardiovascular Events in Patients with Chronic Kidney Disease. Clin Epidemiol 2023; 15:1109-1121. [PMID: 38050604 PMCID: PMC10693773 DOI: 10.2147/clep.s433983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/31/2023] [Indexed: 12/06/2023] Open
Abstract
Purpose To investigate the interplay between chronic kidney disease (CKD) and coronary artery disease (CAD) on the incidence of cardiovascular events in patients with suspected chronic coronary syndrome (CCS). Patients and Methods Patients with suspected CCS who underwent first-time coronary angiography in Western Denmark between 2003 and 2016 were included in this cohort study. Moreover, an age- and sex-matched general population cohort was established. Patients were stratified according to estimated glomerular filtration rate (eGFR). Presence of CAD was defined as ≥1 obstructive stenosis or non-obstructive diffuse disease. Major adverse cardiovascular events (MACE) were defined as a composite of myocardial infarction, ischemic stroke, and cardiac death. Results A total of 42,611 patients were included with a median follow-up of 7.3 years. Patients without and with CAD had MACE rates per 100 person-years that were 0.52 and 1.67 for eGFR ≥90 mL/min/1.73 m2, 0.68 and 2.09 for eGFR 60-89 mL/min/1.73 m2, 1.27 and 3.85 for eGFR 30-59 mL/min/1.73 m2, and 2.27 and 6.92 for eGFR <30 mL/min/1.73 m2. Comparing to eGFR ≥90 mL/min/1.73 m2, the adjusted incidence rate ratios for MACE were 1.29 (1.10-1.51) for eGFR 60-89 mL/min/1.73 m2, 1.86 (1.49-2.33) for eGFR 30-59 mL/min/1.73 m2, and 3.57 (1.92-6.67) for eGFR <30 mL/min/1.73 m2 in patients without CAD, and 1.11 (1.03-1.20), 1.71 (1.55-1.90), and 2.46 (1.96-3.09) in patients with CAD. The inverse relationship between kidney function and risk of MACE was confirmed when comparing patients with and without CAD to matched individuals in the general population. Conclusion Absence of CAD is a strong negative predictor of major adverse cardiovascular events in patients with CKD.
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Affiliation(s)
| | | | | | | | - Christian Daugaard Peters
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Henrik Buus
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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6
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Steen Carlsson K, Faurby M, Nilsson K, Wolden ML. Atherosclerotic Cardiovascular Disease in Type 2 Diabetes: A Retrospective, Observational Study of Economic and Clinical Burden in Sweden. Diabetes Ther 2023; 14:1357-1372. [PMID: 37326822 PMCID: PMC10299967 DOI: 10.1007/s13300-023-01430-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/01/2023] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Individuals with type 2 diabetes (T2D) are at high risk of experiencing atherosclerotic cardiovascular disease (ASCVD), which is associated with morbidity, mortality and healthcare resource utilisation. Clinical guidelines recommend the use of glucose-lowering medications with cardiovascular benefits in individuals with T2D and cardiovascular disease, but there is evidence that this is not reflected in clinical practice. We used linked national registry data from Sweden to compare outcomes in people with T2D and ASCVD against matched controls with T2D without ASCVD, over 5 years. Direct costs (inpatient, outpatient and selected drug costs), indirect costs resulting from work absence, early retirement, cardiovascular events and mortality were examined. METHODS Individuals with T2D who were at least 16 years old and were alive and resident in Sweden on 1 January 2012 were identified in an existing database. In four separate analyses, individuals with a record indicating ASCVD according to a broad definition, peripheral artery disease (PAD), stroke or myocardial infarction (MI) before 1 January 2012 were identified using diagnosis and/or procedure codes and propensity score matched 1:1 to controls with T2D and without ASCVD, using covariates for birth, sex and level of education in 2012. Follow-up continued until death, migration from Sweden or the end of the study period in 2016. RESULTS In total, 80,305 individuals with ASCVD, 15,397 individuals with PAD, 17,539 individuals with previous stroke and 25,729 individuals with previous MI were included. Total mean annual costs per person were €14,785 for PAD (2.7 × costs for controls), €11,397 for previous stroke (2.2 × controls), €10,730 for ASCVD (1.9 × controls) and €10,342 for previous MI (1.7 × controls). Indirect costs and costs of inpatient care were the major cost drivers. ASCVD, PAD, stroke and MI were all associated with an increased likelihood of early retirement, cardiovascular events and mortality. CONCLUSIONS ASCVD is associated with considerable costs, morbidity and mortality in individuals with T2D. These results support structured assessment of ASCVD risk and broader implementation of guideline-recommended treatments in T2D healthcare.
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Affiliation(s)
- Katarina Steen Carlsson
- The Swedish Institute for Health Economics (IHE), Råbygatan 2, 223 61, Lund, Sweden.
- Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden.
| | | | - Kristoffer Nilsson
- The Swedish Institute for Health Economics (IHE), Råbygatan 2, 223 61, Lund, Sweden
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Sirignano P, Margheritini C, Ruggiero F, Panzano C, Filippi F, Rizzo L, Taurino M. The Ability to Look Beyond: The Treatment of Peripheral Arterial Disease. J Clin Med 2023; 12:jcm12093073. [PMID: 37176513 PMCID: PMC10179057 DOI: 10.3390/jcm12093073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023] Open
Abstract
This paper offers a practical overview of the contemporary management of patients with peripheral arterial disease presenting intermittent claudication (IC), including clinical and instrumental diagnosis, risk factors modification, medical management, and evidence-based revascularization indications and techniques. Decision making represents a crucial element in the management of the patient with IC; for this, we think a review of this type could be very useful, especially for non-vascular specialists.
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Affiliation(s)
- Pasqualino Sirignano
- Vascular and Endovascular Surgery Unit, Sant'Andrea Hospital of Rome, Department of General and Specialistic Surgery, "Sapienza" University of Rome, 00189 Rome, Italy
| | - Costanza Margheritini
- Vascular and Endovascular Surgery Unit, Sant'Andrea Hospital of Rome, Department of Molecular and Clinical Medicine, "Sapienza" University of Rome, 00189 Rome, Italy
| | - Federica Ruggiero
- Vascular and Endovascular Surgery Unit, Sant'Andrea Hospital of Rome, Department of Molecular and Clinical Medicine, "Sapienza" University of Rome, 00189 Rome, Italy
| | - Claudia Panzano
- Vascular and Endovascular Surgery Unit, Misericordia Hospital, 58100 Grosseto, Italy
| | - Federico Filippi
- Vascular and Endovascular Surgery Unit, Misericordia Hospital, 58100 Grosseto, Italy
| | - Luigi Rizzo
- Vascular and Endovascular Surgery Unit, Sant'Andrea Hospital of Rome, Department of Molecular and Clinical Medicine, "Sapienza" University of Rome, 00189 Rome, Italy
| | - Maurizio Taurino
- Vascular and Endovascular Surgery Unit, Sant'Andrea Hospital of Rome, Department of Molecular and Clinical Medicine, "Sapienza" University of Rome, 00189 Rome, Italy
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Foussard N, Dari L, Ducasse E, Rigalleau V, Mohammedi K, Caradu C. Lower-limb peripheral arterial disease and amputations in people with diabetes: Risk factors, prognostic value and management. Presse Med 2023; 52:104164. [PMID: 36863662 DOI: 10.1016/j.lpm.2023.104164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/20/2022] [Accepted: 02/17/2023] [Indexed: 03/04/2023] Open
Abstract
Lower-limb peripheral arterial disease (PAD), is a common manifestation of systemic atherosclerosis, resulting from a partial or complete obstruction of at least one lower-limb arteries. PAD is a major endemic disease with an excess risk of major cardiovascular events and death. It also leads to disability, high rates of lower-limb adverse events and non-traumatic amputation. In patients with diabetes, PAD is particularly frequent and has a worse prognosis than in patients without diabetes. The risk factors of PAD are comparable to those for cardiovascular disease. The ankle-brachial index is usually recommended to screen PAD despite its limited performance in patients with diabetes, affected by the presence of peripheral neuropathy, medial arterial calcification, incompressible arteries and infection. Toe brachial index and toe pressure emerge as alternative screening tools. The management of PAD requires strict control of cardiovascular risk factors including diabetes, hypertension and dyslipidaemia, the use of antiplatelet agents and lifestyle management, to reduce cardiovascular adverse events, but few randomized controlled trials have evaluated the benefits of these treatments in PAD. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in PAD prognosis. Further studies are required to increase our understanding of the pathophysiology of PAD and to evaluate the interest of different therapeutic strategies in the occurrence and progression of PAD in patients with diabetes. Here, we present a narrative and contemporary review to synthesize the key epidemiology findings, screening and diagnosis methods, and major therapeutic advances regarding PAD in patients with diabetes.
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Affiliation(s)
- Ninon Foussard
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Loubna Dari
- University of Bordeaux, Faculty of Medicine, Bordeaux, France; Bordeaux University Hospital, Hôpital Saint-André, Vascular Medicine Department, Bordeaux, France
| | - Eric Ducasse
- University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France; Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
| | - Vincent Rigalleau
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France
| | - Kamel Mohammedi
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France.
| | - Caroline Caradu
- Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
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Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Fugar S, Generoso G, Heard DG, Hiremath S, Ho JE, Kalani R, Kazi DS, Ko D, Levine DA, Liu J, Ma J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Virani SS, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation 2023; 147:e93-e621. [PMID: 36695182 DOI: 10.1161/cir.0000000000001123] [Citation(s) in RCA: 1156] [Impact Index Per Article: 1156.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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10
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Ezzatvar Y, García-Hermoso A. Global estimates of diabetes-related amputations incidence in 2010-2020: A systematic review and meta-analysis. Diabetes Res Clin Pract 2023; 195:110194. [PMID: 36464091 DOI: 10.1016/j.diabres.2022.110194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/31/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022]
Abstract
AIMS/HYPOTHESIS This study sought to provide up-to-date pooled global estimates of diabetes-related amputation incidence from 2010 to 2020. METHODS Embase and Medline databases were searched for studies reporting the incidence rate (IR) of diabetes-related amputations from 2010 to 2020. IR estimates of diabetes-related amputations with associated 95% confidence interval (CI) per 100,000 individuals with diabetes were calculated. RESULTS 23 studies were included, reporting 505,390 diabetes-related lower extremity amputations. IR of minor amputations was 139.97 (95% CI 88.18-222.16) per 100,000 individuals with diabetes, among patients with type 1 diabetes was 148.59 (95% CI 65.00-339.68) and in type 2 diabetes was 75.53 (95% CI 29.94-190.54). IR of major amputations was 94.82 (95% CI 56.62-158.80) per 100,000 individuals with diabetes, among patients with type 1 diabetes was 100.76 (95% CI 53.71-189.01) and among type 2 diabetes was 40.58 (95% CI 11.03-149.28). There were 83.84 annual amputations (95% CI 41.67-168.65) per 100,000 women with diabetes and 178.04 (95% CI 81.16-390.55) per 100,000 men. CONCLUSIONS Globally, annual incidence of diabetes-related amputations from 2010 to 2020 has shown to disproportionately affect men and individuals with type 1 diabetes mellitus, although its incidence is not uniform across countries.
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Affiliation(s)
- Yasmin Ezzatvar
- Department of Nursing, Universitat de València, Valencia, Spain.
| | - Antonio García-Hermoso
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
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11
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Schmitt VH, Hobohm L, Vosseler M, Brochhausen C, Münzel T, Espinola‐Klein C, Keller K. Temporal trends in patients with peripheral artery disease influenced by diabetes mellitus in Germany. J Diabetes 2022; 14:670-684. [PMID: 36146952 PMCID: PMC9574718 DOI: 10.1111/1753-0407.13316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 08/16/2022] [Accepted: 09/06/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION In patients with peripheral artery disease (PAD) the presence of diabetes mellitus (DM) is associated with higher morbidity and mortality. Because huge efforts are made to improve medical care of patients with DM including chronic disease programs, the aim of the present study was to investigate temporal trends regarding the clinical burden of DM on PAD patients within a 15-year observational period. METHODS We analyzed all patients hospitalized because of PAD between 2005 and 2019 in Germany stratified regarding DM. RESULTS Overall, 2 654 871 hospitalizations of PAD patients (865 823 with DM) were included. Hospitalizations based on PAD inclined from 142 778 in 2005 to 190 135 in 2019 (β 3956 per year; 95% confidence interval [CI] 3034-4878, p < .001) with simultaneous increase of hospitalizations of PAD patients with DM (2005: 41609 (29.1%) versus 2019: 65 302 (34.3%); β 2019 per year [95% CI 1593-2446], p < .001). Amputation rates (β -0.42 [95% CI -0.44 to -0.40]; p < .001) as well as in-hospital case-fatality rate (2005: 4.7%, 2019: 2.8%; β -0.64 [95% CI -0.69 to -0.59]; p < .001) decreased in diabetic PAD patients during the observational time. In spite of improved morbidity and mortality in the last years of the observational period, patients with DM still suffered from an increased risk for morbidity and mortality during the observational period compared to nondiabetic PAD patients. CONCLUSIONS Despite the progress in DM treatments, DM still was associated with an unfavorable clinical patient profile and remained a substantial risk factor for morbidity and mortality in hospitalized patients with PAD and DM in Germany between 2005 and 2019.
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Affiliation(s)
- Volker H. Schmitt
- Department of CardiologyUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
- German Center for Cardiovascular sdfsResearch (DZHK)Partner Site Rhine MainMainzGermany
| | - Lukas Hobohm
- Department of CardiologyUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
- Center for Thrombosis and Hemostasis (CTH)University Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
| | - Markus Vosseler
- Department of CardiologyUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
| | | | - Thomas Münzel
- Department of CardiologyUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
- German Center for Cardiovascular sdfsResearch (DZHK)Partner Site Rhine MainMainzGermany
| | - Christine Espinola‐Klein
- Department of CardiologyUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
| | - Karsten Keller
- Department of CardiologyUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
- Center for Thrombosis and Hemostasis (CTH)University Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
- Medical Clinic VII, Department of Sports MedicineUniversity Hospital HeidelbergHeidelbergGermany
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12
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Ai X, Yu P, Peng L, Luo L, Liu J, Li S, Lai X, Luan F, Meng X. Berberine: A Review of its Pharmacokinetics Properties and Therapeutic Potentials in Diverse Vascular Diseases. Front Pharmacol 2022; 12:762654. [PMID: 35370628 PMCID: PMC8964367 DOI: 10.3389/fphar.2021.762654] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/20/2021] [Indexed: 12/11/2022] Open
Abstract
Traditional Chinese medicine plays a significant role in the treatment of various diseases and has attracted increasing attention for clinical applications. Vascular diseases affecting vasculature in the heart, cerebrovascular disease, atherosclerosis, and diabetic complications have compromised quality of life for affected individuals and increase the burden on health care services. Berberine, a naturally occurring isoquinoline alkaloid form Rhizoma coptidis, is widely used in China as a folk medicine for its antibacterial and anti-inflammatory properties. Promisingly, an increasing number of studies have identified several cellular and molecular targets for berberine, indicating its potential as an alternative therapeutic strategy for vascular diseases, as well as providing novel evidence that supports the therapeutic potential of berberine to combat vascular diseases. The purpose of this review is to comprehensively and systematically describe the evidence for berberine as a therapeutic agent in vascular diseases, including its pharmacological effects, molecular mechanisms, and pharmacokinetics. According to data published so far, berberine shows remarkable anti-inflammatory, antioxidant, antiapoptotic, and antiautophagic activity via the regulation of multiple signaling pathways, including AMP-activated protein kinase (AMPK), nuclear factor κB (NF-κB), mitogen-activated protein kinase silent information regulator 1 (SIRT-1), hypoxia-inducible factor 1α (HIF-1α), vascular endothelial growth factor phosphoinositide 3-kinase (PI3K), protein kinase B (Akt), janus kinase 2 (JAK-2), Ca2+ channels, and endoplasmic reticulum stress. Moreover, we discuss the existing limitations of berberine in the treatment of vascular diseases, and give corresponding measures. In addition, we propose some research perspectives and challenges, and provide a solid evidence base from which further studies can excavate novel effective drugs from Chinese medicine monomers.
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Affiliation(s)
- Xiaopeng Ai
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China.,Department of Pharmacy, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Peiling Yu
- Department of Pharmacy, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Lixia Peng
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Liuling Luo
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jia Liu
- School of Ethnic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Shengqian Li
- Department of Pharmacy, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xianrong Lai
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Ethnic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Fei Luan
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xianli Meng
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China.,Innovative Institute of Chinese Medicine and Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
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13
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Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, Boehme AK, Buxton AE, Carson AP, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Ferguson JF, Generoso G, Ho JE, Kalani R, Khan SS, Kissela BM, Knutson KL, Levine DA, Lewis TT, Liu J, Loop MS, Ma J, Mussolino ME, Navaneethan SD, Perak AM, Poudel R, Rezk-Hanna M, Roth GA, Schroeder EB, Shah SH, Thacker EL, VanWagner LB, Virani SS, Voecks JH, Wang NY, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association. Circulation 2022; 145:e153-e639. [PMID: 35078371 DOI: 10.1161/cir.0000000000001052] [Citation(s) in RCA: 2369] [Impact Index Per Article: 1184.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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14
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Keller K, Schmitt VH, Vosseler M, Brochhausen C, Münzel T, Hobohm L, Espinola-Klein C. Diabetes Mellitus and Its Impact on Patient-Profile and In-Hospital Outcomes in Peripheral Artery Disease. J Clin Med 2021; 10:jcm10215033. [PMID: 34768552 PMCID: PMC8585025 DOI: 10.3390/jcm10215033] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In patients with peripheral artery disease (PAD), the impact of diabetes mellitus (DM) on patient-profile and adverse in-hospital events is not well investigated. METHODS The German nationwide inpatient sample 2005-2019 was used for this analysis. Hospitalized PAD patients were stratified for DM and the influence of DM on patient-profile and adverse in-hospital events was investigated. RESULTS Our study comprised 2,654,871 hospitalizations (54.3% aged ≥70 years, 36.7% females) of patients with PAD in Germany 2005-2019. Among these, 864,691 (32.6%) patients had DM and 76,716 (2.9%) died during hospitalization. Diabetic PAD patients revealed an aggravated cardiovascular profile (Charlson Comorbidity Index: 6.0 (5.0-8.0) vs. 4.0 (3.0-5.0), p < 0.001). PAD patients with DM showed a higher rate of in-hospital mortality (3.5% vs. 2.6%, p < 0.001), as well as major adverse cardiovascular and cerebrovascular events (MACCE, 4.7% vs. 3.3%, p < 0.001) and had more often operated with amputation surgery (16.4% vs. 9.1%, p < 0.001). DM was an independent predictor of in-hospital mortality (OR 1.077 (95%CI 1.060-1.093), p < 0.001) and MACCE (OR 1.118 (95%CI 1.103-1.133), p < 0.001). In addition, amputations were also associated with DM (OR 1.804 (95%CI 1.790-1.818)), p < 0.001). CONCLUSIONS DM is associated with an unfavorable clinical patient-profile and higher risk for adverse events in PAD patients, including substantially increased in-hospital mortality as well as MACCE rate, and were more often associated with amputation surgeries.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany; (V.H.S.); (M.V.); (T.M.); (L.H.); (C.E.-K.)
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +0049-6131-17-8380; Fax: +0049-6131-17-8461
| | - Volker H. Schmitt
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany; (V.H.S.); (M.V.); (T.M.); (L.H.); (C.E.-K.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Markus Vosseler
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany; (V.H.S.); (M.V.); (T.M.); (L.H.); (C.E.-K.)
| | | | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany; (V.H.S.); (M.V.); (T.M.); (L.H.); (C.E.-K.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Lukas Hobohm
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany; (V.H.S.); (M.V.); (T.M.); (L.H.); (C.E.-K.)
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany
| | - Christine Espinola-Klein
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany; (V.H.S.); (M.V.); (T.M.); (L.H.); (C.E.-K.)
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15
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Lu Q, Wang J, Wei X, Wang G, Xu Y. Risk Factors for Major Amputation in Diabetic Foot Ulcer Patients. Diabetes Metab Syndr Obes 2021; 14:2019-2027. [PMID: 33976562 PMCID: PMC8106455 DOI: 10.2147/dmso.s307815] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/25/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The purpose of our study was to identify the new and the more specific risk factors for major amputation in patients with diabetic foot ulcer (DFU). METHODS We used data from the Electronic Medical Record (EMR) database of our hospital from February 2014 to July 2020. Patients with DFU and amputation were included in the study. The logistic regression model was adjusted for demographic characteristics and related comorbidities between major and minor amputation groups. RESULTS Among 3654 patients with DFU, 363 (9.9%) were amputated. Patients with major versus minor amputation, in multivariable logistic regression models, major amputation independent factors included previous amputation history (odds ratio [OR] 2.31 [95% CI 1.17-4.53], p = 0.02), smoking (2.58 [1.31-5.07], p = 0.01), coronary artery disease (CAD) (2.67 [1.35-5.29], p = 0.03), ankle brachial index (ABI) <0.4 (15.77 [7.51-33.13], p < 0.01), Wagner 5 (5.50 [1.89-16.01], p < 0.01), activated partial thromboplastin time (APTT) (1.23 [1.03-1.48], p = 0.01), glycosylated hemoglobin A1c (HbA1c) (1.23 [1.03-1.48], p = 0.03), hemoglobin (Hb) (0.98 [0.96-1.00], p = 0.01), plasma albumin (ALB) (0.88 [0.81-0.95], p < 0.01) and white blood cell (WBC) (1.10 [1.04-1.16], p < 0.01). CONCLUSION Major amputation was associated with previous amputation history, smoking, CAD, Wagner 5, ABI <0.4, HbA1c, Hb, ALB, WBC, and APTT might be a new independent factor. In view of these factors, early prevention and guidance promptly orientated by multidisciplinary is of great significance to reduce the disability rate and economic burden.
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Affiliation(s)
- Qingwei Lu
- Department of Ulcers and Peripheral Vascular Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300193, People’s Republic of China
| | - Jun Wang
- Department of Ulcers and Peripheral Vascular Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300193, People’s Republic of China
- Correspondence: Jun Wang; Gang Wang Department of Ulcers and Peripheral Vascular Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300000, People’s Republic of China Email ;
| | - Xiaolu Wei
- School of Integrated Traditional Chinese and Western Medicine, Binzhou Medical University, Yantai, 264003, People’s Republic of China
| | - Gang Wang
- Department of Ulcers and Peripheral Vascular Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300193, People’s Republic of China
| | - Yang Xu
- Department of Ulcers and Peripheral Vascular Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300193, People’s Republic of China
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