Similitudes y diferencias entre los pacientes con aterosclerosis sintomática de distintos territorios. Cohorte AIRVAG (Atención Integral al Riesgo VAscular Global)

Albuminuria and polyvascular disease improve multivariate predictive models after an acute cardiovascular event. The AIRVAG cohort

BACKGROUND AND AIMS

There is no consensus regarding risk stratification tools for secondary prevention in atherosclerotic cardiovascular disease. Our aim was to compare the discriminative performance of the Framingham, REGICOR, SCORE, and REACH risk functions and the Bohula-TIMI and SMART risk scores, as well as to assess the potential added value of other clinical variables for the prediction of recurrent events in patients with established vascular disease.

METHODS

A cohort of 269 patients with established vascular disease (52.8% coronary, 32% cerebrovascular, 15.2% PAD) was included. The survival functions of risk groups (low/medium/high) according to commonly used cutoff points for each function/score were compared, and hazard ratios for each were estimated using Cox regression. We calculated Δ Harrell's C statistic, cat-NRI, and cNRI after adding new predictors to a base model including age, sex, total cholesterol, current smoking status, hypertension, and diabetes.

RESULTS

After six years of follow-up (median 4.82 years), 61 events occurred (23%). High-risk groups had a higher risk of recurrent event: SMART (HR: 3.17 [1.55-6.5]), Framingham (HR: 3.08 [1.65-5.75]), REGICOR (HR: 2.71 [1.39-5.27]), SCORE (HR: 2.14 [1.01-4.5], REACH (HR: 5.74 [2.83-11.7]), B-TIMI (HR: 3.68 [0.88-15.3]). Polyvascular disease (three territories HR: 5.6 [2.2-14.25]), albuminuria (HR: 3.55 [2.06-6.11]), and heart failure (HR: 3.11 [1.34-7.25]) also increased risk. Discrimination (Harrell's C) was low but improved after adding albuminuria and polyvascular disease. Both variables also improved the performance of the base model (cNRI.326 [.036; .607]).

CONCLUSIONS

The Framingham, REGICOR, SCORE, and REACH functions and the B-TIMI and SMART scores showed low yet similar performance in secondary prevention. Albuminuria and polyvascular disease improved the predictive performance of major classical cardiovascular risk factors.

Frequency of lower extremity artery disease in type 2 diabetic patients using pulse oximetry and the ankle-brachial index

Objectives: To determine the of undiagnosed lower extremity artery disease using the pulse oximetry in a type 2 diabetic population sample. Methods: Observational, cross-sectional, descriptive study that included 594 type 2 diabetic patients, with no previous history of lower extremity artery disease. Medical history, physical examination, determination of the ankle-brachial index (portable Doppler) and measurement of oxygen saturation in upper and lower extremities (pulse oximeter) were performed. Results: Frequency of lower extremity artery disease determined by ankle-brachial index was 18.4%. No significant correlations were detected between oxygen saturation and the ankle-brachial index except for the relationship between ankle-brachial index vs. oxygen saturation at 30 cm lower limb elevation vs. the supine position at no elevation (0 cm) in subjects under the age of 40. Pulse oximetry showed little diagnostic value in the screening of lower extremity artery disease. A relationship between lower extremity artery disease and age has been found. Its diagnosis was associated with a lower body mass index and lower systolic blood pressure in the lower extremities and higher in the upper extremities. Conclusions: We conclude that pulse oximetry is not useful in the screening for asymptomatic lower extremity artery disease in type 2 diabetics.

Therapeutic inertia in hypercholesterolaemia is associated with ischaemic events in primary care patients. A case-control study

BACKGROUND

The frequency of therapeutic inertia (TI) is very high in the management of vascular risk factors, although its impact on the incidence of ischaemic events is not well-established. Our aim was to investigate the relationship between TI in the treatment of hypercholesterolaemia and the appearance of ischaemic events.

METHODS

An observational, multicentre, case-control study was conducted in 70 primary care centres in Spain. Case subjects (n = 235) were high-risk hypercholesterolaemic patients (both genders, ≥ 18 years) who had had a first event in the 12 months prior to recruitment. They were matched with 235 controls (by vascular risk, age and gender). The observation period was 18 months prior to the onset of a first event (cases) or to date of recruitment (control subjects).

RESULTS

The TI in the basal visit (an average of 7.8 months before the event) was slightly higher in cases than in controls (39.7% vs. 34.8%, NS). However, the accumulated TI was similar in both groups (70.7% for cases and 73.95% for controls, NS). The multivariate analysis, taking ischaemic events as the dependent variable, showed that the TI at baseline visit was significantly associated with the development of the event [OR 2.18 (95% CI 1.04-4.51), p < 0.05]. Other variables also associated with the ischaemic event were a family history of premature vascular disease [OR 3.38 (95% CI 1.35-8.49), p < 0.05] and uncontrolled hypertension [OR 2.35 (95% CI 1.02-5.43), p < 0.05].

CONCLUSION

The TI in high-risk hypercholesterolaemic patients in primary prevention in Spanish primary care centres doubled the risk of an ischaemic event in the short term.

[Lower limb arterial disease and renal artery stenosis]

Peripheral arterial disease (PAD) refers to the atherosclerotic involvement of non-coronary and extracranial arteries, including visceral arteries, the aorta and its branches and the arteries of the limbs. PAD usually refers exclusively to atherosclerosis of the limbs (in particular the lower limbs). Age, male sex, smoking and diabetes, as well as hypertension and dyslipidemia, are the most relevant risk factors for the development of PAD. PAD is frequently associated with coronary heart disease and stroke. PAD patients have increased risk of developing cardiovascular complications (coronary disease, stroke) and total and cardiovascular mortality, even after adjustment by conventional risk factors. Despite this PAD exhibit a worse control of risk factors. This opens up an important opportunity to optimize their control, which can result in an improvement of the prognosis of patients with PAD. Ischemic nephropathy includes a constellation of disorders that are frequently associated: hypertension, renal failure and renal artery stenosis (RAS). RAS risk factors are similar to those of PAD. Recent studies have shown that renal revascularization is not associated with improvement in blood pressure control, preservation of renal function or reduction of cardiovascular events in most patients. Therefore, revascularization should be reserved for selected cases on an individual basis. In all cases, a strict control of vascular risk factors should be attempted.

Impact of atherosclerosis risk factors on the clinical presentation of arterial occlusive disease in Arabic patients

BACKGROUND

Although the risk factors for atherosclerosis have been identified, their impact on the presentation of arterial occlusive disease has not been studied among Arabs.

OBJECTIVE

To determine the correlation between atherosclerotic risk factors and the extent and presentation of atherosclerotic disease in different arterial systems.

METHODS

The present case-control study was performed on a consecutive series of Arabic patients over one year. There were two groups - an atherosclerotic group, which included patients with peripheral arterial disease, extracranial cerebrovascular disease or coronary artery disease (CAD), and the control group, which included patients admitted to one of the general surgical units who were free from atherosclerotic disease. All patients underwent evaluation of risk factors (diabetes mellitus [DM], smoking, dyslipidemia and hypertension) for atherosclerosis and systemic assessment of the vascular tree.

RESULTS

Two hundred fifteen patients in the atherosclerotic group and 191 patients in the control group were included in the study. There were positive correlations between the prevalence of DM, smoking, dyslipidemia and the severity of presentation of peripheral arterial disease, and the extent of CAD. The correlation between the incidence of DM and the severity of presentation of CAD was also significant. The correlation was also positive between the incidence of ex-smoking and hypertension, and the severity of presentation of extracranial cerebrovascular disease.

CONCLUSION

Different risk factors may interact in different ways in the clinical presentation of atherosclerotic disease in different arterial systems.

[Usefulness of the ankle-arm index for detection of peripheral arterial disease in a working population of Junta de Andalucía at Málaga]

BACKGROUND AND OBJECTIVE

Detection of asymptomatic peripheral arterial disease increases the risk of vascular morbibity and mortality. We aimed to estimate the prevalence of clinical and subclinical peripheral arterial disease using the ankle-arm index (AAI) as diagnostic tool in a working population.

SUBJECTS AND METHOD

We included 450 workers, older than 50 years old, attending voluntary regular health check-up at Centro de Prevención de Riesgos Laborales de la Junta de Andalucía in Málaga (Spain). We recorded clinical and anthopometrical data. Blood samples were taken after an overnight fast. Vascular risk was calculated using Framinghan and SCORE scales. Every participant was asked for symptoms of intermittent claudicatio and AAI was measured. AAI was considered normal within 0.9-1.3 values.

RESULTS

Most of our workers were at low- or moderate vascular risk. Only 48 (10.6%) of individuals had an abnormal AAI: 9 (2%) showed an AAI<0.9 and 39 (8.6%) showed an AAI>1.3. An AAI<0.9 was found in 19% of those with a SCORE risk > or = 5%, and in 11% of those having a Framinghan risk > or = 20%. Intermittent claudication was present in 4 out of 9 (44%) of those having an AAI<0.9 and in 7 out of 402 (1.7%) with a normal AAI.

CONCLUSIONS

Systematic screening of peripheral arterial disease using the AAI is not recommended in active working population over 50 years-old of age. Thus, AAI measurement is indicated only for those individuals suffering from intermitent claudicatio and those who are at moderate- or high vascular risk.