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Nishikawa R, Shiomi H, Morimoto T, Yamamoto K, Sakamoto H, Tada T, Kaneda K, Nagao K, Nakatsuma K, Tazaki J, Suwa S, Inoko M, Yamazaki K, Tsuneyoshi H, Komiya T, Ando K, Minatoya K, Furukawa Y, Nakagawa Y, Kimura T. Effects of peripheral artery disease on long-term outcomes after percutaneous coronary intervention versus coronary artery bypass grafting in patients with severe coronary artery disease. J Cardiol 2023:S0914-5087(23)00306-4. [PMID: 38135147 DOI: 10.1016/j.jjcc.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 12/11/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND There is a scarcity of data evaluating the effect of peripheral artery disease (PAD) on long-term mortality after percutaneous coronary intervention (PCI) relative to coronary artery bypass grafting (CABG) in patients with severe coronary artery disease in real-world practice. METHODS Among 14,867 consecutive patients who underwent their first coronary revascularization with PCI or isolated CABG between 2011 and 2013 in the CREDO-Kyoto PCI/CABG registry Cohort-3, the current study population consisted of 3380 patients with three-vessel coronary artery disease or left main coronary artery disease. Long-term clinical outcomes were compared between PCI and CABG stratified by the presence or absence of PAD. Median clinical follow-up was 5.9 (IQR: 5.1-6.8) years. RESULTS There were 461 patients with PAD (PCI: N = 307, CABG: N = 154), and 2919 patients without PAD (PCI: N = 1823, CABG: N = 1096). The cumulative 5-year mortality after coronary revascularization was 31.2 % in patients with PAD and 16.2 % in those without PAD (p < 0.0001). There was a higher risk of PCI relative to CABG for all-cause death in patients with and without PAD (adjusted HR, 1.59; 95%CI, 0.99-2.53; p = 0.054, and HR, 1.25; 95%CI, 1.01-1.56; p = 0.04) without interaction (p interaction p = 0.48); Nevertheless, there was no excess risk of PCI relative to CABG for cardiovascular death regardless of PAD. CONCLUSIONS The long-term mortality after coronary revascularization was significantly higher in severe CAD patients with PAD than those without PAD. There was a higher mortality risk of PCI relative to CABG in patients with and without PAD without interaction, which was mainly driven by excess non-cardiovascular deaths.
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Affiliation(s)
- Ryusuke Nishikawa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Ko Yamamoto
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroki Sakamoto
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Kazuhisa Kaneda
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazuya Nagao
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Kenji Nakatsuma
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Junichi Tazaki
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Moriaki Inoko
- Department of Cardiology, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Kazuhiro Yamazaki
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroshi Tsuneyoshi
- Department of Cardiovascular Surgery, Shizuoka General Hospital, Shizuoka, Japan
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Shiga, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Adiarto S, Nurachman LA, Dewangga R, Indriani S, Taofan T, Alkatiri AA, Firman D, Santoso A. Predicting multi-vascular diseases in patients with coronary artery disease. F1000Res 2023; 12:750. [PMID: 37744767 PMCID: PMC10517298 DOI: 10.12688/f1000research.134648.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 09/26/2023] Open
Abstract
Background: Because of its systemic nature, the occurrence of atherosclerosis in the coronary arteries can also indicate a risk for other vascular diseases. However, screening program targeted for all patients with coronary artery disease (CAD) is highly ineffective and no studies have assessed the risk factors for developing multi-vascular diseases in general. This study constructed a predictive model and scoring system to enable targeted screening for multi-vascular diseases in CAD patients. Methods: This cross-sectional study includes patients with CAD, as diagnosed during coronary angiography or percutaneous coronary intervention from March 2021 to December 2021. Coronary artery stenosis (CAS) and abdominal aortic aneurysm (AAA) were diagnosed using Doppler ultrasound while peripheral artery disease (PAD) was diagnosed based on ABI score. Multivariate logistic regression was conducted to construct the predictive model and risk scores. Validation was conducted using ROC analysis and Hosmer-Lemeshow test. Results: Multivariate analysis showed that ages of >60 years (OR [95% CI] = 1.579 [1.153-2.164]), diabetes mellitus (OR = 1.412 [1.036-1.924]), cerebrovascular disease (OR = 3.656 [2.326-5.747]), and CAD3VD (OR = 1.960 [1.250-3.073]) increased the odds for multi-vascular disease. The model demonstrated good predictive capability (AUC = 0.659) and was well-calibrated (Hosmer-Lemeshow p = 0.379). Targeted screening for high-risk patients reduced the number needed to screen (NNS) from 6 in the general population to 3 and has a high specificity of 96.5% Conclusions: Targeted screening using clinical risk scores was able to decrease NNS with good predictive capability and high specificity.
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Affiliation(s)
- Suko Adiarto
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | | | | | - Suci Indriani
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Taofan Taofan
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Amir Aziz Alkatiri
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Doni Firman
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Anwar Santoso
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
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Lempesis IG, Varrias D, Sagris M, Attaran RR, Altin ES, Bakoyiannis C, Palaiodimos L, Dalamaga M, Kokkinidis DG. Obesity and Peripheral Artery Disease: Current Evidence and Controversies. Curr Obes Rep 2023; 12:264-279. [PMID: 37243875 PMCID: PMC10220347 DOI: 10.1007/s13679-023-00510-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE OF REVIEW Obesity is a significant public health problem and a major risk factor for the development and progression of atherosclerosis and its cardiovascular manifestations. Lower extremity peripheral artery disease (PAD) affects 3%-10% of the Western population and, if left untreated, can lead to devastating outcomes with both an increased risk of morbidity and mortality. Interestingly, the association between obesity and PAD remains debatable. Whereas it is well known that PAD and obesity frequently overlap in the same patients, many studies have demonstrated a negative association between obesity and PAD and a protective effect of obesity on disease development and progression, a phenomenon described as the "obesity paradox." Possible mechanisms for this paradox may include genetic background, as assessed by mendelian randomization studies, adipose tissue dysfunction, and body fat distribution rather than adiposity, while other factors, such as sex, ethnicity, sarcopenia in the elderly population, or aggressive treatment of co-existing metabolic conditions in individuals with obesity compared to those with normal weight, could have some impact as well. RECENT RINDINGS Few reviews and meta-analyses examining systematically the relationship between obesity and PAD exist. The impact of PAD development due to the presence of obesity remains largely controversial. However, the most current evidence, backed by a recent meta-analysis, suggests a potential protective role of a higher body mass index on PAD-related complications and mortality. In this review, we discuss the association between obesity and PAD development, progression, and management, and the potential pathophysiologic mechanisms linking the two diseases.
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Affiliation(s)
- Ioannis G Lempesis
- Department of Biologic Chemistry, School of Medicine, National and Kapodistrian, University of Athens, Mikras Asias 75, 115 27, Athens, Greece.
| | - Dimitrios Varrias
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Marios Sagris
- General Hospital of Nikaia, Piraeus, 184 54, Athens, Greece
| | - Robert R Attaran
- Section of Cardiovascular Medicine, Yale University/Yale New Haven Hospital, 06519, New Haven, CT, USA
| | - Elissa S Altin
- Section of Cardiovascular Medicine, Yale University/Yale New Haven Hospital, 06519, New Haven, CT, USA
| | - Christos Bakoyiannis
- Department of Surgery, Division of Vascular Surgery, Laikon General Hospital, National Kapodistrian University of Athens, 15772, Athens, Greece
| | - Leonidas Palaiodimos
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Maria Dalamaga
- Department of Biologic Chemistry, School of Medicine, National and Kapodistrian, University of Athens, Mikras Asias 75, 115 27, Athens, Greece
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University/Yale New Haven Hospital, 06519, New Haven, CT, USA
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Gouda P, Ramasundarahettige C, Anand S, Muhlhoffer E, Berkowitz S, Fox KA, Eikelboom J, Welsh R. Clinical factors associated with peripheral artery disease in patients with documented coronary artery disease: A post hoc analysis of the COMPASS trial. Atherosclerosis 2021; 331:38-44. [PMID: 34340829 DOI: 10.1016/j.atherosclerosis.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/09/2021] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND AIMS Patients with coronary artery disease (CAD) who also have peripheral artery disease (PAD) are at high risk of subsequent cardiovascular events and mortality. Despite this, PAD in patients with CAD often remains undiagnosed. The objective of this analysis was to assess clinical factors that predict the presence of PAD in patient with documented CAD who also have PAD. METHODS In a post hoc analysis of patients with CAD in the COMPASS trial, we developed separate prediction models for symptomatic lower extremity PAD and documented carotid artery disease (Model 1), asymptomatic lower extremity PAD defined as ABI <0.9 (Model 2) and for any PAD (symptomatic or asymptomatic; Model 3). Using logistic regression models, candidate variables were chosen to predict the presence of PAD. Overall model performance was evaluated for discrimination and calibration using the concordance statistic and Hosmer and Lemeshow Goodness-of-fit chi-square, respectively. The final model was validated by bootstrapping. RESULTS Of 23,402 participants, 3484 (14.9%) had a history of symptomatic PAD or carotid artery disease (Model 1), 1422 (5.7%) participants had asymptomatic PAD (Model 2) and 4906 (20.6%) had any PAD (Model 3). Model 1 demonstrated a C-statistic of 0.667 and goodness-of-fit p-value of 0.859. Model 2 demonstrated a C-statistic of 0.626 and goodness-of-fit p-value of 0.250. Model 3 demonstrated a C-statistic of 0.646 and goodness-of-fit p-value of 0.240. CONCLUSION Routinely available clinical information is only marginally useful to identify patients with CAD and concomitant PAD.
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Affiliation(s)
- Pishoy Gouda
- University of Alberta, Mazankowski Heart Institute, 8440 112, St NW Edmonton, Alberta, T6G 2B7, Canada
| | - Chinthanie Ramasundarahettige
- Mcmaster University, Population Health Research Institute, 237 Barton Street East, Hamilton, Ontario, L8L 2X2, Canada
| | - Sonia Anand
- Mcmaster University, Population Health Research Institute, 237 Barton Street East, Hamilton, Ontario, L8L 2X2, Canada
| | | | | | - Keith Aa Fox
- University of Edinburgh, Old College, South Bridge, Edinburgh, EH8 9YL, UK
| | - John Eikelboom
- Mcmaster University, Population Health Research Institute, 237 Barton Street East, Hamilton, Ontario, L8L 2X2, Canada
| | - Robert Welsh
- University of Alberta, Mazankowski Heart Institute, 8440 112, St NW Edmonton, Alberta, T6G 2B7, Canada.
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5
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Kokkinidis DG, Katamreddy A, Giannopoulos S, Schizas D, Georgopoulos S, Liakakos T, Armstrong EJ, Bakoyiannis C. Risk Models and Scores in Patients with Peripheral Artery Disease and Chronic Limb-threatening Ischemia: A Comprehensive Review. Curr Pharm Des 2021; 27:1277-1288. [PMID: 32472995 DOI: 10.2174/1381612826666200530214459] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/12/2020] [Indexed: 11/22/2022]
Abstract
Peripheral artery disease (PAD) affects more than 200 million patients worldwide and chronic limbthreatening ischemia (CLTI) is the most advanced stage of PAD with very high morbidity and mortality rates. Cardiovascular medicine is trending towards a more personalized approach where each individual patient will be managed according to specific risk factors, disease characteristics, expectations related to their disease and individualized assessment of potential outcomes. For this reason, a number of risk models and scores have been developed during the last few years. Our aim in this comprehensive review article is to provide an overview of selected risk models and scores for patients with PAD and CLTI. Given that some of the published scores were of low quality (minimal discriminatory ability), we included scores that were already externally validated or scores that had promising initial findings. Available scoring systems were grouped in the five following categories according to their utility: i) scores that can detect asymptomatic patients who should be screened for PAD, ii) scores for assessment of functional status and quality of life in patients with PAD, iii) scores assessing risk for amputation and other major adverse limb events among patients with CLTI, iv) scores for the optimal revascularization strategy in each patient and scores predicting successful procedural outcomes; v) scores predicting short or long-term cardiovascular and limb related outcomes after either revascularization or at least angiographic assessment. Limitations of available scoring systems include development and validation in specific populations, lack of external validation (for some of them) and also lack of synchrony with current era endovascular technology. However, with further optimization of current scores and the development of new scores, the field of PAD and CLI can be transitioned to a personalized medicine approach.
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Affiliation(s)
- Damianos G Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Adarsh Katamreddy
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Aurora, CO, United States
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Sotirios Georgopoulos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Theodore Liakakos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Aurora, CO, United States
| | - Christos Bakoyiannis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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6
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Manfrini O, Amaduzzi PL, Cenko E, Bugiardini R. Prognostic implications of peripheral artery disease in coronary artery disease. Curr Opin Pharmacol 2019; 39:121-128. [PMID: 29705248 DOI: 10.1016/j.coph.2018.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 03/07/2018] [Accepted: 04/05/2018] [Indexed: 12/24/2022]
Abstract
Prevalence of peripheral arterial disease in patients with coronary artery disease is considerably higher than in the general population. A graded increase in the risk of major cardiovascular events in a variety of clinical settings is associated with the number of arterial beds affected by peripheral arterial disease. This is not surprising, considering that both coronary artery disease and peripheral arterial disease are linked to a higher prevalence of cardiovascular risk factors and a greater incidence of atherosclerotic burden. Aggressive lipid lowering therapy is associated with less coronary and peripheral arterial disease progression and greater regression. On the contrary, blood pressure therapy should be carefully managed, considering the association of both high and low values of pressure with adverse outcomes.
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Affiliation(s)
- Olivia Manfrini
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Peter Louis Amaduzzi
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Edina Cenko
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Raffaele Bugiardini
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy.
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Abstract
General thinking has previously centered on managing carotid artery stenosis (CAS) by carotid endarterectomy and subsequently, stenting for higher risk patients. However for CAS and other forms of vascular disease, especially when asymptomatic, there is new emphasis on defining underlying mechanisms. Knowledge of these mechanisms can lead to medical treatments that result in possible atherosclerotic plaque stabilization, and even plaque regression, including in the patient with CAS. For now, the key medication class for a medical approach are the statins. Their use is supported by good cardiovascular clinical trial evidence including some directed carotid artery studies, especially with a demonstrated decrease in carotid intima-media thickness. Procedural controversy still exists but the current era in medicine offers significant support for medical management of asymptomatic CAS while techniques to recognize the vulnerable plaque evolve. If CAS converts to a symptomatic status, early referral for endarterectomy or stenting is indicated.
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Affiliation(s)
- Thomas F Whayne
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, Kentucky
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8
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Ruiz Ortiz M, Ogayar C, Romo E, Mesa D, Delgado M, Anguita M, Castillo JC, Arizón JM, Suárez de Lezo J. Long-term survival in elderly patients with stable coronary disease. Eur J Clin Invest 2013; 43:774-82. [PMID: 23659664 DOI: 10.1111/eci.12105] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Accepted: 04/10/2013] [Indexed: 12/24/2022]
Abstract
BACKGROUND This study aimed to assess long-term prognosis of stable coronary artery disease (sCAD) in patients aged ≥ 75 years and to identify clinical predictors of cardiovascular and overall mortality. MATERIALS AND METHODS From February 2000 to January 2007, 391 outpatients aged ≥ 75 years (median 78 years, interquartile range [IQR] 76-81 years, 66% male) with sCAD were recruited in this prospective cohort study. Associations of baseline variables with long-term cardiovascular and all-cause death were investigated. RESULTS After up to 11 years of follow-up (median 4 years, IQR 2-6 years), 89 patients died (23%, 5·45%/year), 35 from cardiovascular causes (9%, 2·14%/year). Multivariate analysis identified family history of coronary disease (HR 4·28, 95% CI 1·22-15·02, P = 0·02), baseline atrial fibrillation (HR 3·18, 95% CI 1·37-7·39, P = 0·007), age (HR 1·61 per 5 year increase, 95% CI 1·04-2·50, P = 0·03), resting heart rate (HR 1·26 per 5 bpm increase, 95% CI 1·09-1·47, P = 0·003) and previous revascularization (HR 0·17, 95% CI 0·04-0·77, P = 0·02) as independent predictors of cardiovascular death, and previous acute coronary syndrome (HR 4·93, 95% CI 1·49-16·30, P = 0·009), baseline atrial fibrillation (HR 1·96, 95% CI 1·12-3·43, P = 0·02), tobacco use (HR 1·69, 95% CI 1·00-2·84, P = 0·049 for ex-smoking and HR 6·78, 95% CI 0·89-51·47, P = 0·06 for active smoking), age (HR 1·58 per 5 year increase, 95% CI 1·18-2·11, P = 0·002), resting heart rate (HR 1·10 per 5 bpm increase, 95% CI 1·00-1·22, P = 0·05) and diastolic blood pressure (HR 0·97, 95% CI 0·94-0·99, P = 0·01) as independent predictors of overall mortality. CONCLUSIONS In this study, 4-years overall mortality was 23% among elderly patients with sCAD. Simple clinical variables can identify patients at higher risk of mortality.
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Affiliation(s)
- Martín Ruiz Ortiz
- Cardiology Department, Reina Sofía University Hospital, Córdoba, Spain.
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9
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Paraskevas KI, Mukherjee D, Whayne TF. Peripheral arterial disease: implications beyond the peripheral circulation. Angiology 2012; 64:569-71. [PMID: 23221278 DOI: 10.1177/0003319712466730] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Peripheral arterial disease (PAD) affects a considerable percentage of the population. The manifestations of this disease are not always clinically overt. As a result, PAD remains underdiagnosed and undertreated. PAD is not just a disease of the peripheral arteries, but also an indication of generalized vascular atherosclerosis. PAD patients also have a high prevalence of other arterial diseases, such as coronary/carotid artery disease and abdominal aortic aneurysms. PAD is also a predictor of increased risk of lung and other cancers. The most often used examination for the establishment of the diagnosis of PAD, the ankle-brachial pressure index (ABPI), is also a predictor of generalized atherosclerosis, future cardiovascular events and cardiovascular mortality. Several markers that have been linked with PAD (e.g. C-reactive protein, serum bilirubin levels) may also have predictive value for other conditions besides PAD (e.g. kidney dysfunction). The management of PAD should therefore not be restricted to the peripheral circulation but should include measurements to manage and decrease the systemic atherosclerotic burden of the patient.
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