Prevalence and correlates of symptomatic peripheral atherosclerosis in individuals with coronary heart disease and cholesterol levels less than 240 mg/dL: baseline results from the Cholesterol and Recurrent Events (CARE) Study

Risk Modification in Patients with Peripheral Arterial Disease: A Retrospective Survey

Peripheral arterial disease (PAD) is underdiagnosed and undertreated. This is despite the high vascular morbidity and mortality rates associated with PAD. There is also evidence that quitting smoking, improving the lipid profile, lowering the blood pressure, and administering antiplatelet drugs reduce the risk of vascular events in these patients. Secondary prevention for patients with PAD is yet to meet the standard of care for those with ischemic heart disease. The authors surveyed 200 claudicants attending a vascular clinic with additional follow-up in a risk modification clinic. After a median follow-up of 28 months (range: 6-65) there was a significant (p=0.001) improvement in walking distance; 34 patients (17%) had a vascular ischemic event. Of those, 11 patients (5.5%) had worsening intermittent claudication and 9 had a stroke/transient ischemic attack; 9 events (4.5%) were fatal. The lipid targets were met in 76% the patients. Half the smokers quit smoking and 94% of the patients were taking antiplatelet drugs or anticoagulants. Blood pressure reached the accepted target in 87% of the patients. Secondary prevention in patients with PAD may reduce the risk of vascular events. Aggressive risk modification is therefore recommended.

Long-term prognostic role of cerebrovascular disease and peripheral arterial disease across the spectrum of acute coronary syndromes

BACKGROUND

In acute coronary syndromes (ACS), the influence of cerebro-vascular disease (CVD) and/or peripheral artery disease (PAD) on short-midterm outcome has been well established. Data on long-term outcome however, are limited. Our study aimed to explore the effect of CVD and PAD on long-term outcome in a cohort of unselected ACS patients, including ST-elevation (STE-ACS) and non-ST-elevation (NSTE-ACS).

METHODS AND RESULTS

The population consisted of 2046 consecutive patients with a confirmed final diagnosis of ACS; 896 (44%) had STE-ACS and 1150 (66%) NSTE-ACS. CVD alone was present in 98 patients (5%), 282 (14%) had PAD alone, and 30 (1.5%) had both. All cause mortality at 5 years was lowest in patients without CVD/PAD (33%), intermediate in patients with either CVD or PAD (62% and 63%, respectively) reaching 80% in those with both CVD and PAD. These findings were confirmed in the STE-ACS and NSTE-ACS subgroups. CVD and PAD remained independent predictors of mortality after multivariable analysis, the combined presence of both carrying the highest risk within each ACS type (HR 4.15, 95% CI 1.83-9.44 for STE-ACS; HR 2.14, 1.29-3.54 for NSTE-ACS). Patients with CVD and/or PAD were less likely to be treated invasively and received less evidence-based treatment at discharge.

CONCLUSIONS

Across the spectrum of ACS, extracardiac vascular disease harbors a negative long-term prognosis that worsens progressively with the number of affected arterial beds.

Epidemiology of smoking-induced cardiovascular disease

Cigarette smoking is a major cause of coronary heart disease, stroke, aortic aneurysm, and peripheral vascular disease. The risk is manifest both as an increased risk for thrombosis of narrowed vessels and as an increased degree of atherosclerosis in those vessels. The cardiovascular risks owing to cigarette smoking increase with the amount smoked and with the duration of smoking. Risks are not reduced by smoking cigarettes with lower machine-measured yields of tar and nicotine, but those who have only smoked pipes or cigars seem to have a lower risk for cardiovascular diseases. Cessation of cigarette smoking reduces disease risks, although risks may remain elevated for a decade or more after cessation.

Process of care and outcomes in peripheral arterial disease

Peripheral arterial disease (PAD) is a prevalent illness that most commonly affects patients older than 60 years. As the population ages, the prevalence of PAD and its associated adverse outcomes will also increase. Adverse outcomes in PAD are either systemic (ie, cardiovascular events such as myocardial infarctions or strokes) or localized to the legs (ie, bypass surgery or amputation). Although much research has focused on adverse systemic outcomes in patients with PAD, less is known about those factors related to adverse limb events. The Centers for Disease Control and Prevention estimate that more than 100,000 amputations are performed in the United States each year. What remains to be determined is the association between how physicians manage patients with PAD (ie, process of care) and the development of adverse limb outcomes. Determining the association of the management of PAD with adverse limb outcomes will highlight those areas in which to focus to improve the quality of care for patients with this disease. Understanding the relationship between risk factors, process of care, and outcomes will be of importance to patients, clinicians, and policy makers. The purpose of this article is to review the burden of PAD and to discuss the association of process of care with adverse limb outcomes in patients with PAD.

Extent and severity of atherosclerotic vascular disease in patients undergoing coronary angiography--the Kuwait Vascular Study

Only a few angiographic studies have correlated the presence and severity of coronary artery disease with atherosclerosis in other arteries. The presence of disease in more than 1 area clearly has important implications on management. One hundred and seventy eight patients had angiographic evaluation of their peripheral arteries and abdominal aorta after routine diagnostic coronary angiography. The extent and severity of vascular disease was correlated with those of coronary artery disease. Of the 178 patients, 73.6% were men (mean age +/- sd was 52.93 +/- 10.12 years). Hypercholesterolemia (59%), systemic hypertension (56.7%) and diabetes mellitus (50.6%) were the major risk factors. Triple-vessel coronary artery disease was present in 48.9%, and 13.5% had normal coronaries. A new atherosclerotic vascular disease score, which reflects the presence and severity of atherosclerotic vascular disease elsewhere, was seen to correlate significantly with the extent of coronary artery disease. Of particular interest was the involvement of the first part of the vertebral artery in 41.6% of patients. The combined involvement of the abdominal aorta, renal artery, and iliac artery segments (together referred to as the lower body segment) was seen almost exclusively in those with 2- or 3-vessel coronary artery disease. Also there was a direct correlation between the extent of coronary artery disease and the score in the lower body segment as opposed to the upper body segment (subclavian, vertebral, and internal mammary arteries). The presence of atherosclerotic vascular disease correlated with the severity of coronary artery disease, particularly in respect to disease in the lower body segment. Thus early detection of such disease in the iliac or femoral arteries has a potential for early diagnosis of significant coronary artery disease.

Atherosclerotic lesions are more frequent in femoral arteries than in carotid arteries independent of increasing number of risk factors

The authors investigated the prevalence of atherosclerotic lesions in carotid and femoral arteries in people with varying risk factors. They searched for differences in the region of manifestation of atherosclerosis due to different risk factors. Over 5 years they investigated 4,200 people (2,600 men, 1,600 women aged 20 to 70 years) who reported feeling healthy. They did a B-mode sonography of the internal, external, and common carotid artery; and the common, the proximal superficial, and profundal femoral artery. They questioned the people regarding hypertension, hypercholesterolemia, diabetes mellitus, and smoking habits. Isolated carotid artery atherosclerosis was found in 2.8% of the men and 1.6% of the women; 10.9% of the men and 4.4% of the women had isolated femoral artery lesions. A combination of atherosclerotic lesions in both arteries was present in 8.3% of the men and 4.0% of the women. When only one risk factor was present atherosclerotic lesions of the femoral arteries were predominant. Diffuse atherosclerosis dominated with increasing number of risk factors. The rate of people with isolated carotid atherosclerosis was highest when no risk factor was present and decreased to a fixed rate of 12% to 17% independent of the number of risk factors. An increasing number of risk factors can be associated with a diffuse manifestation of atherosclerotic lesions. However, there are a certain number of people who demonstrate only carotid artery or femoral artery atherosclerosis independent of the number of risk factors.

Cardiovascular risk factors associated with clinically isolated and diffuse atherosclerosis in Spanish patients with coronary artery disease

BACKGROUND

Patients with coronary artery disease (CAD) associated with peripheral (PAD) or cerebrovascular disease (CVD), a condition called diffuse atherosclerosis, have a higher risk of death than patients with isolated CAD. The prevalence of diffuse atherosclerosis and the atherogenic risk factors associated with this condition in our geographic area have not been described previously.

METHODS

A cohort of 2597 patients (62 +/- 10.8 years, 665 women) consecutively admitted at Bellvitge Hospital because of acute coronary syndromes were studied. CAD patients were divided in two groups with diffuse and located atherosclerosis according to whether they had or they had not an associated PAD or CVD. Baseline history, physical data and lipid profile were recorded in each patient according to a standardized questionnaire.

RESULTS

A total of 370 patients (14.2%) had diffuse atherosclerosis. Among them, there were more men and women older than 55 years than among those with isolated CAD. Patients with diffuse atherosclerosis were more frequently hypertensive, diabetic and former smokers than those with isolated CAD (60.5% vs. 49.4%, P < 0.01; 37.4% vs. 24.5%, P < 0.01; and 47% vs. 35.7%, P < 0.01, respectively). There were no significant differences in the mean values of total cholesterol (TC), low-density cholesterol (LDL-C), high-density cholesterol (HDL-C) and triglycerides between both groups of patients, but patients with diffuse atherosclerosis had a lower HDL-C/TC ratio, with borderline statistical significance (0.18 +/- 0.06 vs. 0.19 +/- 0.06, P = 0.06). Using multiple logistic regression analysis, the variables associated with diffuse atherosclerosis in men were age greater than 55 years (OR 1.97, CI 1.33-2.93), hypertension (OR 1.50, CI 1.14-2.20), diabetes (OR 1.78, CI 1.20-2.70), smoking (former smokers) (OR 2.09, CI 1.36-3.24) and HDL-C/TC < 0.20 (OR 1.60, CI 1.18-2.17); and in women hypertension (OR 3.43, CI 1.48-7.94) and diabetes (OR 2.58, CI 1.55-4.80).

CONCLUSIONS

Clinically overt diffuse atherosclerosis is a relatively common disease. Older patients and those with hypertension, diabetes or low HDL-C/TC ratio are more likely to have diffuse atherosclerosis than those without these conditions.

A lipid hypothesis: prediction, observation and the triglyceride/HDL gap

Lowering serum lipid levels prevents myocardial infarctions. But are we targeting the right lipoproteins in our preventive therapy? Are we getting the maximum benefit? Triglycerides certainly deserve more attention than they have yet received. Most of the trials of lipid-lowering therapy have ignored them and this omission may explain the divergence between the fall in morbidity predicted from the epidemiological evidence and the reductions observed in the clinical trials. The evidence that the statins reduce coronary morbidity and mortality, and that this reduction is associated with a fall in LDL cholesterol, is overwhelming. But the potential value of the statins may be limited by their relative inability to increase the concentration of cardioprotective HDL. The fibrates, either alone, or in combination with a statin, retain a central role in the management of patients with mixed hyperlipidaemia who are undoubtedly at high risk of premature coronary artery disease.