Diagnostic value of signs and symptoms associated with peripheral arterial occlusive disease seen in general practice: a multivariable approach

Mortality of older persons with and without abnormalities in the physical examination of arterial system

BACKGROUND

Ankle-brachial index (ABI) is a screening tool for peripheral arterial disease (PAD). However, persons with normal ABI may still exhibit abnormalities in the physical examination of arterial system (PHEA).

OBJECTIVE

In older persons from the PolSenior study, we aimed to assess the risk of total mortality associated with abnormalities in PHEA in the context of dichotomised ABI.

METHODS

We used data from the PolSenior survey and matched them with mortality information from the Polish Census Bureau. We obtained sociodemographic, medical history, and lifestyle data. The PHEA by a geriatrician included carotid, femoral, popliteal, posterior tibial and the dorsalis pedis arterial pulses, and auscultation of aorta, carotid, femoral, and renal arteries. Ankle-brachial index was tibial to brachial SBP ratio. We plotted the stratified Kaplan-Meier curves and used Cox's regression to assess the unadjusted and adjusted influence of PHEA result on time to death.

RESULTS

The mean (standard deviation, SD) age of 852 persons (46.7% women) was 74.7 (10.6) years. In the ABI < 0.9 group, the PHEA was not associated with mortality. However, in the ABI ≥ 0.9 group, both in unadjusted and adjusted (RHR; 95% CI: 1.08; 1.02-1.16, p = 0.01) Cox regression, PHEA greater by 1 score was associated with mortality. Presence of 4 or more PHEA abnormalities was raising the risk in the ABI ≥ 0.9 group to the level associated with ABI < 0.9.

CONCLUSIONS

In the older persons with normal ABI, the greater number of abnormalities during physical examination of arteries may be indicative of higher risk of death.

Accurate Noninvasive Arterial Assessment of the Wounded Lower Limb: A Clinical Challenge for Wound Practitioners

Arterial investigations are an essential part of lower extremity wound assessment. The results of these investigations assist the wound clinician to determine the etiology of the wound, predict healing capacity, and inform further management. There are a number of noninvasive testing methods available to practitioners, all with varying levels of reliability and accuracy. Clinical wound assessment guidelines give varied recommendations when it comes to lower limb vascular assessment in the presence of a wound. This leaves clinicians with little guidance on how to choose the most appropriate test, and uncertainty remains about which tests provide the most accurate information in different patient-specific contexts. Conditions such as advanced age, diabetes, and renal disease are known to affect the accuracy of some commonly used lower limb arterial assessment methods, and alternate testing methods should be considered in these cases. This seminal review discusses the reliability and accuracy of lower limb vascular assessment methods used to guide lower limb arterial assessment in the presence of wounds.

Physical examination to screen for peripheral artery disease in a defined Primary Care population: A diagnostic accuracy study

INTRODUCTION

Peripheral arterial disease (PAD) is an underdiagnosed prevalent disease which implies high cardiovascular risk. Professionals usually depend on physical examination to screen for PAD.

OBJECTIVE

To assess the diagnostic accuracy of physical examination to screen for PAD in a rural Primary Care population and to evaluate the nurse-physician level of agreement in pedal pulse palpation.

METHODS

Diagnostic accuracy study in which two experienced professionals (physician-nurse) prospectively performed pedal pulse palpation (grading as absent, reduced, normal, or bounding), femoral bruit auscultation and calf circumference (index tests) comparing with Doppler ABI (reference test, positive cut-off: 0.9 ≥ ABI ≥ 1.4) in 158 consecutive subjects.

INCLUSION CRITERIA

presence of diabetes, dyslipidaemia, hypertension, smoking habit (current or former), or age ≥ 65.

RESULTS

Of 315 legs included, PAD was confirmed in 38 (12.1%) legs. Absent dorsalis pedis (DP) and posterior tibial (PT) pulses were found in 37 (11.7%) and 67 (21.3%) legs, respectively. Regarding nurse evaluation, when a positive test was set if DP or PT were absent (more sensitive cut-off), sensitivity was = 86.8 (95% CI: 74.8-98.9), specificity = 82.7 (95% CI: 78.0-87.3), likelihood ratio+ = 5.01 (95% CI: 3.77-6.67), likelihood ratio- = 0.16 (95% CI: 0.07-0.36), and diagnostic odds ratio (dOR) = 31.5 (95% CI: 11.7-84.8). Age, diabetes, and calcification (ABI ≥ 1.4) influenced the rate of a false negative finding in pedal palpation. Physician-nurse weighted kappa coefficient was = 0.649 (95% CI: 0.599-0.699). The presence of a femoral bruit auscultation had a dOR = 3.8 (95% CI: 1.1-13.1), and a calf circumference <34.55 cm had a dOR = 3.2 (95% CI: 1.6-6.4).

CONCLUSIONS AND RELEVANCE

In a mainly asymptomatic Primary Care population, pedal pulse palpation was by far the best diagnostic test, with good diagnostic accuracy and inter-rater agreement. In view of a high sensitivity and capacity to rule out the disease, pedal pulse palpation could be performed as a screening test for PAD and individuals at high cardiovascular risk.

Signs and symptoms in adult patients with acute dyspnea: a systematic review and meta-analysis

INTRODUCTION

Rapid and accurate diagnosis of patients with a new episode of acute dyspnea is a common challenge for Primary Care or Emergency Physicians.

OBJECTIVE

To determine the diagnostic accuracy of signs and symptoms in adult patients with a new episode of acute dyspnea presenting to a GP or an Emergency Physician (EP).

PATIENTS AND METHODS

This was a diagnostic systematic review. Using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, EMBASE, tracing references, and by contacting experts, studies were identified on the diagnostic accuracy of additional signs and symptoms in adult patients with acute or suddenly worsening dyspnea, presenting to a GP or an EP. Study quality was assessed using QUADAS and results were pooled using a random-effects model. Sensitivity, specificity, positive and negative likelihood ratio (NLR), and positive and negative predictive values for a diagnosis of heart failure (HF) were calculated for the combination of acute dyspnea and each additional sign or symptom in the selected studies.

RESULTS

Eight of the 24 identified studies were carried out in the ED and provided us with all the required data, including 4737 patients. All publications reported HF; two studies additionally investigated pulmonary embolism, acute exacerbations of chronic obstructive pulmonary disease or asthma, acute pulmonary infectious diseases, or acute coronary syndrome. The prevalence of HF in patients with acute dyspnea ranged from 25 to 59%. Heterogeneity was present in all analyses.Comparing signs and symptoms, sensitivity was very poor for the presence of fever (0.05) and sputum production (0.06), and poor for fatigue (0.36-0.76), orthopnea (0.2-0.76), paroxysmal nocturnal dyspnea (0.23-0.70), elevated jugular venous pressure (0.19-0.70), rales (0.32-0.88), and peripheral edema (0.29-0.77). Specificity was poor for fatigue (0.28-0.69), moderate for the presence of fever (0.76-0.88), sputum production (0.73-0.89), orthopnea (0.49-0.92), paroxysmal nocturnal dyspnea (0.52-0.93), and rales (0.31-0.98), and good for elevated jugular venous pressure (0.75-0.97) and peripheral edema (0.67-0.89).For all other signs and symptoms, sensitivities varied between 0.20 and 0.43; specificities for symptoms varied widely between 0.37 and 0.91 and those of signs between 0.20 and 1.0.The pooled sensitivities, however, remained poor: below 0.55. Pooled specificity of most signs ranged between 0.69 and 0.88. The positive likelihood ratio was between 0.64 and 4.11 and the NLR was between 0.59 and 1.29 with one outlier: rales (pooled NLR=0.35).

CONCLUSION

This systematic review, which only included patients from ED settings, did not identify any single sign or symptom that had acceptable sensitivity to be useful in ruling out a diagnosis of HF, chronic obstructive pulmonary disease, asthma, or pulmonary embolism. Elevated jugular venous pressure (0.88, pooled odds ratio: 7), added third heart sound (0.97), and lung crepitations (0.77, pooled odds ratio: 11) are useful in ruling in HF.

Why do authors derive new cardiovascular clinical prediction rules in the presence of existing rules? A mixed methods study

Background

Researchers should examine existing evidence to determine the need for a new study. It is unknown whether developers evaluate existing evidence to justify new cardiovascular clinical prediction rules (CPRs).

Objective

We aimed to assess whether authors of cardiovascular CPRs cited existing CPRs, why some authors did not cite existing CPRs, and why they thought existing CPRs were insufficient.

Method

Derivation studies of cardiovascular CPRs from the International Register of Clinical Prediction Rules for Primary Care were evaluated. We reviewed the introduction sections to determine whether existing CPRs were cited. Using thematic content analysis, the stated reasons for determining existing cardiovascular CPRs insufficient were explored. Study authors were surveyed via e-mail and post. We asked whether they were aware of any existing cardiovascular CPRs at the time of derivation, how they searched for existing CPRs, and whether they thought it was important to cite existing CPRs.

Results

Of 85 derivation studies included, 48 (56.5%) cited existing CPRs, 33 (38.8%) did not cite any CPR, and four (4.7%) declared there was none to cite. Content analysis identified five categories of existing CPRs insufficiency related to: (1) derivation (5 studies; 11.4% of 44), (2) construct (31 studies; 70.5%), (3) performance (10 studies; 22.7%), (4) transferability (13 studies; 29.5%), and (5) evidence (8 studies; 18.2%). Authors of 54 derivation studies (71.1% of 76 authors contacted) responded to the survey. Twenty-five authors (46.3%) reported they were aware of existing CPR at the time of derivation. Twenty-nine authors (53.7%) declared they conducted a systematic search to identify existing CPRs. Most authors (90.7%) indicated citing existing CPRs was important.

Conclusion

Cardiovascular CPRs are often developed without citing existing CPRs although most authors agree it is important. Common justifications for new CPRs concerned construct, including choice of predictor variables or relevance of outcomes. Developers should clearly justify why new CPRs are needed with reference to existing CPRs to avoid unnecessary duplication.

The role of the community clinician in early detection, referral and treatment of critical limb ischaemia

Critical limb ischaemia (CLI) is a significant public health issue worldwide, with an ever-growing incidence among people over 65. Awareness of CLI is low, particularly among non-vascular clinicians, leading to underdiagnosis and undertreatment. A diagnosis of CLI is known to have a grave effect on a person's quality of life, with devastating outcomes for both their life and limb, often resulting in uncontrolled pain, amputation or early death from a cardiovascular event. Community nurses and podiatrists are key clinicians who can play a crucial and active role in earlier identification, rapid referral and ongoing non-surgical care for this overlooked population.

Peripheral arterial disease associated with caries and periodontal disease

BACKGROUND

Peripheral arterial disease (PAD) is an important cardiovascular disorder of the peripheral arteries. Chronic infections, such as periodontitis, may play an important role in the etiology and pathophysiology of PAD and other cardiovascular conditions. Recently, Streptococcus mutans has been found with high frequency in atheromatous plaques. The aim of this study is to evaluate the possible clinical and microbiologic association between PAD and periodontitis and dental caries.

METHODS

Thirty patients with PAD and 30 control individuals were selected. PAD and its severity were established by the use of the ankle-brachial index (ABI). Clinical attachment loss (AL); probing depth; decayed, missing, and filled teeth (DMFT) index; and C-reactive protein (CRP) levels were evaluated. The presence of bacterial DNA from Streptococcus mutans, Porphyromonas gingivalis, Tannerella forsythia, Prevotella intermedia, Treponema denticola, and Aggregatibacter actinomycetemcomitans was identified by polymerase chain reaction in subgingival biofilm and serum.

RESULTS

Patients with ≥30% AL ≥ 4 mm had six-fold increased risk of having PAD (odds ratio = 8.18; 95% confidence interval = 1.21 to 35.23; P = 0.031). There was statistical difference in the CRP (P = 0.0413) and DMFT index (P = 0.0002), with elevated number of missing teeth (P = 0.0459) in the PAD group compared with the control group. There were no significant differences in the frequency of bacteria in serum and subgingival plaque.

CONCLUSION

There was a positive relationship between periodontitis based on AL and PAD determined by the ABI (odds ratio = 8.18).

Ankle-Brachial index by oscillometry: A very useful method to assess peripheral arterial disease in diabetes

Background:

Peripheral Arterial Disease (PAD) remains the least recognized form of atherosclerosis. The Ankle-Brachial Index (ABI) has emerged as one of the potent markers of diffuse atherosclerosis, cardiovascular (CV) risk, and overall survival in general public, especially in diabetics. The important reason for the lack of early diagnosis is the non-availability of a test that is easy to perform and less expensive, with no training required.

Objectives:

To evaluate the osillometric method of performing ABI with regard to its usefulness in detecting PAD cases and to correlate the signs and symptoms with ABI.

Materials and Methods:

Two hundred diabetics of varying duration attending the clinic for a period of eight months, from August 2006 to April 2007, were evaluated for signs, symptoms, and risk factors. ABI was performed using the oscillometric method. The positives were confirmed by Doppler evaluation. An equal number of age- and sex-matched controls, which were ABI negative, were also assessed by Doppler. Sensitivity and Specificity were determined.

Results:

There were 120 males and 80 females. Twelve males (10%) and six females (7.5%) were ABI positive. On Doppler, eleven males (91.5%) and three females (50%) were true positives. There were six false negatives from the controls (three each). The Sensitivity was 70% and Specificity was 75%. Symptoms and signs correlated well with ABI positives. Hypertension was the most important risk factor.

Conclusions:

In spite of the limitations, the oscillometric method of performing ABI is a simple procedure, easy to perform, does not require training and can be performed as an outpatient procedure not only by doctors, but also by the paramedical staff to detect more PAD cases.

The accuracy of the physical examination for the detection of lower extremity peripheral arterial disease

BACKGROUND

Peripheral arterial disease (PAD) is a major risk factor for adverse cardiovascular events. There has been a definite push for wider use of the ankle-brachial index (ABI) as a simple screening tool for PAD. Perhaps this has occurred to the detriment of a thorough physical examination.

OBJECTIVE

To assess the accuracy of the physical examination to detect clinically significant PAD compared with the ABI.

METHODS

PADfile, the PAD module of CARDIOfile (the Kingston Heart Clinic's cardiology database [Kingston, Ontario]), was searched for all patients who underwent peripheral arterial testing. Of 1619 patients, 1236 had all of the necessary data entered. Patients' lower limbs were divided into two groups: those with a normal ABI between 0.91 and 1.30, and those with an abnormal ABI of 0.90 or lower. Peripheral pulses were graded as either absent or present. Absent was graded as 0⁄3, present but reduced (1⁄3), normal (2⁄3) or bounding (3⁄3). Femoral bruits were graded as either present (1) or absent (0). Using the ABI as the gold standard, the sensitivity, specificity, negative predictive value (NPV), positive predictive value and overall accuracy were calculated for the dorsalis pedis pulse, the posterior tibial pulse, both pedal pulses, the presence or absence of a femoral bruit and, finally, for a combination of both pedal pulses and the presence or absence of a femoral bruit.

RESULTS

In 1236 patients who underwent PAD testing and who underwent a complete peripheral vascular physical examination (all dorsalis pedis and posterior tibial pulses palpated and auscultation for a femoral bruit), the sensitivity, specificity, NPV, positive predictive value and accuracy for PAD were 58.2%, 98.3%, 94.9%, 81.1% and 93.8%, respectively.

CONCLUSIONS

The clinical examination of the peripheral arterial foot pulses and the auscultation for a femoral bruit had a high degree of accuracy (93.8%) for the detection or exclusion of PAD compared with the ABI using the cut-off of 0.90 or lower. If both peripheral foot pulses are present in both lower limbs and there are no femoral bruits, the specificity and NPV of 98.3% and 94.9%, respectively, make the measurement of the ABI seem redundant. The emphasis in PAD detection should be redirected toward encouraging a thorough physical examination.

Foot temperature in healthy individuals: effects of ambient temperature and age

BACKGROUND

Patient complaints of excessively warm or cold feet are common in medical practice. Such symptoms can be caused by underlying vascular or neurologic disease, and measurement of foot temperature during daily activity and sleep could provide a deeper understanding of their actual thermal basis.

METHODS

We used a Thermochron iButton to assess surface foot temperature variation and its relationship to ambient temperature during the day with activity and at night during sleep in 39 healthy individuals aged 18 to 65 years in a temperate region of the United States. We simultaneously used actigraphy to record leg movement.

RESULTS

We identified a mean +/- SD awake temperature of 30.6 degrees +/- 2.6 degrees C and asleep temperature of 34.0 degrees +/- 1.8 degrees C, with values reaching as low as 15.9 degrees C in the winter and as high as 37.5 degrees C in the summer. Foot temperature was found to be independent of foot movement or sex; however, there was, as expected, a strong association between foot temperature and ambient temperature (r = .59, P < .001). Several measures of foot temperature variation demonstrated a significant or near-significant reduction with increasing age, including the Euclidean distance (r = -.38, P = .02) for awake periods and the variance (r = -.30, P = .06) during sleep.

CONCLUSIONS

These results provide data on the normal variation of foot temperature in individuals living in a temperate climate and demonstrate the potential use of Thermochron iButton technology in clinical contexts, including the evaluation of patients with excessively warm or cold feet.

Cardiovascular outcome stratification using the ankle-brachial pressure index

OBJECTIVES

To investigate, in patients with peripheral arterial disease (PAD), the association between the level of the Ankle-Brachial Pressure Index (ABPI) at time of diagnosis and clinical outcome.

METHODS

The data set of the Limburg PAOD Longitudinal Study (n=3649, mean follow-up time 7.2 years) was analyzed for this purpose. The ABPI was measured by trained personnel using handheld Doppler devices. Subjects were classified into 6 baseline ABPI categories ranging from ABPI > or = 1.10 ('certainly normal') to ABPI<0.50 ('seriously reduced'). Outcome measures were progressive limb ischaemia, cardiovascular morbidity and cardiovascular mortality. Cox proportional hazard models were used to investigate the associations (including hazard ratio's, HR) between different ABPI categories and outcome events.

RESULTS

As compared to persons with an ABPI > or = 1.10 ('certainly normal'), patients with a baseline ABPI <1.00 (categories 'probably normal' and worse) were at high risk to develop progressive limb ischaemia (HR 3.3 - 9.0). Additionally, patients with a baseline ABPI <0.90 (categories 'moderately reduced' and worse) were at higher risk to experience a non-fatal cardiovascular disease (HR 1.5 - 1.7). Moreover, patients with a baseline ABPI <0.70 ('clearly' and 'seriously' reduced ABPI) were at high risk to die from a cardiovascular or other cause (HR 2.3).

CONCLUSION

The ABPI can be helpful in identifying subjects at high risk for a poor cardiovascular outcome, in whom strict cardiovascular risk management would be appropriate.

[Evidence-based recommendations on primary diagnostics of peripheral arterial occlusive disease in geriatric patients]

The prevalence of peripheral arterial occlusive disease (PAOD) is high in elderly patients and its clinical manifestation is often atypical. Comorbidity and morbidity as a consequence of PAOD are significant. Therefore, standardized primary diagnostics are required among geriatric patients. Drawn from a search of the literature, evidence-based recommendations are provided. Pulse palpation and the evaluation of a patient's medical history are obligatory components of primary diagnostics, even in the absence of typical symptoms. In the case of pathological and ambiguous findings, measuring Doppler ankle pressures is suggested as the next diagnostic step. Further measures depend on the following factors: the presence of lesions on the leg with disturbed blood flow, predominantly in the foot and lower leg areas, degree of PAOD-related ailments, and, finally, intended surgery of the affected leg for other medical reasons.

Emerging Evidence for Neuroischemic Diabetic Foot Ulcers: Model of Care and How to Adapt Practice

Although neuropathic ulceration remains the commonest type of foot ulcers among patients with diabetes, recent data suggest that ischemic (and therefore, neuroischemic) ulcers are on the rise. The high prevalence and incidence of diabetes and its attendant foot complications, coupled with the current trend where increasingly diabetes care is being provided by general practitioners (primary care physicians) would mean that primary care practices are expected to see greater numbers of diabetic foot ulcer patients. Unfortunately, these settings are frequently ill-equipped to appropriately manage diabetic foot ulcers either due to lack of adequately trained personnel and access to multidisciplinary foot care teams. Whereas neuropathic foot ulceration may appear to be less challenging, neuroischemic or ischemic ulcers portend a higher risk of adverse outcomes, including non-healing, infection, amputation, and death. The last 2 decades have witnessed a paradigm shift from neuropathy as the main etiological factor in diabetic foot disease to an ever-increasing preponderance of ischemic and/or neuroischemic ulceration. Available literature does not always consider the limited access primary care practices have to specialized multidisciplinary foot care teams. Additionally, in the case of neuroischemic and/or ischemic ulcers, existing guidelines on their diagnosis and management are varied and unclear. This review aimed at providing a simple understanding to the complex evidence base for diagnosing and treating neuroischemic and/or ischemic ulcers in a primary care setting. It emphasizes the need for urgent vascular review in all patients with ischemic/ neuroischemic ulcers and advocates effective participation of vascular specialists in diabetic foot clinics and combined ward rounds.

Prospective assessment of lower-extremity peripheral arterial disease in diabetic patients using a novel automated optical device

A new optical device based on the photoplethysmograph (PPG) method and an innovative algorithm for the assessment of lower-extremity peripheral arterial disease was investigated prospectively in patients with type II diabetes. This new functional PPG (fPPG) technique uses a cuffless functional test to assess diabetic peripheral arterial disease without operator dependency and the incompressible arteries, issues associated with ankle brachial pressure index (ABPI) measurement. Diabetic patients (n = 24; 47 legs; age, 70 +/- 3 years) were recruited from the vascular clinic, and controls (n = 15; 30 legs; age, 66 +/- 5 years) were recruited from the orthopedic outpatient clinic. All underwent resting ABPI, fPPG, and duplex angiography (DA) as "gold standard." fPPG requires the placement of an optical probe on the toe for acquisition of pulsatile arterial perfusion for a period of 30 seconds with the leg in supine and raised at 45 degrees positions. The data were analyzed, and indices were generated by an automated computer system. In those with diabetes, fPPG correlated significantly with DA (r = -.68, P < .01) and ABPI (r = -.65, P < .01). We also found a significant correlation between ABPI and DA (r = .81, P < .01). The analysis of the receiver operator curve showed that optimum sensitivity and specificity for ABPI and fPPG were 80% and 93% and 83% and 71%, respectively, against DA. This method uses changes in pulsatile arterial blood volume using a simple cuffless functional test. The fPPG investigation period was much shorter (5 minutes) with independence of operator skills, whereas ABPI took longer (10-15 minutes) and required operator experience. Although the fPPG results are promising, further improvement (eg, by incorporation of functional skin color and temperature changes) is required to improve the sensitivity and specificity of the system.

Intermittent claudication in the Erfurt Male Cohort (ERFORT) Study: its determinants and the impact on mortality. A population-based prospective cohort study with 30 years of follow-up

AIMS

Intermittent claudication (IC) is the most common symptom of peripheral arterial disease and is associated with an increased mortality. Within the Erfurt Male Cohort (ERFORT) Study, one of the most long-lasting population-based prospective cohort studies in Europe, we investigated (i) which variables predict the development of incident IC determined by the WHO Rose questionnaire over a period of 15 years and (ii) if IC is predictive for 30 years all-cause mortality.

METHODS

The baseline survey examined a random population-based sample of 1160 males aged 40-59 years with three follow-up examinations 5, 10 and 15 years after enrollment using each time the Rose questionnaire.

RESULTS

An adjusted Cox regression analysis revealed smoking (HR (95% CI), 2.20 (1.24-3.92), p=0.01), diabetes mellitus (HR (95% CI), 4.68 (1.61-13.63), p=0.01) and coronary heart disease (HR (95% CI), 2.74 (1.08-6.96), p=0.03) to be significantly associated with incident IC. Participants with an IC had an significantly increased age-adjusted 30 years all-cause mortality (HR (95% CI), 1.56 (1.16-2.10), p=0.003). This association remained still significantly predictive after adjustment for other cardiovascular risk factors.

CONCLUSIONS

Mainly smoking and diabetes mellitus are associated with incident IC. A positive Rose questionnaire is a strong predictor for all-cause mortality over 30 years. The simplicity of their use makes questionnaires highly attractive for identification of high-risk patients in primary health care.

Effect of type 2 diabetes mellitus on exercise intolerance and the physiological responses to exercise in peripheral arterial disease

AIMS/HYPOTHESIS

There are conflicting data about the effect of type 2 diabetes mellitus on exercise tolerance in peripheral arterial disease. To elucidate this problem, we compared the tolerance and physiological responses to treadmill and cycle exercise in 31 patients with peripheral arterial disease and intermittent claudication.

MATERIALS AND METHODS

One group of these patients had type 2 diabetes (n = 12) and its members were matched for sex and age with a group of patients who did not have diabetes (n = 12). Since BMI and body weight were greater in the diabetic group (28.4 +/- 3.7 vs 25.2 +/- 2.4 kg/m(2); 84.0 +/- 14.6 vs 73.8 +/- 8.0 kg), we also studied a third, 'heavy' group of non-diabetic patients with claudication of similar age (n = 7; BMI = 30.9 +/- 5.3 kg/m(2); body weight = 85.2 +/- 8.2 kg).

RESULTS

Compared with the 'light' non-diabetic group, maximum treadmill times were shorter for the diabetic and heavy non-diabetic groups (1,448 vs 845 and 915 s; ANOVA p = 0.01); maximum cycle time also tended to be shorter (ANOVA, p = 0.08) in the diabetic and heavy non-diabetic groups (median = 1,231 vs 730 and 797 s). The majority of physiological responses assessed were not different between the groups, although the time constant of oxygen uptake during submaximal treadmill and cycle exercise was significantly larger (ANOVA p < 0.05) for the diabetic group.

CONCLUSIONS/INTERPRETATION

These data demonstrate that exercise tolerance is lower in diabetic than non-diabetic patients with claudication, but that this difference is due to obesity rather than diabetes itself.

Diagnostic Value of Proton MR Spectroscopy in Peripheral Arterial Occlusive Disease: A Prospective Evaluation

OBJECTIVE

The objective of the present study was to determine the detectability of metabolic alterations in patients with peripheral arterial occlusive disease (PAOD) using proton MR spectroscopy (hydrogen-1 MR spectroscopy).

SUBJECTS AND METHODS

Twenty-seven people were included in this study: 10 patients with PAOD and a pain-free walking distance of less than 200 m served as the patient group and 17 young healthy subjects served as a control group. Hydrogen-1 MR spectroscopy was performed on a 1.5-T scanner using an extremity coil and a point-resolved spectroscopy (PRESS) sequence (TR/TE, 1,500/30; 256 repetitions). For the patient group, a voxel was localized in the gastrocnemius muscle of the diseased leg. The data were processed using standard 1H MR spectroscopy tools. The identification of resonances detected on all MR spectra was made: intramyocellular lipids at 1.2 ppm, extramyocellular lipids at 1.6 ppm, lactate at 4.1 ppm, glucose with two main peaks at 3.4 and 3.8 ppm, choline at 3.2 ppm, and creatine at 3.0 and 3.9 ppm. To avoid operator bias, three spectral intensities were measured after correcting baseline and phase of MR spectra each time. The creatine signal was used as an internal reference; thus, all spectra were scaled relative to creatine. We compared the resultant intensity ratios between the two groups using the Mann-Whitney U test.

RESULTS

The lactate-creatine quotient was higher in the patient group, with a ratio of 1.6, than in the control group, with a ratio of 0.6. The glutamate-creatine ratio was higher in the patient group than in the control group (1.3 vs 0.8, respectively). All other ratios were higher in the control group. The best ratio for differentiating between healthy subjects and patients with PAOD was the glucose-lactate ratio. The patient group had a glucose-lactate quotient of 5.4, whereas the control group had a glucose-lactate quotient of 21.5 (p = 0.001).

CONCLUSION

Proton MR spectroscopy has the potential to allow identification of patients who have PAOD on the basis of altered muscle metabolism.

Absent pedal pulse and impaired balance in older people: a cross-sectional and longitudinal study

BACKGROUND AND AIMS

The purpose of this study was to determine the relationship between abnormal pedal pulse status and postural balance in older people.

METHODS

Prospective, population-based cohort study of older residents in the city of Jyväskylä, Finland. A total of 419 individuals aged 75 or 80 at baseline, with known lower extremity pulse status and balance tests performed on a force platform, were eligible for analysis.

RESULTS

Cross-sectionally, persons with both dorsal pedal artery pulses absent were found to sway more (p=0.047 anteroposterior velocity, normal standing eyes-open position). The risk of being unable to do the full tandem stance was twofold (OR=2.20, 95% CI 1.29-3.78) for persons without palpable dorsal pedal arteries compared with those with normal pulse status. Balance deterioration was observed at five years (p<0.001 for time) but without group-by-time interaction. At ten years, however, the interaction term became significant for the normal standing eyes-closed position (p=0.025 for anteroposterior velocity and p=0.026 for mediolateral velocity), indicating greater balance deterioration among those with both dorsal pedal artery pulses absent.

CONCLUSIONS

According to our study, the absence of both dorsal pedal artery pulses is associated with impaired balance in older people. The association was observed both cross-sectionally and longitudinally. In addition, as diminished pedal pulses are frequently associated with impaired lower extremity circulation, our results have also produced information on the possible pathophysiological mechanisms of balance deterioration in older people, which warrant further study.

Measurement, calculation, and normal range of the ankle-arm index: a bibliometric analysis and recommendation for standardization

Since its introduction in 1950, a variety of methods of measurement and calculation have been used to establish the ankle-arm index (AAI). This has resulted in variations of its normal range and difficulty in comparing study results. Hence, the objective of our study was to analyze the disparate methods used to assess AAI and its normal range and to recommend a standardized method to assess AAI based on that analysis. We made an inventory of the disparate AAI methods and its normal range reported in 100 randomly selected publications and recommend the means of such standardization. We recommend that an experienced observer assess AAI with the patient at rest in the supine position. The width of the sphygmometer cuffs should be 1.5 times that of the extremity to be measured, and brachial and crural pulses should be detected using a Doppler device. Systolic pressures should be measured at both arms and over the anterior and posterior arteries of both legs, with the cuff placed just proximally to the malleoli. The left arm pressure ought to be used as denominator and the mean of pressures of both crural arteries of each leg ought to be used for the numerator of the AAI for that leg. We advocate 0.90 as the cut-off value to distinguish patients who need further arterial assessment.

Validation of the auscultatory method for diagnosing peripheral arterial disease

BACKGROUND

The Ankle brachial index (ABI) has been shown to be useful in diagnosing peripheral arterial disease (PAD). Ankle systolic blood pressures are measured by a Doppler device; however, general physicians cannot always use it in daily practice. The ausculutatory method (AUS) is an alternative method and quite easy to perform, but has not yet been validated in diagnosing PAD.

OBJECTIVE

To validate AUS for diagnosing PAD based on ABI, compared with Doppler method as gold standard.

METHODS

Cross-sectional study. Study subjects were 119 patients aged 50 years and older, who were consecutively admitted to the division of general internal medicine in two community hospitals in Japan. We measured the systolic blood pressures of the brachial and the posterior tibial arteries by two methods. We calculated the ABI from the systolic blood pressure obtained by these two methods. PAD was considered to be present when ABI </=0.90 by the Doppler method.

RESULTS

PAD was diagnosed in 22 (18.5%) of 119 patients. Korotkoff sounds of legs were inaudible by AUS in 47 (39.5%) patients. The likelihood ratios for diagnosing PAD patients by AUS were 2.7 (95% CI 1.9 to 3.9) in cases with inaudible Korotkoff sounds, 0.7 (95% CI 0.2 to 1.9) when ABI </=0.9 and 0.09 (95% CI 0.02 to 0.4) when ABI >0.9.

CONCLUSIONS

While AUS is not efficient enough to confirm the presence of PAD based on ABI, it could be clinically useful in excluding PAD when ABI >0.90. When measuring ankle blood pressure by AUS in the daily practice, it is important to realise its strengths and weaknesses.

Peripheral arterial disease: comparison of color duplex US and contrast-enhanced MR angiography for diagnosis

PURPOSE

To prospectively compare the diagnostic accuracies of color duplex ultrasonography (US) and contrast material-enhanced magnetic resonance (MR) angiography and to assess interobserver agreement regarding contrast-enhanced MR angiographic findings in patients suspected of having peripheral arterial disease (PAD).

MATERIALS AND METHODS

The institutional review board approved the study, and all patients provided signed informed consent. Two hundred ninety-five patients referred for diagnostic and preinterventional work-up of PAD with duplex US also underwent gadolinium-enhanced MR angiography. Data sets were reviewed for presence or absence of 50% or greater luminal reduction, which indicated hemodynamically significant stenosis, and to determine interobserver agreement. At duplex US, a peak systolic velocity ratio of 2.5 or greater indicated significant stenosis. Primary outcome measures were differences between duplex US and contrast-enhanced MR angiography in sensitivity and specificity for detection of significant stenosis, as assessed with the McNemar test, and interobserver agreement between the two contrast-enhanced MR angiogram readings, expressed as quadratic weighted kappa values. Intraarterial digital subtraction angiography (DSA) was the reference standard.

RESULTS

Two hundred forty-nine patients had at least one hemodynamically significant stenotic lesion at contrast-enhanced MR angiography, duplex US, or both examinations. One hundred fifty-two patients underwent intraarterial DSA. The quadratic weighted kappa for agreement regarding the presence of 50% or greater stenosis at contrast-enhanced MR angiography was 0.89 (95% confidence interval [CI]: 0.87, 0.91). Sensitivity of duplex US was 76% (95% CI: 69%, 82%); specificity, 93% (95% CI: 91%, 95%); and accuracy, 89%. Sensitivity and specificity of contrast-enhanced MR angiography were 84% (95% CI: 78%, 89%) and 97% (95% CI: 95%, 98%), respectively; accuracy was 94%. Sensitivity (P = .002) and specificity (P = .03) of contrast-enhanced MR angiography were significantly higher.

CONCLUSION

Results of this prospective comparison between contrast-enhanced MR angiography and duplex US provide evidence that contrast-enhanced MR angiography is more sensitive and specific for diagnosis and preinterventional work-up of PAD.

Beauty is in the eye of the examiner: reaching agreement about physical signs and their value

Despite advances in other areas, evidence-based medicine is yet to make substantial inroads on the standard medical physical examination. We have reviewed the evidence about the accuracy and reliability of the physical examination and common clinical signs. The physical examination includes many signs of marginal accuracy and reproducibility. These may not be appreciated by clinicians and could adversely affect decisions about treatment and investigations or the teaching and examination of students and doctors-in-training. We provide a selected summary of the reliability and accuracy as well as important messages of key findings in the physical examination.

The case for early detection and integrated intervention in patients with peripheral arterial disease and intermittent claudication

Peripheral arterial disease (PAD) is defined as atherosclerotic disease of the aorta and arteries of the lower extremities. The most frequent manifestations of ischemia occur in the lower extremity arteries, with intermittent claudication as the most common symptom. Intermittent claudication, which is characterized by temporary pain brought on by muscle exertion, is usually experienced in the calf muscles and typically subsides with rest. The atherosclerotic nature of PAD/intermittent claudication makes it an important predictor of risk for cardio- and cerebrovascular disease, as well as limb loss. Thus, active screening and early diagnosis of PAD/intermittent claudication, in addition to aggressive management that incorporates risk factor modification, exercise therapy, platelet inhibition and other appropriate pharmacotherapy, and potential lifestyle changes, play important roles in overall patient management. Pharmacotherapy with cilostazol has been shown to improve maximal and pain-free walking distances. Uncontrolled and severely debilitating intermittent claudication may require revascularization.

Comparison of treatment plans for peripheral arterial disease made with multi-station contrast medium-enhanced magnetic resonance angiography and duplex ultrasound scanning

OBJECTIVE

This study was undertaken to investigate the effects of substituting multi-station total outflow contrast medium-enhanced magnetic resonance angiography (CE-MRA) for color duplex ultrasound (US) scanning on treatment planning in the diagnostic workup of patients with suspected or known peripheral arterial occlusive disease. Patients and methods One hundred consecutive patients referred because of suspected or proved peripheral arterial occlusive disease to a University Hospital underwent both aortoiliac duplex US scanning and multi-station total outflow CE-MRA. For 73 of these patients (57% men; mean age, 62 years) treatment or treatment plans could be retraced. Eighteen patients also underwent femoro-popliteal duplex US scanning. Three experienced vascular surgeons retrospectively formulated two sets of treatment plans based on standardized clinical parameters and either duplex US scanning or CE-MRA. The main outcome measure was proportion of patients for whom the treatment plan matched actual treatment without additional use of intra-arterial digital subtraction angiography. Actual treatment, based on all available information, including results of duplex US scanning, CE-MRA, and any other diagnostic tests, served as the standard of reference.

RESULTS

Duplex US scanning provided enough information for treatment planning in 46, 45, and 53 patients versus 67, 68, and 66 patients when CE-MRA was used (surgeons 1, 2, and 3, respectively; surgeons 1 and 2, P <.001; surgeon 3, P =.007). Treatment plans based on duplex US scanning exactly matched actual treatment in 37 of 73 patients (51%; surgeon 1), 36 of 73 patients (49%; surgeon 2), and 46 of 73 patients (63%; surgeon 3). Treatment plans based on CE-MRA exactly matched actual treatment in 56 of 73 patients (77%; surgeon 1), 55 of 73 patients (75%; surgeon 2), and 51 of 73 patients (70%; surgeon 3). Positive predictive value and negative predictive value of duplex US scanning as measures of ability to discriminate between surgical and nonsurgical treatment were 0 of 0 (undefined) and 43 of 46 (93%), 1 of 2 (50%) and 40 of 43 (93%), and 5 of 5 (100%) and 44 of 48 (92%) for surgeons 1, 2, and 3, respectively. For CE-MRA, positive and negative predictive values were 11 of 13 (85%) and 50 of 54 (93%), 10 of 12 (83%) and 51 of 56 (91%), and 8 of 13 (62%) and 48 of 53 (91%), respectively, for surgeons 1, 2, and 3.

CONCLUSION

Compared with aorto-iliac and femoro-popliteal duplex US scanning, multi-station total outflow CE-MRA is more effective for treatment planning in most patients with known or suspected peripheral arterial occlusive disease.

Peripheral arterial occlusive disease: prognostic value of signs, symptoms, and the ankle-brachial pressure index

OBJECTIVES

To determine whether different levels of the ankle-brachial pressure index (ABPI) are associated with an increased risk for progressive limb ischemia, nonfatal and fatal cardiovascular events. To investigate the prognostic value of signs and symptoms associated with peripheral arterial occlusive disease (PAOD).

DESIGN

Prospective follow-up study.

SETTING

Eighteen general practice centers in the Netherlands.

PARTICIPANTS

Three thousand six hundred forty-nine participants (53% female) with a mean age of 59 years (range: 40-78 years).

MAIN OUTCOME MEASURES

Progressive limb ischemia, cardiovascular morbidity and mortality.

RESULTS

At baseline, 458 participants had PAOD, defined as an ABPI < 0.95. Among these, 148 (32.2%) had an ABPI < 0.70. Cox proportional hazards models showed that after a mean follow-up period of 7.2 years, PAOD patients with an ABPI < 0.70 were at higher risk for cardiovascular death, compared with participants with a moderately reduced ABPI (< 0.95 - > or = 0.70): HR 2.3 versus 1.2. Older age, complaints of intermittent claudication, abnormal pedal pulses, elevated blood pressure, and coexisting cardiovascular disease at baseline were also significant independent prognostic factors for one or more of the adverse outcome events in these patients.

CONCLUSION

The ABPI is inversely associated with cardiovascular mortality in PAOD patients. A low ABPI is an independent predictor for cardiovascular mortality in PAOD patients.

New-onset palpitations in general practice: assessing the discriminant value of items within the clinical history

BACKGROUND

Palpitations are non-specific, with less than half of patients experiencing palpitations having a cardiac arrhythmia. Currently it seems that there is little evidence available to assist GPs in discriminating between patients complaining of palpitations who have significant cardiac arrhythmias and those who do not.

OBJECTIVES

Our aim was to estimate discriminant functions for specific items of clinical information in relation to the categorization of a patient (aged over 18 years) with a symptom of new-onset palpitations presenting to primary care.

METHODS

A network of 62 GPs spread amongst 36 practices agreed to recruit patients with new-onset palpitations over the course of a 9-month study period. Patients consenting to be involved in the study were asked a number of questions, focusing particularly on the medical history, and were requested to complete a Hospital Anxiety and Depression Scale. Each patient was also provided with a RhythmCard cardiac event recorder for up to 2 weeks and was asked to record their heart rhythm if they experienced palpitations. Odds ratios (adjusted for age and sex) were used to compare the clinical information obtained from patients with the final diagnosis.

RESULTS

Of the 139 patients with palpitations presenting to GPs, it would appear that males [odds ratio = 2.1 (1.0-4.5)], those with regular palpitations [odds ratio = 2.5 (1.0-5.8)], those experiencing palpitations at work [odds ratio = 3.0 (1.3-7.2)] and those experiencing palpitations affected by sleeping (odds ratio = 3.3 (1.4-7.7)] were more likely to have a cardiac cause for their palpitations. Similar findings were made in an analysis focusing solely on the 81 patients with a RhythmCard result. Furthermore, amongst this group, it is interesting to note that patients with regular palpitations were more than twice as likely to have a 'significant' cardiac arrhythmia as a cause for their palpitations. There were suggestions of dose-response effects between the rate of the palpitation, the duration of the palpitation and the likelihood of it being a 'significant' arrhythmia.

CONCLUSIONS

This study provides some information on the characteristics of patients reporting palpitations to GPs who may have 'significant' cardiac arrhythmias. Based on this work, we believe that a larger community-based study would be worthwhile and would provide useful and useable clinical discriminant information for GPs in the settings where they work and amongst the types of patients they encounter.