Incidence of peripheral arterial disease in the ARTPER population cohort after 5 years of follow-up

Alteration of the ankle brachial index, follow-up of patients at risk of peripheral arterial disease, a descriptive longitudinal study

Background The objective of this study was to detect peripheral arterial disease (PAD) by measuring the ankle-brachial index (ABI) in patients attending medical offices in primary health care who presented a moderate or high risk on the risk scale of Framingham. Design longitudinal descriptive. Setting urban health center. Materials and methods Patients at risk of peripheral arterial disease of the lower limbs: diabetes mellitus (DM), cardiovascular disease (CVD), high cardiovascular risk (HCR) (SCORE>5%), and/or compatible symptoms. Consecutive sampling, n=136 (expected prevalence 8%, alpha 0.05, precision 0.95, projected losses 20%). Dependent variable: ankle-brachial index (ABI). Independent variables: hypertension (HBP), age, sex, CVD, DM, glycosylated hemoglobin (HbA1C), hyperlipidemia (HLP), LDL cholesterol (LDL), smoking, body mass index (BMI), pulses, treatment. Multivariate analysis: linear regression. Confidence level 95%. Results From a sample of 136 patients, 90 were male (66.2%) and 46 were female (33.8%), with a mean age of 72.2 years (in 2021), and a standard deviation (SD) of 7. The prevalence of abnormal ABI (ABI <0.9) was 11%, with a mean ABI of 0.7 (SD 0.18). The bivariate analysis showed a significant relationship between abnormal ABI and pulse palpation (p<0.0001). Excluding patients with ABI ≥ 1.4, in the multivariate analysis (coefficient of determination 0.977), the B coefficients and their 95% confidence intervals (CI) are as follows: age B=0.006, 95% CI (0.002-0.010) (p=0.003); diabetes B=0.289, 95% CI (0.1-0.479) (p=0.003); pulse palpation B= -0.199, 95% CI (-0.289- -0.11) (p<0.0001). Conclusions Doctor consultations in primary care are a favorable context for making an early diagnosis of PAD, by measuring the ABI. The performance of the ABI should be included as part of the annual examination for chronic patients who regularly attend consultations, particularly those with moderate or high cardiovascular risk. In this way, preventive measures could be intensified to prevent future cardiovascular complications in these patients. The predictors of ABI are age, diabetes, and palpation of pulses.

[Evolution of the prevalence of peripheral artery disease in clinical practice: A descriptive population study with real databases (SIDIAP-CMBD)]

OBJECTIVE

To evaluate, with real world data (SIDIAP and CMBD), the evolution of the prevalence of peripheral arterial disease (PAD) in the Catalan population and the cardiovascular risk factors present in people with this pathology.

DESIGN

Longitudinal descriptive population study. SITE: Primary health care.

PARTICIPANTS

Patients listed in SIDIAP and CMBD with a diagnosis of peripheral artery disease between 2008 and 2018 ≥ 35 years, as well as those without a diagnosis, but with an ABI < 0.9 in SIDIAP.

INTERVENTIONS AND MAIN MEASUREMENTS

Main variable AP (ICD-9, ICD-10). Sociodemographic data, risk factors and cardiovascular disease, drug use and prevalent cardiovascular events at the time of diagnosis.

RESULTS

141,520 patients were studied. 75% had hypertension, 58% were smokers or former smokers, and 23% had a myocardial infarction. The global prevalence increased from 1.15% in 2008 to 3.10% in 2018. The prevalence of PAD increased with age, with a moderate increase at younger ages, and more pronounced in > 55 years, exceeding 10% in > 85 years.

CONCLUSION

This is a population study where it is observed that the evolution of the prevalence of peripheral artery disease has presented a constant increase during the years 2008-2018, being higher in men, especially from 55 years of age. Studies with large databases can facilitate the design and implementation of new policies in national health systems.

Body Fat Distribution, Cardiometabolic Traits, and Risk of Major Lower-Extremity Arterial Disease in Postmenopausal Women

OBJECTIVE

To assess the relationship between body fat distribution and incident lower-extremity arterial disease (LEAD).

RESEARCH DESIGN AND METHODS

We included 155,925 postmenopausal women with anthropometric measures from the Women's Health Initiative who had no known LEAD at recruitment. A subset of 10,894 participants had body composition data quantified by DXA. Incident cases of symptomatic LEAD were ascertained and adjudicated through medical record review.

RESULTS

We identified 1,152 incident cases of LEAD during a median 18.8 years follow-up. After multivariable adjustment and mutual adjustment, waist and hip circumferences were positively and inversely associated with risk of LEAD, respectively (both P-trend < 0.0001). In a subset (n = 22,561) where various cardiometabolic biomarkers were quantified, a similar positive association of waist circumference with risk of LEAD was eliminated after adjustment for diabetes and HOMA of insulin resistance (P-trend = 0.89), whereas hip circumference remained inversely associated with the risk after adjustment for major cardiometabolic traits (P-trend = 0.0031). In the DXA subset, higher trunk fat (P-trend = 0.0081) and higher leg fat (P-trend < 0.0001) were associated with higher and lower risk of LEAD, respectively. Further adjustment for diabetes, dyslipidemia, and blood pressure diminished the association for trunk fat (P-trend = 0.49), yet the inverse association for leg fat persisted (P-trend = 0.0082).

CONCLUSIONS

Among U.S. postmenopausal women, a positive association of upper-body fat with risk of LEAD appeared to be attributable to traditional risk factors, especially insulin resistance. Lower-body fat was inversely associated with risk of LEAD beyond known risk factors.

Effects of Three Different Methods Defining Onset of Peripheral Artery Disease on the Assessments of Incidence and Important Predictors - Results from the German Epidemiological Trial on Ankle Brachial Index (getABI)

Purpose

The common definition of asymptomatic peripheral artery disease (PAD) by a single determination of the ankle brachial index (ABI) has some uncertainty due to measurement errors. This may impact estimates of PAD incidence and assessment of PAD risk factors. To investigate this issue, we used three methods to define asymptomatic PAD and made use of data from the German Epidemiological Trial on Ankle Brachial Index (getABI).

Patients and Methods

A total of 6,880 unselected subjects aged ≥65 years, enrolled by 344 trained general practitioners, had ABI assessments at baseline and four visits during follow-up. The first approach defined asymptomatic PAD onset as soon as a single ABI value was below 0.9 (single ABI). The second approach employed a regression method using all available ABI values (regression A), while for the third approach (regression B), an extended regression beyond the last valid ABI value for the observation time of the study was allowed. For each approach, we calculated PAD incidence rates and assessed the effect of important PAD predictors using multivariable Cox proportional hazards regression.

Results

The regression method A showed the lowest (25.0 events per 1,000 person years) and the single ABI method the highest incidence rate (41.2). The regression methods assigned greater impact to several risk factors of incident PAD. Using regression A, the hazard ratios (HR) of active smoking (2.36; 95% CI 1.92 to 2.90) and of diabetes (1.33; 95% CI 1.13 to 1.56), using regression B the HR of older age (1.72; 95% CI 1.50 to 1.97) were about twice as high as the corresponding HR of the single ABI approach.

Conclusion

Use of the single ABI method leads to higher PAD incidence rates and to lower impact of important PAD predictors compared to regression methods. For an alert risk factor management, multiple ABI determination may be useful.

Socioeconomic factors and the onset of peripheral artery disease in older adults

Background: As evidence concerning the impact of socioeconomic factors on the risk of peripheral artery disease (PAD) is sparse, we assessed the association of education and area-level factors (population density, type of municipality and local unemployment rate) on the onset of PAD in older adults. Patients and methods: The analysis used data of the getABI study, a prospective cohort study with seven years of follow-up. Onset of PAD was determined by ankle brachial index (<0.9) or PAD symptoms. Cox regression analysis was employed. Results: Out of 5,444 primary care attendees without PAD at baseline, there were 1,381 participants with PAD onset (cumulative observation time 31,739 years), yielding an event rate of 43.5 (0.95 confidence interval [0.95 CI] 41.2-45.8) per 1,000 person-years. Multivariable Cox regression analysis showed an association of PAD onset with low education (hazard ratio 1.29; 0.95 CI 1.14-1.46; P<0.001), high population density (0.93; 0.89-0.98; P=0.002), small cities (compared to large cities) (0.71; 0.53-0.96; P=0.027) and high local unemployment rate (1.04; 1.00-1.07; P=0.032). The impact of low education on PAD onset was higher for men (2.11; 1.64-2.72) than for women (1.22; 1.07-1.40) (interaction term P=0.013). Conclusions: Socioeconomic factors, education as well as area-level socioeconomic indicators, make independent contributions to PAD onset in older adults.

Foot Health Assessment and Problem Identification in a Dominican Batey Community: A Descriptive Study

PURPOSE

Foot problems can adversely impact foot function and quality of life. Foot problems are often overlooked, particularly in populations with limited health care access. Little is known about the foot health of Haitian immigrants who live and work in the bateyes (rural sugarcane villages) of the Dominican Republic. These immigrant workers may experience foot problems that could affect foot function and the ability to work and provide for their families.

DESIGN

Cross-sectional, exploratory, descriptive study design.

SUBJECTS AND SETTING

A convenience sample of adults was recruited from an ongoing community-based participatory research project evaluating a mobile hypertension screening and treatment clinic program in 11 Dominican batey communities.

METHODS

Foot health was assessed using the Foot Problems Checklist, a 24-item survey instrument developed for this study based on a review of the literature and foot clinician expertise. A certified foot care nurse recorded foot health data on the Foot Problems Checklist via visual and physical inspection.

RESULTS

Study participants were 25 females and 16 males, aged 18 to 90 years, and all had at least one foot health problem. The most common foot problems were calluses (78%), dry skin (76%), thick nails (59%), jagged nails (29%), long/overgrown nails (17%), and skin fissures (12%).

CONCLUSIONS

While the foot problems we observed were not considered serious, they could become progressively debilitating and be prevented with proper self-management guided by appropriate knowledge and skills and available supplies. We recommend the development and testing of foot care self-management interventions deliverable via mobile clinics to increase access and improve foot health outcomes.

Diabetes as a risk factor for incident peripheral arterial disease in women compared to men: a systematic review and meta-analysis

Aims/hypothesis

Previous meta-analyses have suggested that diabetes confers a greater excess risk of coronary heart disease, stroke, vascular dementia, and heart failure in women compared to men. While the underlying mechanism that explains such greater excess risk is unknown, in the current meta-analysis we hypothesized that we would find a similar sex difference in the relationship between diabetes and peripheral arterial disease (PAD).

Methods

PubMed MEDLINE, the Cochrane Database of Systematic Reviews, and Embase were systematically searched for prospective population-based cohort studies, with no restriction on publication date, language, or country. We included studies that reported the relative risk (RR), and its variability, for incident PAD associated with diabetes in both sexes. We excluded studies that did not adjust at least for age, and in which participants had pre-existing PAD. In cases where sex-specific results were not reported, study authors were contacted. Random-effects meta-analyses with inverse variance weighting were used to obtain summary sex-specific RRs and the women: men ratio of RRs for PAD. The Newcastle–Ottawa scale was used to assess study quality.

Results

Data from seven cohorts, totalling 2071,260 participants (49.8% women), were included. The relative risk for incident PAD associated with diabetes compared with no diabetes was 1.96 (95% CI 1.29–2.63) in women and 1.84 (95% CI 1.29–2.86) in men, after adjusting for potential confounders. The multiple-adjusted RR ratio was 1.05 (95% CI 0.90–1.22), with virtually no heterogeneity between studies (I² = 0%). All studies scored 6–8, on the Newcastle–Ottawa scale of 0–9, indicating good quality. Eleven of the 12 studies that met review inclusion criteria did not report sex-specific relative risk, and these data were collected through direct correspondence with the study authors.

Conclusion/interpretation

Consistent with other studies, we found evidence that diabetes is an independent risk factor for PAD. However, in contrast to similar studies of other types of cardiovascular disease, we did not find evidence that diabetes confers a greater excess risk in women compared to men for PAD. More research is needed to explain this sex differential between PAD and other forms of CVD, in the sequelae of diabetes. In addition, we found that very few studies reported the sex-specific relative risk for the association between diabetes and PAD, adding to existing evidence for the need for improved reporting of sex-disaggregated results in cardiovascular disease research.

Low, borderline and normal ankle-brachial index as a predictor of incidents outcomes in the Mediterranean based-population ARTPER cohort after 9 years follow-up

BACKGROUND

Guidelines recommended adopting the same cardiovascular risk modification strategies used for coronary disease in case of low Ankle-brachial index (ABI), but here exist few studies on long-term cardiovascular outcomes in patients with borderline ABI and even fewer on the general population.

AIM

The aim of the present study was to analyze the relationship between long-term cardiovascular events and low, borderline and normal ABI after a 9-year follow up of a Mediterranean population with low cardiovascular risk.

DESIGN AND SETTING

A population-based prospective cohort study was performed in the province of Barcelona, Spain.

METHOD

A total of 3,786 subjects >49 years were recruited from 2006-2008. Baseline ABI was 1.08 ± 0.16. Subjects were followed from the time of enrollment to the end of follow-up in 2016 via phone calls every 6 months, systematic reviews of primary-care and hospital medical records and analysis of the SIDIAP (Information System for Primary Care Research) database to confirm the possible appearance of cardiovascular events.

RESULTS

3146 individuals participated in the study. 2,420 (77%) subjects had normal ABI, 524 (17%) had borderline ABI, and 202 (6.4%) had low ABI. In comparison with normal and borderline subjects, patients with lower ABI had more comorbidities, such as hypertension, hypercholesterolemia and diabetes. Cumulative MACE incidence at 9 years was 20% in patients with low ABI, 6% in borderline ABI and 5% in normal ABI. The annual MACE incidence after 9 years follow-up was significantly higher in people with low ABI (26.9/1000py) (p<0.001) than in borderline (6.6/1000py) and in normal ABI (5.6/1000py). Subjects with borderline ABI are at significantly higher risk for coronary disease (HR: 1.58; 95% CI: 1.02-2, 43; p = 0,040) compared to subjects with normal ABI, after adjustment.

CONCLUSION

The results of the present study support that low ABI was independently associated with higher incidence of MACE, ICE, cardiovascular and no cardiovascular mortality; while borderline ABI had significantly moderate risk for coronary disease than normal ABI.

Prescription rate of anti-atherosclerotic drugs in German nursing homes and its impact on outcome

BACKGROUND

Peripheral arterial disease (PAD) is one of the major manifestations of general atherosclerosis and strongly associated with increased cardiovascular morbidity and mortality. Because only few epidemiologic studies are available concerning the prevalence of PAD in inhabitants ≥ 80 years of age, we screened inhabitants of nursing care homes in Germany for PAD and cardiovascular diseases and to assess the one year mortality.

PATIENTS AND METHODS

We conducted a prospective cohort study, screening inhabitants of 42 nursing homes for PAD. Demographic data, comorbidities, cardiovascular risk factors and daily medication were collected. PAD was defined as ankle-brachial index < 0.9. During a follow up period of one year, cardio- and cerebrovascular events and mortality were recorded, as well as the rate of falls and major amputation.

RESULTS

1,329 probands (391 men, 938 women) > 60 years were eligible for further analysis. The mean age was 84.1 years (range 61-107 years) and the prevalence of PAD was 31.5 % . Media sclerosis was found in up to 17 %, and an existing diagnosis of PAD (in case of pathological ABI) and undertreatment was common. Probands with PAD were less likely to be treated according to guideline recommendations (antiplatelet therapy, beta blockers, statins) than probands with coronary artery disease (CAD). The overall one-year mortality was 19.8 % (n = 236), significantly higher than for a gender and age matched German population (p < 0.001).

CONCLUSIONS

The current study shows a high prevalence of PAD in German nursing care homes. The one year mortality was not significantly different between probands with PAD and those with severe PAD (defined as an ABI of ≤ 0.5), whereas a media sclerosis was associated with an increased risk in probands with CAD in comparison to those without. Use of anti-diabetic agents and aspirin in monotherapy was associated with a reduced one-year mortality risk.

Effectiveness of risk minimization measures for the use of cilostazol in United Kingdom, Spain, Sweden, and Germany

Purpose

The purpose of the study is to evaluate the effectiveness of risk minimization measures—labeling changes and communication to health care professionals—recommended by the European Medicines Agency for use of cilostazol for the treatment of intermittent claudication in Europe.

Methods

Observational study of cilostazol in The Health Improvement Network (United Kingdom), EpiChron Cohort (Spain), SIDIAP (Spain), Swedish National Databases, and GePaRD (Germany).

Among new users of cilostazol, we compared the prevalence of conditions targeted by the risk minimization measures in the periods before (2002‐2012) and after (2014) implementation. Conditions evaluated were prevalence of smoking, cardiovascular conditions, concurrent use of ≥2 antiplatelet agents, concurrent use of potent CYP3A4/CYP2C19 inhibitors and high‐dose cilostazol, early monitoring of all users, and continuous monitoring of users at high cardiovascular risk.

Results

We included 22 593 and 1821 new users of cilostazol before and after implementation of risk minimization measures, respectively. After implementation, the frequency of several conditions related to the labeling changes improved in all the study populations: prevalence of use decreased between 13% (EpiChron) and 57% (SIDIAP), frequency of cardiovascular contraindications decreased between 8% (GePaRD) and 84% (EpiChron), and concurrent use of high‐dose cilostazol and potent CYP3A4/CYP2C19 inhibitors decreased between 6% (Sweden) and 100% (EpiChron). The frequency of other conditions improved in most study populations, except smoking, which decreased only in EpiChron (48% reduction).

Conclusions

This study indicates that the risk minimization measures implemented by the EMA for the use of cilostazol have been effective in all European countries studied, except for smoking cessation before initiating cilostazol, which remains an area of improvement.

Twenty-Year Predictors of Peripheral Arterial Disease Compared With Coronary Heart Disease in the Scottish Heart Health Extended Cohort (SHHEC)

BACKGROUND

Coronary heart disease and peripheral arterial disease (PAD) affect different vascular territories. Supplementing baseline findings with assays from stored serum, we compared their 20-year predictors.

METHODS AND RESULTS

We randomly recruited 15 737 disease-free men and women aged 30 to 75 years across Scotland between 1984 and 1995 and followed them through 2009 for death and hospital diagnoses. Of these, 3098 developed coronary heart disease (19.7%), and 499 PAD (3.2%). Hazard ratios for 45 variables in the Cox model were adjusted for age and sex and for factors in the 2007 ASSIGN cardiovascular risk score. Forty-four of them were entered into parsimonious predictive models, tested by c-statistics and net reclassification improvements. Many hazard ratios diminished with adjustment and parsimonious modeling, leaving significant survivors. The hazard ratios were mostly higher in PAD. New parsimonious models increased the c-statistic and net reclassification improvements over ASSIGN variables alone but varied in their components and ranking. Coronary heart disease and PAD shared 7 of the 9 factors from ASSIGN: age, sex, family history, socioeconomic status, diabetes mellitus, tobacco smoking, and systolic blood pressure (but neither total nor high-density lipoprotein cholesterol); plus 4 new ones: NT-pro-BNP, cotinine, high-sensitivity C-reactive protein, and cystatin-C. The highest ranked hazard ratios for continuous factors in coronary heart disease were those for age, total cholesterol, high-sensitivity troponin, NT-pro-BNP, cotinine, apolipoprotein A, and waist circumference (plus 10 more); in PAD they were age, high-sensitivity C-reactive protein, systolic blood pressure, expired carbon monoxide, cotinine, socioeconomic status, and lipoprotein (a) (plus 5 more).

CONCLUSIONS

The mixture of shared with disparate determinants for arterial disease in the heart and the legs implies nonidentical pathogenesis: cholesterol dominant in the former, and inflammation (high-sensitivity C-reactive protein, diabetes mellitus, smoking) in the latter.