Simultaneous Arterial Pressure Recordings Improve the Detection of Endofibrosis

Calf and non-calf hemodynamic recovery in patients with arterial claudication: Implication for exercise training

BACKGROUND

Previous studies in patients with arterial claudication have focused on calf hemodynamic recovery. We hypothesized that the duration of hemodynamic recovery with TcpO2 at calf and non-calf levels would be shorter than 10 min. We analyzed the factors that influence the recovery time.

METHODS

We monitored limb changes minus chest changes from rest (DROP) of transcutaneous oximetry on buttocks, thighs and calves, during and following a treadmill test (3.2 km/h; 10% grade). We calculated the time required to reach 50% (50%RT) and 10% (90%RT) of minimal DROP value (DROPm) from walking cessation. Regression analyses were used to determine the factors associated to 50%RT and 90%RT.

RESULTS

Of the 132 patients studied, 18.2% reported isolated non-calf pain by history. Of the 792 recovery time values, only 3 (0.4%) and 23 (2.9%) were in excess of 10 min for 50%RT and for 90%RT, respectively. A weak correlation was found between each of the 792 DROPm and 50%RT (r = -0.270, p < 0.001) as well as for 90%RT (r = -0.311 p < 0.001). Lowest DROPm and BMI (but not age, sex, the use of beta-blockers, the duration of the walking period) were associated to both 50%RT and 90%RT.

CONCLUSION

Although recovery duration correlates significantly with the severity of ischemia of the same location, a wide discrepancy exists and the longest recovery time does not always correlate to the localization of the most severe ischemia. Non-calf ischemia should be measured when one aims at objectifying the biological effects of exercise or the effects of treatments on recovery from exercise.

Arterial endofibrosis in endurance athletes: Prospective comparison of the diagnostic accuracy of intra-arterial digital subtraction angiography and computed tomography angiography

PURPOSE

To prospectively compare the diagnostic capabilities of computed tomography angiography (CTA) to those of digital subtraction angiography (DSA) in endurance athletes with suspicion of arterial endofibrosis.

MATERIALS AND METHODS

Forty-five athletes (39 men, 6 women; median age: 30 years, interquartile range: 23-42 years) prospectively underwent DSA and CTA without (n=5) or with (n=40) electrocardiogram gating. DSA was interpreted by a single expert (experience of 15 years). CTA was independently interpreted by three other readers (experience of 5-8 years). Readers assessed the presence and degree of stenoses on iliac and femoral arteries and the overall diagnosis (negative, uncertain, positive) of endofibrosis at the limb level. Sensitivities and specificities of DSA and CTA were estimated at the limb level using histological findings and long-term follow-up as reference, and compared using the McNemar test.

RESULTS

For diagnosing and quantifying stenoses, concordance between DSA and CTA was moderate-to-good for common and external iliac arteries, moderate for lateral circumflex arteries and poor-to-moderate for the other branches of the deep femoral artery. It was good for all readers for the overall diagnosis of endofibrosis. After long-term follow-up (median, 95 months; interquartile range: 7-109 months), DSA sensitivity and specificity were respectively 88.6% (39/44; 95% confidence interval [CI]: 76-95%) and 75% (24/32; 95% CI: 57.9-86.7%); CTA sensitivity and specificity were respectively 88.6% (39/44; 95% CI: 76-95%; P>0.99) and 84.4% (27/32; 95% CI: 68.2-93.1%; P=0.51), 86.3% (38/44; 95% CI: 73.3-93.6%; P>0.99) and 75% (24/32; 95% CI: 57.9-86.7%; P>0.99), and 84.1% (37/44; 95% CI: 70.6-92.1%; P=0.68) and 75% (24/32; 95% CI: 57.9-86.7%; P>0.99) for the three readers.

CONCLUSION

CTA shows performances similar to those of DSA in predicting the long-term diagnosis of endofibrosis in endurance athletes with suggestive symptoms.

Post-exercise ankle blood pressure and ankle to brachial index after heavy load bicycle exercise

The American Heart Association (AHA) recommendations for diagnosing peripheral artery disease (PAD) after exercise are a decrease >20% of ankle brachial index (ABI) or >30 mm Hg of ankle systolic blood pressure (ASBP) from resting values. We evaluated ABI and ASBP values during incremental maximal exercise in physically active and asymptomatic patients. Patients (n = 726) underwent incremental bicycle tests with pre- and post-exercise recording of all four limbs arterial pressures simultaneously. Univariate and multivariate analyses were performed to define the correlation between post-exercise ABI with various clinical factors, including age. Thereafter, the population was divided into groups of age: less than 40 (G < 40), from 40 to 44 (G40/44) from 45 to 49 (G45/49), from 50 to 54 (G50/54), from 55 to 59 (G55/59), from 60 to 64 (G60/64), and 65 and above (G ≥ 65) years. Results are mean ± SD. * is two-tailed P < .05 for ANOVA with Dunnett's post-hoc test from G40. Changes from rest in ASBP were -3 ± 22 (G < 40), -2 ± 20 (G40/44), 4 ± 22* (G45/49), 10 ± 25* (G50/54), 18 ± 21* (G55/59), 23 ± 27* (G60/64), and 16 ± 22* (G ≥ 65) mm Hg. Decreases from rest in ABI were 32 ± 9 (G < 40), 33 ± 9 (G40/44), 29 ± 8 (G45/49), 27 ± 10* (G50/54), 24 ± 7* (G55/59), 22 ± 12* (G60/64), and 21 ± 12* (G ≥ 65) % of resting ABI. Maximal incremental exercise results in ABI and ASBP changes are mostly dependent on age. The AHA limits for post-exercise ABI are inadequate following maximal incremental bicycle testing. Future studies detecting PAD in active patients should account for the effect of age.

Discrepancies in Prevalence of Peripheral Arterial Disease between Lower Extremities at Rest and Postexercise

Background  Lower extremity peripheral arterial disease (PAD) is a common medical condition causing substantial morbidity. Limited data exist on whether discrepancies in PAD prevalence exist between the lower extremities using resting ankle-brachial indices (ABIs) and postexercise pressures. Objective  We predicted the prevalence of PAD between the lower extremities. Methods and Results  Consecutive patients who had undergone a noninvasive arterial lower extremity study at Mayo Clinic, Rochester, MN, between January 1996 and December 2012 with suspected PAD were retrospectively reviewed. We identified 12,312 consecutive patients who underwent an arterial lower extremity and an exercise treadmill study. Prevalence of PAD was assessed at rest and after exercise using two criteria: a resting ABI ≤ 0.90 and a postexercise pressure decrease of > 30 mm Hg. Mean age was 67 ± 12 years and there were 4,780 (39%) women studied. At rest, we found a higher prevalence of PAD on the left extremity (27.4%) compared with the right (24.6%) ( p  < 0.0001). After exercise, we found a higher prevalence of PAD on the right extremity (25.1%) compared with the left (19.0%) ( p  < 0.0001). These discrepancies between the prevalence of PAD at rest and after exercise were present in women and men. Conclusion  Using validated criteria of a resting ABI of ≤ 0.90 and postexercise ankle pressure decrease > 30 mm Hg, our results suggest that there is a significantly higher prevalence of PAD in the left lower extremity at rest, in contrast to a greater prevalence of abnormal postexercise testing in the right lower extremity. The reason(s) of these discrepancies remain to be studied.

Time and reliability issues associated with automatic vs. manual measurements of Ankle to Brachial pressure Index (ABI) following heavy load exercise

OBJECTIVES

Ankle to brachial index after heavy load exercise is the most accurate way of diagnosing minor arterial lesions in athletes, such as endofibrosis. The reliability and practical aspects of ankle to brachial index measurements after heavy-load exercise have not been studied. The purpose of this study was to analyze the interest of oscillometric automatic vs. manual Doppler measurements, for the calculation of ankle to brachial index, after heavy-load exercise in athletes.

DESIGN

Prospective single-center study.

METHODS

Fifteen healthy trained athletes performed an incremental test twice. Ankle to brachial index measurements were performed at Rest, as soon as possible after exercise (Rec-0), and then started at the 3rd minute of recovery (Rec-3), by two operators using each one of the two ankle to brachial index measurement methods.

RESULTS

Mean times for automatic vs. manual ankle to brachial availability were 99 ± 18 s vs. 113 ± 25 s (p = 0.005) and 44 ± 25 s vs. 53 ± 12 s (p = 0.001) respectively at Rec-0 and Rec-3. Ankle to brachial index values from the two methods were highly correlated (r = 0.89). Mean absolute differences of automatic vs. manual ankle to brachial values from test-retest were 0.04 ± 0.05 vs. 0.08 ± 0.08 (p > 0.05) and 0.07 ± 0.05 vs. 0.09 ± 0.10 (p > 0.05) at Rest and Rec-0.

CONCLUSIONS

Automatic method allows obtaining faster and simultaneously post-exercise ankle to brachial index measurement compare to the manual Doppler. This time issue does not result in a significant change in absolute ankle to brachial index values, nor in the absolute differences of these in test-retest. Nevertheless, the test-retest variability of post-exercise ankle to brachial index results seems smaller with the automatic than the manual method.

Endofibrosis in athletes: is a simple bedside exercise helpful or sufficient for the diagnosis?

OBJECTIVE

Ankle-to-brachial index (ABI) can be easily performed by all physicians. The Ruffier-Dickson (RD) test is an easy procedure to attain moderate exercise at the bedside for physicians who do not have an ergometer.

DESIGN

Retrospective analysis.

SETTING

Tertiary care, institutional practice.

PATIENTS

Fifty-three asymptomatic athletes and 22 patients suffering from unilateral pain due to histologically proven exercise-induced arterial endofibrosis (EIAE).

INTERVENTION

Brachial and ankle systolic blood pressures were measured in the supine position on the suspected leg in EIAE or left leg in controls, at rest (rest) and at the first minute of the recovery from incremental maximal cycle ergometer exercise (maxCE) and Ruffier-Dickson (RD) exercise tests.

MAIN OUTCOME MEASURES

Comparison of ABI(rest), ABI(maxCE), and ABI(RD) in discriminating patients from normal subjects, using receiver operating characteristics (ROC) curves.

RESULTS

Area (+/-SE of area) of ROC curve was 0.76 +/- 0.06 for ABI(rest), 0.83 +/- 0.05 for ABI(RD) (nonsignificant from rest), and 0.99 +/- 0.01 for ABI(maxCE) (P < 0.01 from ABI(RD) and P < 0.001 from ABI(rest)). An ABI(maxCE) below 0.48 was 100% specific and 80% sensitive for EIAE. For the RD test, a 100% negative predictive value was only attained for postexercise ABI values higher than 0.92.

CONCLUSION

ABI after maximal cycle ergometer exercise is more accurate than ABI after an RD test to search for unilateral EIAE in athletes.