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Sheth MS, Yu B, Chu A, Porter J, Tam DY, Ferreira‐Legere LE, Goodman SG, Farkouh ME, Ko DT, Abdel‐Qadir H, Udell JA. Eligibility and Implementation of Rivaroxaban for Secondary Prevention of Atherothrombosis in Clinical Practice-Insights From the CANHEART Study. J Am Heart Assoc 2022; 11:e026553. [PMID: 36515238 PMCID: PMC9798819 DOI: 10.1161/jaha.122.026553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background The COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial decreased major adverse cardiovascular events with very low-dose rivaroxaban and aspirin in patients with coronary artery disease and peripheral artery disease. We examined the eligibility and potential real-world impact of this strategy on the COMPASS-eligible population. Methods and Results COMPASS eligibility criteria were applied to the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) registry, a population-based cohort of Ontario adults. We compared 5-year major adverse cardiovascular events and major bleeding rates stratified by COMPASS eligibility and by clinical risk factors. We applied COMPASS trial rivaroxaban/aspirin arm hazard ratios to estimate the potential impact on the COMPASS-eligible cohort. Among 362 797 patients with coronary artery disease or peripheral artery disease, 38% were deemed eligible, 47% ineligible, and 15% indeterminate. Among eligible patients, a greater number of risk factors was associated with higher rates of cardiovascular outcomes, whereas bleeding rates increased minimally. Over 5 years, applying COMPASS treatment effects to eligible patients resulted in a 2.4% absolute risk reduction of major adverse cardiovascular events and a number needed to treat of 42, and a 1.3% absolute risk increase of major bleeding and number needed to harm (NNH) of 77. Those with at least 2 risk factors had a 3.0% absolute risk reduction of major adverse cardiovascular events (number needed to treat =34) and a 1.6% absolute risk increase of major bleeding (number needed to harm =61). Conclusions Implementation of very-low-dose rivaroxaban therapy would potentially impact ≈$$ \approx $$2 in 5 patients with atherosclerotic disease in Ontario. Eligible individuals with ≥$$ \ge $$2 comorbidities represent a high-risk subgroup that may derive the greatest benefit-to-risk ratio. Selection of patients with high-risk predisposing factors appears appropriate in routine practice.
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Affiliation(s)
- Maya S. Sheth
- Women’s College Research InstituteTorontoCanada,Dalla Lana School of Public HealthUniversity of TorontoCanada
| | | | | | | | - Derrick Y Tam
- ICESTorontoCanada,Schulich Heart Centre, Sunnybrook Health Sciences CentreTorontoCanada,Institute of Health Policy, Management, and EvaluationUniversity of TorontoCanada
| | | | - Shaun G. Goodman
- Applied Health Research Centre, Li Ka Shing Knowledge InstituteSt Michael’s HospitalTorontoCanada,Department of Medicine, Faculty of MedicineUniversity of TorontoCanada
| | - Michael E. Farkouh
- Applied Health Research Centre, Li Ka Shing Knowledge InstituteSt Michael’s HospitalTorontoCanada,Department of Medicine, Faculty of MedicineUniversity of TorontoCanada,Peter Munk Cardiac CentreUniversity Health NetworkTorontoCanada
| | - Dennis T. Ko
- ICESTorontoCanada,Schulich Heart Centre, Sunnybrook Health Sciences CentreTorontoCanada,Institute of Health Policy, Management, and EvaluationUniversity of TorontoCanada
| | - Husam Abdel‐Qadir
- Women’s College Research InstituteTorontoCanada,ICESTorontoCanada,Institute of Health Policy, Management, and EvaluationUniversity of TorontoCanada,Department of Medicine, Faculty of MedicineUniversity of TorontoCanada,Peter Munk Cardiac CentreUniversity Health NetworkTorontoCanada,Cardiovascular Division, Department of MedicineWomen’s College HospitalTorontoCanada
| | - Jacob A. Udell
- Women’s College Research InstituteTorontoCanada,ICESTorontoCanada,Institute of Health Policy, Management, and EvaluationUniversity of TorontoCanada,Applied Health Research Centre, Li Ka Shing Knowledge InstituteSt Michael’s HospitalTorontoCanada,Department of Medicine, Faculty of MedicineUniversity of TorontoCanada,Peter Munk Cardiac CentreUniversity Health NetworkTorontoCanada,Cardiovascular Division, Department of MedicineWomen’s College HospitalTorontoCanada
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2
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Biscetti F, Cecchini AL, Rando MM, Nardella E, Gasbarrini A, Massetti M, Flex A. Principal predictors of major adverse limb events in diabetic peripheral artery disease: A narrative review. ATHEROSCLEROSIS PLUS 2021; 46:1-14. [PMID: 36643723 PMCID: PMC9833249 DOI: 10.1016/j.athplu.2021.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/10/2021] [Accepted: 10/28/2021] [Indexed: 01/18/2023]
Abstract
Background and aims The increasing prevalence of diabetes mellitus is causing a massive growth of peripheral artery disease incidences, a disabling complication of diabetic atherosclerosis, which leads often to the amputation of the affected limb. Critical limb ischemia is the terminal disease stage, which requires a prompt intervention to relieve pain and save limbs. However, patients undergoing revascularization often suffer from cardiovascular, cerebrovascular and major adverse limb events with poor outcomes. Furthermore, the same procedure performed in apparently similar patients has various outcomes and lack of an outcome predictive support causes a high lower limb arterial revascularization rate with disastrous effects for patients. We collected the main risk factors of major adverse limb events in a more readable and immediate format of the topic, to propose an overview of parameters to manage effectively peripheral artery disease patients and to propose basics of a new predictive tool to prevent from disabling vascular complications of the disease. Methods Most recent and updated literature about the prevalence of major adverse limb events in peripheral artery disease was reviewed to identify possible main predictors. Results In this article, we summarized major risk factors of limb revascularization failure and disabling vascular complications collecting those parameters principally responsible for major adverse limb events, which provides physio-pathological explanation of their role in peripheral artery disease. Conclusion We evaluated and listed a panel of possible predictors of MALE (Major Adverse Limb Event) in order to contribute to the development of a predictive score, based on a summary of the main risk factors reported in scientific articles, which could improve the management of peripheral artery disease by preventing vascular accidents.
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Affiliation(s)
- Federico Biscetti
- Internal and Cardiovascular Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy,Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy,Corresponding author. Internal and Cardiovascular Medicine Unit. Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, Rome, 00168, Italy.
| | | | - Maria Margherita Rando
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Elisabetta Nardella
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, Universitá Cattolica del Sacro Cuore, Roma, Italy
| | - Massimo Massetti
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Andrea Flex
- Internal and Cardiovascular Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy,Department of Medical and Surgical Sciences, Universitá Cattolica del Sacro Cuore, Roma, Italy
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3
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Signorelli SS, Marino E, Scuto S, Di Raimondo D. Pathophysiology of Peripheral Arterial Disease (PAD): A Review on Oxidative Disorders. Int J Mol Sci 2020; 21:ijms21124393. [PMID: 32575692 PMCID: PMC7352779 DOI: 10.3390/ijms21124393] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/13/2020] [Accepted: 06/18/2020] [Indexed: 12/14/2022] Open
Abstract
Peripheral arterial disease (PAD) is an atherosclerotic disease that affects a wide range of the world’s population, reaching up to 200 million individuals worldwide. PAD particularly affects elderly individuals (>65 years old). PAD is often underdiagnosed or underestimated, although specificity in diagnosis is shown by an ankle/brachial approach, and the high cardiovascular event risk that affected the PAD patients. A number of pathophysiologic pathways operate in chronic arterial ischemia of lower limbs, giving the possibility to improve therapeutic strategies and the outcome of patients. This review aims to provide a well detailed description of such fundamental issues as physical exercise, biochemistry of physical exercise, skeletal muscle in PAD, heme oxygenase 1 (HO-1) in PAD, and antioxidants in PAD. These issues are closely related to the oxidative stress in PAD. We want to draw attention to the pathophysiologic pathways that are considered to be beneficial in order to achieve more effective options to treat PAD patients.
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Affiliation(s)
- Salvatore Santo Signorelli
- Department of Clinical and Experimental Medicine, University of Catania, 95125 Catania, Italy; (E.M.); (S.S.)
- Correspondence: ; Tel.: +39-09-5378-2545
| | - Elisa Marino
- Department of Clinical and Experimental Medicine, University of Catania, 95125 Catania, Italy; (E.M.); (S.S.)
| | - Salvatore Scuto
- Department of Clinical and Experimental Medicine, University of Catania, 95125 Catania, Italy; (E.M.); (S.S.)
| | - Domenico Di Raimondo
- Division of Internal Medicine and Stroke Care, Department of Promoting Health, Maternal-Infant. Excellence and Internal and Specialized Medicine (Promise) G. D’Alessandro, University of Palermo, 90127 Palermo, Italy;
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4
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Oxidative Stress in Peripheral Arterial Disease (PAD) Mechanism and Biomarkers. Antioxidants (Basel) 2019; 8:antiox8090367. [PMID: 31480714 PMCID: PMC6770183 DOI: 10.3390/antiox8090367] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 12/13/2022] Open
Abstract
Hemodynamic dysfunction mainly characterizes pathophysiology of peripheral arterial disease (PAD) leading to chronic ischemia. Hemodynamic dysfunction is the origin of intermittent claudication (chronic PAD) or of critical limb ischemia (very severe PAD). Notably, it is well known that oxidative stress (OxS) plays a pathophysiological role in PAD. The higher production of reactive oxygen species (ROS) from OxS and reduced redox capability are two crucial players in initiating and progressing PAD. A number of biomarkers highlight OxS and monitor it in PAD. The present review summarizes data on OxS, on biomarkers available to mark OxS occurrence and to monitor on PAD progression, as well as to evaluate the effects treatments in PAD patients. In conclusion, by detailing OxS and its biomarkers, we hope to encourage more studies to focus on drugs which combat OxS and inflammation.
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5
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Cameron SJ, Mix DS, Ture SK, Schmidt RA, Mohan A, Pariser D, Stoner MC, Shah P, Chen L, Zhang H, Field DJ, Modjeski KL, Toth S, Morrell CN. Hypoxia and Ischemia Promote a Maladaptive Platelet Phenotype. Arterioscler Thromb Vasc Biol 2018; 38:1594-1606. [PMID: 29724818 PMCID: PMC6023774 DOI: 10.1161/atvbaha.118.311186] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 04/17/2018] [Indexed: 12/26/2022]
Abstract
Supplemental Digital Content is available in the text. Objective— Reduced blood flow and tissue oxygen tension conditions result from thrombotic and vascular diseases such as myocardial infarction, stroke, and peripheral vascular disease. It is largely assumed that while platelet activation is increased by an acute vascular event, chronic vascular inflammation, and ischemia, the platelet activation pathways and responses are not themselves changed by the disease process. We, therefore, sought to determine whether the platelet phenotype is altered by hypoxic and ischemic conditions. Approach and Results— In a cohort of patients with metabolic and peripheral artery disease, platelet activity was enhanced, and inhibition with oral antiplatelet agents was impaired compared with platelets from control subjects, suggesting a difference in platelet phenotype caused by the disease. Isolated murine and human platelets exposed to reduced oxygen (hypoxia chamber, 5% O2) had increased expression of some proteins that augment platelet activation compared with platelets in normoxic conditions (21% O2). Using a murine model of critical limb ischemia, platelet activity was increased even 2 weeks postsurgery compared with sham surgery mice. This effect was partly inhibited in platelet-specific ERK5 (extracellular regulated protein kinase 5) knockout mice. Conclusions— These findings suggest that ischemic disease changes the platelet phenotype and alters platelet agonist responses because of changes in the expression of signal transduction pathway proteins. Platelet phenotype and function should, therefore, be better characterized in ischemic and hypoxic diseases to understand the benefits and limitations of antiplatelet therapy.
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Affiliation(s)
- Scott J Cameron
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.) .,Division of Cardiology, Department of Medicine (S.J.C., C.N.M.)
| | - Doran S Mix
- Division of Vascular Surgery, Department of Surgery (D.S.M., M.C.S., S.T.), University of Rochester School of Medicine, NY
| | - Sara K Ture
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Rachel A Schmidt
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Amy Mohan
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Daphne Pariser
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Michael C Stoner
- Division of Vascular Surgery, Department of Surgery (D.S.M., M.C.S., S.T.), University of Rochester School of Medicine, NY
| | - Punit Shah
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD (P.S., L.C., H.Z.)
| | - Lijun Chen
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD (P.S., L.C., H.Z.)
| | - Hui Zhang
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD (P.S., L.C., H.Z.)
| | - David J Field
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Kristina L Modjeski
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Sandra Toth
- Division of Vascular Surgery, Department of Surgery (D.S.M., M.C.S., S.T.), University of Rochester School of Medicine, NY
| | - Craig N Morrell
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.).,Division of Cardiology, Department of Medicine (S.J.C., C.N.M.)
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Improving the therapeutic efficacy of mesenchymal stromal cells to restore perfusion in critical limb ischemia through pulsed focused ultrasound. Sci Rep 2017; 7:41550. [PMID: 28169278 PMCID: PMC5294408 DOI: 10.1038/srep41550] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 12/21/2016] [Indexed: 12/13/2022] Open
Abstract
Mesenchymal stem cells (MSC) are promising therapeutics for critical limb ischemia (CLI). Mechanotransduction from pulsed focused ultrasound (pFUS) upregulates local chemoattractants to enhance homing of intravenously (IV)-infused MSC and improve outcomes. This study investigated whether pFUS exposures to skeletal muscle would improve local homing of iv-infused MSCs and their therapeutic efficacy compared to iv-infused MSCs alone. CLI was induced by external iliac arterial cauterization in 10–12-month-old mice. pFUS/MSC treatments were delayed 14 days, when surgical inflammation subsided. Mice were treated with iv-saline, pFUS alone, IV-MSC, or pFUS and IV-MSC. Proteomic analyses revealed pFUS upregulated local chemoattractants and increased MSC tropism to CLI muscle. By 7 weeks post-treatment, pFUS + MSC significantly increased perfusion and CD31 expression, while reducing fibrosis compared to saline. pFUS or MSC alone reduced fibrosis, but did not increase perfusion or CD31. Furthermore, MSCs homing to pFUS-treated CLI muscle expressed more vascular endothelial growth factor (VEGF) and interleukin-10 (IL-10) than MSCs homing to non-pFUS-treated muscle. pFUS + MSC improved perfusion and vascular density in this clinically-relevant CLI model. The molecular effects of pFUS increased both MSC homing and MSC production of VEGF and IL-10, suggesting microenvironmental changes from pFUS also increased potency of MSCs in situ to further enhance their efficacy.
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7
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Chang CJ, Chen YT, Liu CS, Lin WY, Lin CL, Lin MC, Kao CH. Atrial Fibrillation Increases the Risk of Peripheral Arterial Disease With Relative Complications and Mortality: A Population-Based Cohort Study. Medicine (Baltimore) 2016; 95:e3002. [PMID: 26945422 PMCID: PMC4782906 DOI: 10.1097/md.0000000000003002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Atrial fibrillation (AF), an increasing prevalent cardiac arrhythmia due to aging general population, has many common risk factors with peripheral arterial disease (PAD). However, it is unclear whether AF is associated with a risk of PAD. We investigated the prevalence of AF and PAD in the general population and the risk of PAD among the AF population. This longitudinal, nationwide, population-based cohort study was conducted using data from the Taiwan National Health Insurance Research Database recorded during 2000 to 2011. In total, 3814 and 15,364 patients were included in the AF and non-AF cohorts, respectively. Univariate and multivariate Cox proportional hazard regression models were used for examining the effects of AF on the risk of outcomes. The average follow-up periods of PAD were 4.96 ± 3.28 and 5.29 ± 3.35 years for the AF and non-AF cohorts, respectively. Overall, the risk of PAD showed a significantly higher risk in the AF cohort (adjusted HR=1.31, 95% CI=1.19-1.45) compared with the non-AF cohort. Similar results were observed for heart failure and stroke, where the AF cohort had a 1.83-fold and 2.53-fold higher risk of developing heart failure and stroke. The AF cohort also had a significant increased risk for mortality (adjusted HR=1.66, 95% CI=1.49-1.84). The present study indicated that the incidence of PAD, heart failure, stroke, and overall mortality is higher in patients with AF than in those without it.
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Affiliation(s)
- Chia-Jung Chang
- From the Department of Family Medicine (C-JC, Y-TC, C-SL, W-YL); Medical Research (C-JC, Y-TC), China Medical University Hospital, Taichung; School of Medicine (C-SL, W-YL), National Taiwan University Hospital; Graduate Institute of Clinical Medical Science (C-SL, W-YL), National Taiwan University Hospital; Department of Family Medicine (W-YL), National Taiwan University Hospital, Taipei; Management Office for Health Data (C-LL); College of Medicine (C-LL), China Medical University, Taichung; Department of Nuclear Medicine (M-CL), E-Da Hospital, I-Shou University, Kaohsiung; Graduate Institute of Clinical Medical Science and School of Medicine (C-HK), College of Medicine, China Medical University; and Department of Nuclear Medicine and PET Center (C-HK), China Medical University Hospital, Taichung, Taiwan
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8
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Hosaka A, Miyata T, Onishi Y, Liao L, Zhang Q. Clinical and economic burden in patients with diagnosis of peripheral arterial disease in a claims database in Japan. Clin Ther 2014; 36:1223-30, 1230.e1-4. [PMID: 25012730 DOI: 10.1016/j.clinthera.2014.06.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 04/26/2014] [Accepted: 06/09/2014] [Indexed: 11/17/2022]
Abstract
PURPOSE The effect of peripheral arterial disease (PAD) among young and middle-aged adults can be significant, but no previous study has examined the prognosis and the associated health care cost of the disease in this population. We evaluated the clinical and economic burden of PAD in patients from a large claims database to clarify the effect of the disease on a relatively young working Japanese population. METHODS Patients aged ≥45 and ≤64 years with first PAD diagnosis between 2005 and 2011 comprised the PAD cohort (n = 362); an age- and sex-matched non-PAD comparison cohort (n = 362) was also identified. Rates of cardiovascular events/interventions, health care utilization, and costs were compared. FINDINGS The mean (SD) age of the cohort was 52.8 (5.6) years and 40.8% were women. Baseline Charlson comorbidity index was significantly higher in the PAD cohort than in the non-PAD cohort (1.90 [2.19] vs 1.16 [1.99]; P < 0.001). The PAD cohort had significantly higher first-year event rates than did the non-PAD cohort for myocardial infarction (2.2% vs 0.2%; P = 0.019) and ischemic stroke (4.1% vs 0.5%; P = 0.001). Health care utilization was significantly greater for the PAD cohort for all parameters assessed (number of hospitalization, inpatient days, and outpatient visits) in the first year (all, P < 0.001). Total annual costs for health care were significantly higher in the PAD cohort than in the non-PAD cohort in the first year (P < 0.001). Among patients with diabetes, patients with PAD (n = 98) had significantly greater first-year event rates (myocardial infarction, ischemic stroke, coronary artery bypass surgery, peripheral arterial revascularization, percutaneous coronary intervention, and limb amputation; all, P < 0.001), significantly greater number of clinic visits (P = 0.023), and total cost burden than did patients without PAD (n = 63). IMPLICATIONS Even in a relatively young working Japanese population, PAD is associated with substantial clinical and economic burden.
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Affiliation(s)
- Akihiro Hosaka
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
| | - Tetsuro Miyata
- Vascular Center, Sanno Hospital and Sanno Medical Center, Tokyo, Japan
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9
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Jover E, Marín F, Roldán V, Montoro-García S, Valdés M, Lip GYH. Atherosclerosis and thromboembolic risk in atrial fibrillation: focus on peripheral vascular disease. Ann Med 2013; 45:274-90. [PMID: 23216106 DOI: 10.3109/07853890.2012.732702] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice. It results in a 5-fold increased risk for stroke and thromboembolism and is associated with a high morbidity and mortality. AF shares several risk factors and pathophysiological features with atherosclerosis. Hence AF is often complicated by a variety of other cardiovascular conditions. Indeed, peripheral vascular disease (PVD) is highly prevalent among AF patients and associates with increased mortality. Inclusion of PVD within stroke risk scoring systems such as the CHA2DS2-VASc score improves risk stratification of AF patients. Of note, PVD has not been previously well documented nor looked for in observational studies or clinical trials. The aim of this present review article is to provide an overview of the association between atherosclerosis (with particular focus on PVD) and AF as well as its complications.
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Affiliation(s)
- Eva Jover
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
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Ghannam M, Rodriguez Y, Ehrmann D, Grossman PM. Ankle-brachial index as a clinical tool. Am J Med 2012; 125:1171-2. [PMID: 23022125 DOI: 10.1016/j.amjmed.2012.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 06/18/2012] [Accepted: 06/18/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Michael Ghannam
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109-5052, USA.
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Faglia E. Characteristics of peripheral arterial disease and its relevance to the diabetic population. INT J LOW EXTR WOUND 2011; 10:152-66. [PMID: 21856972 DOI: 10.1177/1534734611417352] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Peripheral arterial disease (PAD) is very frequent in diabetics, and it increases with age. Foot examination contributes poorly to diagnosis of PAD. The ankle-brachial index (ABI) measurement is considered the most accurate noninvasive diagnostic method when evaluating PAD: ABI evaluation is recommended in all diabetics aged >50 years. Many diabetic patients with PAD have a concomitant sensitive neuropathy: as a consequence, perception of ischemic pain is remarkably reduced or completely blocked. The result is that the prevalence of claudication in the diabetic population with PAD is lower than the prevalence of critical limb ischemia (CLI) in this population. CLI is a major risk factor for lower extremity amputation without revascularization. Ankle and toe pressures and oxygen tension at the foot are the noninvasive diagnostic parameters of CLI though the medial artery calcification inhibits accurate determination of the ankle and toe pressures, especially when a forefoot ulcer is present. In diabetics, the anatomical localization is mainly distal; arterial wall calcification is frequently observed and occlusion occurs more frequently than stenosis. Such anatomical features, along with the difficulties in the diagnostic approach, account for the fundamental role of CLI as the main prognostic indicator for major amputation. PAD is an expression of systemic atherosclerotic disease. Prognosis of patients with PAD is related to the presence and extent of underlying coronary artery disease (CAD) but also to the severity of PAD: in particular, patients in whom revascularization is not feasible have the highest mortality rate.
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Affiliation(s)
- Ezio Faglia
- Diabetic Foot Centre, IRCCS MultiMedica, Milan, Italy.
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12
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Pattillo CB, Bir S, Rajaram V, Kevil CG. Inorganic nitrite and chronic tissue ischaemia: a novel therapeutic modality for peripheral vascular diseases. Cardiovasc Res 2010; 89:533-41. [PMID: 20851809 DOI: 10.1093/cvr/cvq297] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Ischaemic tissue damage represents the ultimate form of tissue pathophysiology due to cardiovascular disease, which is the leading cause of morbidity and mortality across the globe. A significant amount of basic research and clinical investigation has been focused on identifying cellular and molecular pathways to alleviate tissue damage and dysfunction due to ischaemia and subsequent reperfusion. Over many years, the gaseous molecule nitric oxide (NO) has emerged as an important regulator of cardiovascular health as well as protector against tissue ischaemia and reperfusion injury. However, clinical translation of NO therapy for these pathophysiological conditions has not been realized for various reasons. Work from our laboratory and several others suggests that a new form of NO-associated therapy may be possible through the use of nitrite anion (sodium nitrite), a prodrug which can be reduced to NO in ischaemic tissues. In this manner, nitrite anion serves as a highly selective NO donor in ischaemic tissues without substantially altering otherwise normal tissue. This surprising and novel discovery has reinvigorated hopes for effectively restoring NO bioavailability in vulnerable tissues while continuing to reveal the complexity of NO biology and metabolism within the cardiovascular system. However, some concerns may exist regarding the effect of nitrite on carcinogenesis. This review highlights the emergence of nitrite anion as a selective NO prodrug for ischaemic tissue disorders and discusses the potential therapeutic utility of this agent for peripheral vascular disease.
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Affiliation(s)
- Christopher B Pattillo
- Department of Pathology and Cardiology, LSU Health Sciences Center-Shreveport, 1501 Kings Hwy, Shreveport, LA 71130, USA
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Papanas N, Kakagia D, Papatheodorou K, Papazoglou D, Alexandridou M, Pagkalos A, Karadimas E, Maltezos E. Lanarkshire Oximetry Index as a Diagnostic Tool for Peripheral Arterial Disease in Type 2 Diabetes: A Pilot Study. Angiology 2010; 61:388-391. [DOI: 10.1177/0003319709358696] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
We evaluated the Lanarkshire Oximetry Index (LOI) for the diagnosis of peripheral arterial disease (PAD) in type 2 diabetic patients, using the Ankle-Brachial Index (ABI) as gold standard. We included 161 patients (71 men, mean age 63.1 ± 9.8 years). Peripheral arterial disease was defined as ABI < 0.9. Two cut-off values of LOI (<0.9 and <0.8) were assessed for the diagnosis of PAD. Sensitivity and specificity for PAD were 93.3% and 89.1%, respectively, using a LOI cut-off value of 0.9, while they were 40% and 99.3%, respectively, using a LOI cut-off value of 0.8. Agreement between LOI and ABI was moderate (P < .001). There was a significant positive correlation between ABI and LOI (r = .377, P < .001). Lanarkshire Oximetry Index is a potentially useful alternative diagnostic test for PAD in type 2 diabetes. A cut-off value of 0.9 has high sensitivity and modest specificity. Agreement between LOI and ABI is moderate.
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Affiliation(s)
- N. Papanas
- Outpatient Clinic of the Diabetic Foot in the Second Department of Internal Medicine, Democritus University of Thrace, Greece,
| | - D. Kakagia
- Department of Plastic Surgery, Democritus University of Thrace, Greece
| | - K. Papatheodorou
- Outpatient Clinic of the Diabetic Foot in the Second Department of Internal Medicine, Democritus University of Thrace, Greece
| | - D. Papazoglou
- Outpatient Clinic of the Diabetic Foot in the Second Department of Internal Medicine, Democritus University of Thrace, Greece
| | - M. Alexandridou
- Outpatient Clinic of the Diabetic Foot in the Second Department of Internal Medicine, Democritus University of Thrace, Greece
| | - A. Pagkalos
- Outpatient Clinic of the Diabetic Foot in the Second Department of Internal Medicine, Democritus University of Thrace, Greece
| | - E.J. Karadimas
- NHS Department of Orthopaedics, University Hospital of Alexandroupolis, Greece
| | - E. Maltezos
- Outpatient Clinic of the Diabetic Foot in the Second Department of Internal Medicine, Democritus University of Thrace, Greece
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