Global epidemiology of lower extremity artery disease in the 21st century (2000-21): a systematic review and meta-analysis

AIMS

The epidemiology of lower extremity artery disease (LEAD) is evolving. This meta-analysis of aggregate data aimed to (i) determine the global prevalence of LEAD and by regions in the 21st century and (ii) update the associated risk factors in this period.

METHODS AND RESULTS

A systematic literature review was performed through PubMed, Cochrane, Scopus, Science Direct, and Google Scholar databases, restricted to general population studies between January 2000 and September 2021, with LEAD defined by a low (

CONCLUSION

This meta-analysis highlights a currently high prevalence of LEAD worldwide, with substantial differences in global regions and between sexes. The strongest associations were found with metabolic risk factors.

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Key Words

• Epidemiology
• General population
• Lower extremity artery disease
• Meta-analysis
• Prevalence
• Risk factors

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MESH Headings

• Aged
• Female
• Humans
• Male
• Middle Aged
• Global Health
• Lower Extremity/blood supply
• Peripheral Arterial Disease/epidemiology
• Peripheral Arterial Disease/diagnosis
• Prevalence
• Risk Assessment
• Risk Factors

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Grants

• Association limousine de Recherche et Développement en Cardiologie Interventionelle

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Affiliation(s)

Caroline Adou EpiMaCT Research Unit U1094 Inserm U270 IRD EpiMaCT, School of Medicine, Limoges University, 2ave Marcland, 87025 Limoges, France
Julien Magne EpiMaCT Research Unit U1094 Inserm U270 IRD EpiMaCT, School of Medicine, Limoges University, 2ave Marcland, 87025 Limoges, France
Nana Gazere EpiMaCT Research Unit U1094 Inserm U270 IRD EpiMaCT, School of Medicine, Limoges University, 2ave Marcland, 87025 Limoges, France
Maissa Aouida EpiMaCT Research Unit U1094 Inserm U270 IRD EpiMaCT, School of Medicine, Limoges University, 2ave Marcland, 87025 Limoges, France
Lucie Chastaingt EpiMaCT Research Unit U1094 Inserm U270 IRD EpiMaCT, School of Medicine, Limoges University, 2ave Marcland, 87025 Limoges, France Department of Vascular Surgery and Vascular Medicine, Dupuytren University Hospital, Limoges, France
Victor Aboyans EpiMaCT Research Unit U1094 Inserm U270 IRD EpiMaCT, School of Medicine, Limoges University, 2ave Marcland, 87025 Limoges, France Department of Cardiology, Dupuytren University Hospital, 16 rue Bernard Descottes, 87042 Limoges, France

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Invasiveness of previous treatment for peripheral arterial disease and risk of adverse cardiac events after coronary stenting

Patients with peripheral arterial disease (PADs), undergoing percutaneous coronary intervention (PCI), have higher adverse event risks. The effect of invasiveness of PADs treatment on PCI outcome is unknown. This study assessed the impact of the invasiveness of previous PADs treatment (invasive or non-invasive) on event risks after PCI with contemporary drug-eluting stents. This post-hoc analysis pooled 3-year patient-level data of PCI all-comer patients living in the eastern Netherlands, previously treated for PADs. PADs included symptomatic atherosclerotic lesion in the lower or upper extremities; carotid or vertebral arteries; mesenteric arteries or aorta. Invasive PADs treatment comprised endarterectomy, bypass surgery, percutaneous transluminal angioplasty, stenting or amputation; non-invasive treatment consisted of medication and participation in exercise programs. Primary endpoint was (coronary) target vessel failure: composite of cardiac mortality, target vessel-related myocardial infarction, or clinically indicated target vessel revascularization. Of 461 PCI patients with PADs, information on PADs treatment was available in 357 (77.4%) patients; 249 (69.7%) were treated invasively and 108 (30.3%) non-invasively. Baseline and PCI procedural characteristics showed no between-group difference. Invasiveness of PADs treatment was not associated with adverse event risks, including target vessel failure (20.5% vs. 16.0%; HR: 1.30, 95%-CI 0.75-2.26, p = 0.35), major adverse cardiac events (23.3% vs. 20.4%; HR: 1.16, 95%-CI 0.71-1.90, p = 0.55), and all-cause mortality (12.1% vs. 8.3%; HR: 1.48, 95%-CI 0.70-3.13, p = 0.30). In PADs patients participating in PCI trials, we found no significant relation between the invasiveness of previous PADs treatment and 3-year outcome after PCI. Consequently, high-risk PCI patients can be identified by consulting medical records, searching for PADs, irrespective of the invasiveness of PADs treatment.

Ankle-Brachial Index: Diagnostic Tool of Peripheral Arterial Disease and Predictor of Cardiovascular Risk-An Update of Current Knowledge

The ankle-brachial index (ABI) was introduced as a screening method for the diagnosis of lower extremity peripheral arterial disease (PAD). Later findings recognized ABI as a prognostic marker of adverse cardiovascular events due to its relation to atherosclerosis in other vascular territories. This narrative review aims to appraise the validity, reliability, and utility of ABI in the detection of PAD and the determination of global atherosclerotic cardiovascular risk. While the ABI value can be influenced by different physiological characteristics including age, sex, body position, and techniques used for ABI determination, it has high specificity and reproducibility in the assessment of vascular patients. In conclusion, when used correctly, the ABI remains a reliable and invaluable indicator of lower-limb perfusion and a useful tool for predicting the risk of future cardiovascular events. However, its underutilization in clinical settings is noteworthy.

Individual and joint effects of borderline ankle-brachial index and high plasma total homocysteine on all-cause death in hypertensive adults

BACKGROUND

The cardiovascular hazards of total homocysteine (tHcy) are long known. In addition, despite the acknowledgment on the importance of low ankle-brachial index (ABI) (< 0.9), borderline ABI (0.91-0.99) was once commonly overlooked. This study aims to explore the independent and joint effect of tHcy level and borderline ABI on all-cause death in hypertensive population.

METHODS

This study included 10,538 participants from China H-type Hypertension Registry Study. ABI was described into two groups: normal ABI (1.00-1.40) and borderline ABI. tHcy level was also divided into two groups: < 15.02 and ≥ 15.02 μmo/L. Four groups were analyzed, using COX proportional hazard regression model, separately and pairwise to observe the independent and joint effect on all-cause death.

RESULTS

A total of 126 (1.2%) deaths were observed in the 1.7 years follow-up time. Borderline ABI has a higher predicted risk of death than normal ABI (HR = 1.87, 95%CI: 1.17-3.00) after adjusting for potential covariates. Compare with tHcy level < 15.02 μmo/L (low tHcy), those with tHcy ≥ 15.02 μmo/L (high tHcy) had higher risk to event outcome (HR = 1.99, 95% CI: 1.30-3.05). According to the cumulative hazard curve, group with borderline ABI and high tHcy level has significantly higher altitude and larger increasing rate over follow-up period compare to other groups. Among those with borderline ABI, participants with high tHcy had higher death risk than those with low tHcy, nevertheless, no significant different between borderline and normal ABI among those with low tHcy levels.

CONCLUSIONS

Borderline ABI and tHcy level both have independent predictive value on all-cause death. The combined group of borderline ABI and high tHcy has highest risk factor of outcomes, which suggested the mutual additive value of borderline ABI and tHcy. More attention should be given to the importance of borderline ABI in hypertensive population, especially with elevated tHcy level.

Dose-Response Association of Low and Normal Ankle Brachial Index With the Risk of Cardiovascular Disease Morbidity and Mortality

We quantitatively evaluated the dose-response association of low and normal ankle brachial index (ABI) with the risk of morbidity and mortality from cardiovascular diseases (CVDs). PubMed, Embase, and Web of Science were systematically searched for cohort studies. Random effects or fixed effects models were used to estimate the pooled relative risks (RRs) and 95% confidence intervals (95% CIs). Generalized least squares regression was used to assess study-specific dose-response associations per 0.1 ABI decrease. Restricted cubic splines were used to evaluate linear or nonlinear trends. Twelve cohort studies (57 031 participants) were included in this meta-analysis. For low vs normal ABI levels, the pooled RRs were 2.03 (95% CI, 1.72-2.41; I² = 52.9%; p_{heterogeneity}=0.030) and 2.29 (95% CI, 1.98-2.64; I² = 39.5%; p_{heterogeneity} =0.158) for CVD morbidity and CVD mortality, respectively. For per 0.1 ABI decrease from 1.40 the risk for CVD morbidity and CVD mortality increased by 8% (1.08, 95% CI 1.04-1.11) and 11% (1.11, 95% CI 1.07-1.15), respectively. Restricted cubic splines showed inverse linear associations for CVD morbidity and CVD mortality. As a non-invasive index, lower ABI was significantly associated with the increased risk of morbidity and mortality from CVDs in an inverse linear manner.

Identifying peripheral arterial disease in the elderly patients using machine-learning algorithms

BACKGROUND

Peripheral artery disease (PAD) is a common syndrome in elderly people. Recently, artificial intelligence (AI) algorithms, in particular machine-learning algorithms, have been increasingly used in disease diagnosis.

AIM

In this study, we designed an effective diagnostic model of PAD in the elderly patients using artificial intelligence.

METHODS

The study was performed with 539 participants, all over 80 years in age, who underwent the measurements of Doppler ultrasonography and ankle-brachial pressure index (ABI). Blood samples were collected. ABI and two machine-learning algorithms (MLAs)-logistic regression and a random forest (RF) model-were established to diagnose PAD. The sensitivity and specificity of the models were analyzed. An additional RF model was designed based on the most significant features of the original RF model and a prospective study was conducted to demonstrate its external validity.

RESULTS

Thirteen of the 28 features introduced to the MLAs differed significantly between PAD and non-PAD participants. The respective sensitivities and specificities of logistic regression, RF, and ABI were as follows: logistic regression (81.5%, 83.8%), RF (89.3%, 91.6%) and ABI (85.1%, 84.5%). In the prospective study, the newly designed RF model based on the most significant seven features exhibited an acceptable performance rate for the diagnosis of PAD with 100.0% sensitivity and 90.3% specificity.

CONCLUSIONS

An RF model was a more effective method than the logistic regression and ABI for the diagnosis of PAD in an elderly cohort.

Ankle-Brachial Index and Subsequent Risk of Severe Ischemic Leg Outcomes: The ARIC Study

Background Ankle-brachial index (ABI) is used to identify lower-extremity peripheral artery disease (PAD). However, its association with severe ischemic leg outcomes (eg, amputation) has not been investigated in the general population. Methods and Results Among 13 735 ARIC (Atherosclerosis Risk in Communities) study participants without clinical manifestations of PAD (mean age, 54 [SD, 5.8] years; 44.4% men; and 73.6% White) at baseline (1987-1989), we quantified the prospective association between ABI and subsequent severe ischemic leg outcomes, critical limb ischemia (PAD with rest pain or tissue loss) and ischemic leg amputation (PAD requiring amputation) according to discharge diagnosis. Over a median follow-up of ≈28 years, there were 221 and 129 events of critical limb ischemia and ischemic leg amputation, respectively. After adjusting for demographics, ABI ≤0.90 versus 1.11 to 1.20 had a ≈4-fold higher risk of critical limb ischemia and ischemic leg amputation (hazard ratios, 3.85 [95% CI, 2.09-7.11] and 4.39 [95% CI, 2.08-9.27]). The magnitude of the association was modestly attenuated after multivariable adjustment (hazard ratios, 2.44 [95% CI, 1.29-4.61] and 2.72 [95% CI, 1.25-5.91], respectively). ABI 0.91 to 1.00 and 1.01 to 1.10 were also associated with these severe leg outcomes, with hazard ratios ranging from 1.7 to 2.0 after accounting for potential clinical and demographic confounders. The associations were largely consistent across various subgroups. Conclusions In a middle-aged community-based cohort, lower ABI was independently and robustly associated with increased risk of severe ischemic leg outcomes. Our results further support ABI ≤0.90 as a threshold diagnosing PAD and also suggest the importance of recognizing the prognostic value of ABI 0.91 to 1.10 for limb prognosis.

Racial and Ethnic Disparities in Peripheral Artery Disease

Peripheral artery disease is an obstructive, atherosclerotic disease of the lower extremities causing significant morbidity and mortality. Black Americans are disproportionately affected by this disease while they are also less likely to be diagnosed and promptly treated. The consequences of this disparity can be grim as Black Americans bear the burden of lower extremity amputation resulting from severe peripheral artery disease. The risk factors of peripheral artery disease and how they differentially affect certain groups are discussed in addition to a review of pharmacological and nonpharmacological treatment modalities. The purpose of this review is to highlight health care inequities and provide a review and resource of available recommendations for clinical management of all patients with peripheral artery disease.

Associations Between Systolic Interarm Differences in Blood Pressure and Cardiovascular Disease Outcomes and Mortality: Individual Participant Data Meta-Analysis, Development and Validation of a Prognostic Algorithm: The INTERPRESS-IPD Collaboration

Systolic interarm differences in blood pressure have been associated with all-cause mortality and cardiovascular disease. We undertook individual participant data meta-analyses to (1) quantify independent associations of systolic interarm difference with mortality and cardiovascular events; (2) develop and validate prognostic models incorporating interarm difference, and (3) determine whether interarm difference remains associated with risk after adjustment for common cardiovascular risk scores. We searched for studies recording bilateral blood pressure and outcomes, established agreements with collaborating authors, and created a single international dataset: the Inter-arm Blood Pressure Difference - Individual Participant Data (INTERPRESS-IPD) Collaboration. Data were merged from 24 studies (53 827 participants). Systolic interarm difference was associated with all-cause and cardiovascular mortality: continuous hazard ratios 1.05 (95% CI, 1.02-1.08) and 1.06 (95% CI, 1.02-1.11), respectively, per 5 mm Hg systolic interarm difference. Hazard ratios for all-cause mortality increased with interarm difference magnitude from a ≥5 mm Hg threshold (hazard ratio, 1.07 [95% CI, 1.01-1.14]). Systolic interarm differences per 5 mm Hg were associated with cardiovascular events in people without preexisting disease, after adjustment for Atherosclerotic Cardiovascular Disease (hazard ratio, 1.04 [95% CI, 1.00-1.08]), Framingham (hazard ratio, 1.04 [95% CI, 1.01-1.08]), or QRISK cardiovascular disease risk algorithm version 2 (QRISK2) (hazard ratio, 1.12 [95% CI, 1.06-1.18]) cardiovascular risk scores. Our findings confirm that systolic interarm difference is associated with increased all-cause mortality, cardiovascular mortality, and cardiovascular events. Blood pressure should be measured in both arms during cardiovascular assessment. A systolic interarm difference of 10 mm Hg is proposed as the upper limit of normal. Registration: URL: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42015031227.

Analysis of angiographic characteristics and intervention of vitamin D in type 2 diabetes mellitus complicated with lower extremity arterial disease

AIMS

Previous studies have suggested that type 2 diabetes mellitus with lower extremity arterial disease is related to 25-hydroxyvitamin D deficiency. The purpose of this study is to explore the relation between vitamin D supplementation and the characteristics of type 2 diabetes mellitus complicated with lower extremity arterial disease.

METHODS

The clinical data of 514 patients and 148 healthy subjects treated in the First Hospital of Lanzhou University from January 2012 to June 2019 were collected, including the clinical data, ankle-brachial index, and medical records of lower limb artery angiography. We divided the patients into control group (NC group), type 2 diabetes mellitus group (DM group), lower extremity artery disease in type 2 diabetes mellitus without vitamin D supplement group (DM1 group) and lower extremity artery disease in type 2 diabetes mellitus with vitamin D supplement group (DM2 group). The level of serum 25(OH)D was analyzed and the characteristics of arterial lesions of lower extremities were compared by DSA arteriography in DM1 and DM2 group, respectively.

RESULTS

Compared with the NC group, serum 25(OH)D level decreased in DM group (25.39 ± 4.94 ng/mL vs 19.43 ± 5.98 ng/mL) and significantly decreased in DM1 and DM2 group (14.22 ± 5.64 ng/mL vs 17.36 ± 6.25 ng/mL). However, the level of serum 25(OH)D in the DM2 group was higher than that in the DM1 group. Compared with the DM1 group, the disease rate of the inferior knee artery (65% vs 39.3%) and occlusion rate (11.5% vs 3.7%)were decreased in the DM2 group (P < 0.05). Logistic stepwise regression analysis showed that serum 25(OH)D level was a risk factor for lower extremity arterial disease in patients with type 2 diabetes mellitus (OR = 0.898,95%CI = 0.856-0.942).

CONCLUSIONS

The serum level of 25(OH)D in patients with type 2 diabetes mellitus complicated with lower extremity arterial disease is decreased, and level of 25 (OH) D is related to stenosis and occlusion rate, especially in inferior genicular artery in T2DM complicated with LEAD. A high level of 25(OH)D may be a protective factor in type 2 diabetes with lower extremity arterial disease.

Ankle-brachial index and incident heart failure with reduced versus preserved ejection fraction: The Multi-Ethnic Study of Atherosclerosis

This study investigated the relationship between ankle-brachial index (ABI) and risk for heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). ABI has previously been associated with mortality, cardiovascular disease (CVD), and overall HF but the relationship between ABI and risk of HF stratified by EF has not been well characterized. We analyzed data from 6553 participants (53% female; mean age 62 ± 10 years) enrolled in the Multi-Ethnic Study of Atherosclerosis (MESA) who were free of known clinical CVD/HF at baseline (2000-2002) and had baseline ABI measured. Participants were classified as low (≤ 0.90), borderline-low (0.91-1.00), normal (1.01-1.40), and high (> 1.40) ABI. Incident hospitalized HF was determined over a median follow-up of 14 years; we classified HF events (n = 321) as HFrEF with EF < 50% (n = 155, 54%) or HFpEF with EF ⩾ 50% (n = 133, 46%). Low ABI was associated with incident HFrEF (hazard ratio (HR): 2.02, 95% CI 1.19-3.40, p = 0.01) and had no significant association with HFpEF (HR: 0.67, 95% CI 0.30-1.48, p = 0.32). Borderline-low and high ABI were not significantly associated with HFrEF or HFpEF. Cubic spline analyses showed association with both low and high ABI for HFrEF and high ABI for HFpEF. A 1 SD lower ABI (for ABI < 1.1) was associated with incident HFrEF in multivariable analysis (HR: 1.27, 95% CI 1.05-1.54) but was not significant after additionally adjusting for interim myocardial infarction (HR: 1.21, 95% CI 0.99-1.48). Low ABI was associated with higher risk for incident HFrEF but not HFpEF in persons free of known CVD. Future studies of a larger size are needed for high ABI analyses.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

GUIDELINE SUMMARY

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Global vascular guidelines on the management of chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

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.

Prevalence of peripheral arterial disease in patients with heart failure with preserved ejection fraction

OBJECTIVES

To describe the prevalence of the reduced ankle-brachial index (ABI) in patients with heart failure (HF) with preserved ejection fraction (HFpEF) attended at a HF clinic in the metropolitan region of Porto Alegre, and to compar the patients to those with reduced ejection fraction (HFrEF).

METHODS

A descriptive observational study, included patients referred to the heart failure clinic in HU-Ulbra with HFpEF or HFrEF and diastolic dysfunction, and measurements of ABIs using vascular Doppler equipment were performed in both groups.

RESULTS

The sample consisted of 106 patients with HF, 53.9% of the patients had HFpEF, and 19.4% had a diagnosis of peripheral arterial disease (PAD) (ABI less than 0.9). PAD was identified in 24.1% of the patients with HFpEF, while15.8% of patients in the HFrEF group were diagnosed with PAD.

CONCLUSION

Our results did not identify a significantly different prevalence of altered and compatible PAD values in patients with HFpEF. However, we showed a prevalence of 19.4%, a high value if we consider similar populations.

Expert consensus on clinical assessment and intervention of vascular aging in China (2018)

With the development of geriatric medicine, more and more reported research has found that as humans grow old, their blood vessels also age. Blood vessels are vital components of various organs. Vascular aging is an important physiological and pathological basis for the aging of organs and systems of the human body and is the common pathogenesis of various chronic diseases in the elderly. Early detection of vascular aging and the use of correct methods to delay and treat vascular aging are of great significance to prevent and control chronic diseases in the elderly and to deal with the increasingly serious problems of population aging. For this purpose, this consensus is formulated for use by geriatric doctors and related personnel.

Prevalence of lower extremities peripheral arterial disease among Egyptian ischemic patients attending cardiac rehabilitation unit

Background

Atherosclerosis is progressive and diffuse pathological disorders which can simultaneously affect multiple vascular beds. Diagnosing Lower extremities peripheral arterial disease (PAD) in patients with Coronary artery disease (CAD) admitted to cardiac rehabilitation program can help to tailor exercise regimen to fit these patients, in addition, early treatment and/or intervention may help to control progression of the disease.

Aim

The study is to search for the prevalence of undiagnosed PAD using ankle brachial index (ABI) in Egyptian patients with documented CAD undergoing cardiac rehabilitation program.

Patients and Methods

The study included 200 patients with documented CAD scheduled for cardiac rehabilitation in Cardiology department, Ain Shams University, with exclusion of patients with known (diagnosed) PAD. All patients underwent ABI using Doppler ultrasonography. The patients were divided into two groups; Study group with positive ABI (≤ 0.9) and Control group with negative ABI (> 0.9).

Results

We found that the prevalence of undiagnosed PAD in those patients was 14.5% (29 patients). The incidence of PAD is increased in patients above 60 years (p = 0.001) and in presence of hypertension/uncontrolled systolic blood pressure (p = 0.002), Dyslipidemia (p = 0.005), or family history of ischemic heart disease (p = 0.035). PAD is associated also with impaired left ventricular systolic function and presence of segmental wall motion abnormalities at rest. Impaired eGFR increased the risk of development of PAD (p = 0.016). PAD was associated more with patients presented by multivessel lesions by coronary angiography and in presence of ischemic ECG changes.

Conclusion

This study shows that significant PAD is present in almost 15% of ischemic Egyptian patients. We recommend ABI to be done routinely in patients with significant CAD for exclusion or diagnosis of PAD to help in treatment and improving quality of life in addition to modification of cardiac rehabilitation program in presence of PAD according to its severity.

Brachial-ankle pulse wave velocity, cardio-ankle vascular index, and prognosis

Background

Brachial–ankle pulse wave velocity (baPWV) and cardio-ankle vascular index (CAVI) are indices of arterial stiffness, and several studies have used these indices. However, there is no comprehensive review of these parameters in the prognostic significance.

Methods

The aim of this study was to review the articles exploring the prognostic significance of these parameters. Articles demonstrating independent significance after multivariate analysis on the Cox proportional hazards model were defined as “successful.” The success rate was compared using Fisher’s exact test. In addition, multivariate logistic regression analysis was performed to explore the independent determinants of the success of prognostic prediction.

Results

The success rate of the baPWV articles (65.7% [46/70]) tended to be higher than that of the CAVI articles (40.0% [6/15]; P=0.083). Multivariate analysis demonstrated that log (number of patients) (OR 11.20, 95% CI 2.45–51.70, P=0.002) and dialysis population (OR 0.28, 95% CI 0.08–0.94, P=0.039) were positive and negative independent determinants of the success of prognostic prediction, respectively. In addition, after redefining two studies as the absence of arteriosclerosis obliterans (ASO) exclusion, baPWV (OR 3.36, 95% CI 0.86–13.20, P=0.083) and the existence of exclusion criteria of ASO (OR 3.08, 95% CI 0.96–9.93, P=0.060) exhibited statistical tendency in the multivariate analysis.

Conclusion

This study demonstrated that the number of study participants and dialysis population were the independent determinants of the success of prognostic prediction. This study also showed the importance of exclusion criteria of ASO when using these indices. In addition, a prospective large-scale study to confirm the superiority in the prognostic prediction of these indices is warranted.

Cardio-Ankle Vascular Index as a Surrogate Marker of Early Atherosclerotic Cardiovascular Disease in Koreans with Type 2 Diabetes Mellitus

BACKGROUND

Carotid artery intima medial thickness (IMT), brachial-ankle pulse wave velocity (baPWV), and ankle-brachial index (ABI) are commonly used surrogate markers of subclinical atherosclerosis in patients with type 2 diabetes mellitus (T2DM). The cardio-ankle vascular index (CAVI) is a complement to the baPWV, which is affected by blood pressure. However, it is unclear which marker is the most sensitive predictor of atherosclerotic cardiovascular disease (ASCVD).

METHODS

This was a retrospective non-interventional study that enrolled 219 patients with T2DM. The correlations among IMT, ABI, and CAVI as well as the relationship of these tests to the 10-year ASCVD risk were also analyzed.

RESULTS

Among the 219 patients, 39 (17.8%) had ASCVD. In the non-ASCVD group, CAVI correlated significantly with IMT after adjusting for confounding variables, but ABI was not associated with CAVI or IMT. The analyses after dividing the non-ASCVD group into three subgroups according to the CAVI score (<8, ≥8 and <9, and ≥9) demonstrated the significant increase in the mean IMT, 10-year ASCVD risk and number of metabolic syndrome risk factors, and decrease in the mean ABI in the high-CAVI group. A high CAVI was an independent risk factor in the non-ASCVD group for both a high 10-year ASCVD risk (≥7.5%; odds ratio [OR], 2.42; P<0.001) and atherosclerosis (mean IMT ≥1 mm; OR, 1.53; P=0.007).

CONCLUSION

In Korean patients with T2DM without ASCVD, CAVI was the most sensitive of several surrogate markers for the detection of subclinical atherosclerosis.

Pitfalls in the ankle-brachial index and brachial-ankle pulse wave velocity

Background

The ankle-brachial index (ABI) and pulse wave velocity (PWV) are indices of atherosclerosis and arterial stiffness. The Japan-made measuring devices of those indices have spread widely because of their convenience and the significance of the parameters. However, studies that comprehensively discuss the various pitfalls in using these indices are not available.

Methods

This study presents several representative pitfalls in using the ABI and brachial-ankle PWV (baPWV) by showing the result sheets of the device, “the Vascular Profiler”. Furthermore, some considerations when utilizing these indices in the future are also discussed.

Results

Several diseases such as arteriosclerosis obliterans (ASO), arterial calcification in the lower limb, arterial stenosis in the right upper-limb, aortic valve diseases, arterial stenosis in the upper-limb of the contralateral side of the hemodialysis access, are the representative pitfalls when evaluating ABI and baPWV. Moreover, a measurement error is found to actually exist. Furthermore, same phenomena are considered most likely to occur when using other similar indices and devices.

Conclusion

The ABI and baPWV are the useful and significant biomarkers. Nevertheless, caution is sometimes necessary when interpreting them. Moreover, rigorous patient exclusion criteria should be considered when using those indices in the severely conditioned patient population. And the results of this study can be applied to enhance the literacy using other indices, such as the cardio-ankle vascular index and other similar devices.

Impressive predictive value of ankle-brachial index for very long-term outcomes in patients with cardiovascular disease: IMPACT-ABI study

Background

The ankle—brachial index (ABI) is a marker of generalized atherosclerosis and is predictive of future cardiovascular events. However, few studies have assessed its relation to long-term future cardiovascular events, especially in patients with borderline ABI. We therefore evaluated the relationship between long-term future cardiovascular events and ABI.

Methods

In the IMPACT-ABI study, a single-center, retrospective cohort study, we enrolled 3131 consecutive patients (67 ± 13 years; 82% male) hospitalized for cardiovascular disease and measured ABI between January 2005 and December 2012. After excluding patients with an ABI > 1.4, the remaining 3056 patients were categorized as having low ABI (≤ 0.9), borderline ABI (0.91–0.99), or normal ABI (1.00–1.40). The primary endpoint was MACE (cardiovascular death, myocardial infarction [MI] and stroke). The secondary endpoints were cardiovascular death, MI, stroke, admission due to heart failure, and major bleeding.

Results

During a 4.8-year mean follow-up period, the incidences of MACE (low vs. borderline vs. normal: 32.9% vs. 25.0% vs. 14.6%, P<0.0001) and cardiovascular death (26.2% vs. 18.7% vs. 8.9%, P<0.0001) differed significantly across ABIs. The incidences of stroke (9.1% vs. 8.6% vs. 4.8%, P<0.0001) and heart failure (25.7% vs. 20.8% vs. 8.9%, P<0.0001) were significantly higher in the low and borderline ABI groups than in the normal ABI group. But the incidences of MI and major bleeding were similar in the borderline and normal ABI groups. The hazard ratios for MACE adjusted for traditional atherosclerosis risk factors were significantly higher in patients with low and borderline ABI than those with normal ABI (HR, 1.93; 95%CI: 1.44–2.59, P < 0.0001, HR, 1.54; 95% CI: 1.03–2.29, P = 0.035).

Conclusions

The incidence of long-term adverse events was markedly higher among patients with low or borderline ABI than among those with normal ABI. This suggests that more attention should be paid to patients with borderline ABIs, especially with regard to cardiovascular death, stroke, and heart failure.

Detection of Subclinical Peripheral Artery Ischemia in Healthy Male Smokers by an Ankle-Brachial Index After Exercise: Sasayama Study

We investigated the relationship between smoking and the risk of nonnormal (≤0.99) ankle-brachial index (ABI) at rest and after ankle plantar flexion exercise in healthy male community dwellers. A cross-sectional study was performed including 228 Japanese men aged 40 to 64 years without a history of cardiovascular diseases. Participants were classified as never, ex-, and current smokers. We estimated the multivariate-adjusted odds ratios (ORs) for nonnormal ABI of ex- and current smokers in relation to never smokers after adjusting for age and other confounding factors. At rest, the prevalence of nonnormal ABI was not significantly different by smoking status. After exercise, the prevalence of nonnormal ABI increased from 1.8% to 11.5% in ex-smokers and from 3.8% to 17.0% in current smokers, while the prevalence did not significantly change in never smokers. The multivariate-adjusted OR for nonnormal ABI after ankle plantar flexion exercise, in relation to never smokers, was 3.85 (95% confidence interval [CI]: 0.79-18.9) for ex-smokers and 6.97 (95% CI: 1.32-36.7) for current smokers. Our results suggest that ABI after ankle plantar flexion exercise is useful for early detection of subclinical peripheral artery ischemia in male smokers without typical symptoms.

Early Detection System of Vascular Disease and Its Application Prospect

Markers of imaging, structure, and function reflecting vascular damage, integrating a long time accumulation effect of traditional and unrecognized cardiovascular risk factors, can be regarded as surrogate endpoints of target organ damage before the occurrence of clinical events. Prevention of cardiovascular disease requires risk stratification and treatment of traditional risk factors, such as smoking, hypertension, hyperlipidemia, and diabetes. However, traditional risk stratification is not sufficient to provide accurate assessment of future cardiovascular events. Therefore, vascular injury related parameters obtained by ultrasound or other noninvasive devices, as a surrogate parameter of subclinical cardiovascular disease, can improve cardiovascular risk assessment and optimize the preventive treatment strategy. Thus, we will summarize the research progress and clinical application of early assessment technology of vascular diseases in the present review.

Lipoprotein-associated phospholipase A2 and risk of incident peripheral arterial disease in a multi-ethnic cohort: The Multi-Ethnic Study of Atherosclerosis

Prospective studies supporting a relationship between elevated lipoprotein-associated phospholipase A₂ (Lp-PLA₂) and incident peripheral arterial disease (PAD) are limited. We evaluated the association of Lp-PLA₂ with incident PAD in a multi-ethnic cohort without clinical cardiovascular disease. A total of 4622 participants with measurement of Lp-PLA₂ mass and Lp-PLA₂ activity and an ankle-brachial index (ABI) between 0.9 and 1.4 were followed for the development of PAD (median follow-up = 9.3 years), defined as an ABI ⩽0.9 and decline from baseline ⩾0.15. There were 158 incident PAD events during follow-up. In adjusted logistic regression models, each higher standard deviation of both Lp-PLA₂ activity and mass did not confer an increased risk of developing PAD [odds ratios, (95% confidence intervals)]: 0.92 (0.66-1.27) for Lp-PLA₂ activity and 1.06 (0.85-1.34) for mass. Additionally, no significant interaction was found according to ethnicity: p=0.43 for Lp-PLA₂ activity and p=0.55 for Lp-PLA₂ mass. We found no evidence of an association between Lp-PLA₂ and incident PAD.

Prognostic significance of ankle brachial pressure index: A systematic review and meta-analysis

Purpose To synthesize and quantify the excess risk of morbidity and mortality in individuals with low ankle-brachial pressure index. Methods Electronic databases were searched to identify studies investigating morbidity and mortality outcomes in individuals undergoing ankle-brachial pressure index measurement. Meta-analysis of the outcomes was performed using fixed- or random-effects models. Uncertainties related to varying follow-up periods among the studies were resolved by meta-analysis of time-to-event outcomes. Results Forty-three observational cohort studies, enrolling 94,254 participants, were selected. A low ankle-brachial pressure index (<0.9) was associated with a significant risk of all-cause mortality (risk ratio: 2.52, 95% CI 2.26-2.82, P < 0.00001); cardiovascular mortality (risk ratio: 2.94, 95% CI 2.72-3.18, P < 0.00001); cerebrovascular event (risk ratio: 2.17, 95% CI 1.90-2.47, P < 0.00001); myocardial infarction (risk ratio: 2.28, 95% CI 2.07-2.51, P < 0.00001); fatal myocardial infarction (risk ratio: 2.81, 95% CI 2.33-3.40, P < 0.00001); fatal stroke (risk ratio: 2.28, 95% CI 1.80-2.89, P < 0.00001); and the composite of myocardial infarction, stroke, and death (risk ratio: 2.29, 95% CI 1.87-2.81, P < 0.00001). Similar findings resulted from analyses of individuals with asymptomatic PAD, individuals with cardiovascular or cerebrovascular co-morbidity, and patients with diabetes. Conclusions A low ankle-brachial pressure index is associated with an increased risk of subsequent cardiovascular and cerebrovascular morbidity and mortality. Randomised controlled trials are required to investigate the effectiveness of screening for PAD in asymptomatic and undiagnosed individuals and to evaluate benefits of early treatment of screen-detected PAD.

Vascular Function and Intima-media Thickness of a Leg Artery in Peripheral Artery Disease: A Comparison of Buerger Disease and Atherosclerotic Peripheral Artery Disease

Aim: Both vascular function and structure are independent predictors of cardiovascular events. The purpose of this study was to evaluate vascular function and structure of a leg artery in patients with peripheral artery disease (PAD).

Methods: We measured flow-mediated vasodilatation (FMD) and nitroglycerine-induced vasodilation (NID) as indices of vascular function and intima-media thickness (IMT) as an index of vascular structure of the popliteal artery in 100 subjects, including 20 patients with Buerger disease and 30 patients with atherosclerotic PAD, 20 age- and sex-matched subjects without Buerger disease (control group) and 30 age- and sex-matched patients without atherosclerotic PAD (control group).

Results: IMT was significantly larger in the Buerger group than in the control group (Buerger, 0.63 ± 0.20 mm; control, 0.50 ± 0.07 mm; P = 0.01), whereas there were no significant differences in FMD and NID between the two groups. IMT was significantly larger in the atherosclerotic PAD group than in the control group (atherosclerotic PAD, 0.80 ± 0.22 mm; control, 0.65 ± 0.14 mm; P < 0.01), and FMD and NID were significantly smaller in the atherosclerotic PAD group than in the control group (FMD: atherosclerotic PAD, 3.9% ± 1.1%; control, 5.0% ± 1.8%; P < 0.01; and NID: atherosclerotic PAD, 6.1% ± 2.0%; control, 8.4% ± 2.1%; P < 0.01).

Conclusion: These findings suggest that vascular function is preserved in patients with Buerger disease and that both vascular function and vascular structure are impaired in patients with atherosclerotic PAD.

The association between ankle-brachial index and asymptomatic cranial-carotid stenosis: a population-based, cross-sectional study of 5440 Han Chinese

BACKGROUND AND PURPOSE

Routine screening for asymptomatic cranial-carotid stenosis (ACCS) is controversial and recommendation in clinical practice is vague. The ankle-brachial index (ABI) is reported as a predictor for cardiovascular disease. However, there is a scarcity of data about the association between abnormal ABI and ACCS. A population-based cross-sectional study was conducted to explore the relationship between ABI and ACCS.

METHODS

A sample of 5440 Chinese adults aged 40-94 years old was recruited from 2010 to 2011. The ABI was measured using a portable Doppler device and ACCS was evaluated by bilateral carotid duplex ultrasound and portable examination devices. A logistic regression model was used to analyse the association between ABI and ACCS after adjusting for potential confounding factors.

RESULTS

A low ABI was associated with ACCS [odds ratio (OR) 1.95, 95% confidence interval (CI) 1.42-2.67] after adjusting for potential confounders. When the data were stratified by age and sex, the correlation remained statistically significant in the male (OR 2.32, 95% CI 1.60-3.37) and elderly (OR 3.07, 95% CI 1.97-4.78) subgroups compared to the female (OR 1.26, 95% CI 0.67-2.39) and middle-aged groups (OR 1.27, 95% CI 0.77-2.12), respectively.

CONCLUSION

This study demonstrated that low ABI is a significant risk factor for ACCS in male and elderly Chinese adults.

Epidemiology of peripheral artery disease

New data on the epidemiology of peripheral artery disease (PAD) are available, and they should be integrated with previous data. We provide an updated, integrated overview of the epidemiology of PAD, a focused literature review was conducted on the epidemiology of PAD. The PAD results were grouped into symptoms, diagnosis, prevalence, and incidence both in the United States and globally, risk factors, progression, coprevalence with other atherosclerotic disease, and association with incident cardiovascular morbidity and mortality. The most common symptom of PAD is intermittent claudication, but noninvasive measures, such as the ankle-brachial index, show that asymptomatic PAD is several times more common in the population than intermittent claudication. PAD prevalence and incidence are both sharply age-related, rising >10% among patients in their 60s and 70s. With aging of the global population, it seems likely that PAD will be increasingly common in the future. Prevalence seems to be higher among men than women for more severe or symptomatic disease. The major risk factors for PAD are similar to those for coronary and cerebrovascular disease, with some differences in the relative importance of factors. Smoking is a particularly strong risk factor for PAD, as is diabetes mellitus, and several newer risk markers have shown independent associations with PAD. PAD is strongly associated with concomitant coronary and cerebrovascular diseases. After adjustment for known cardiovascular disease risk factors, PAD is associated with an increased risk of incident coronary and cerebrovascular disease morbidity and mortality.

Relationship between low Ankle-Brachial Index and rapid renal function decline in patients with atrial fibrillation: a prospective multicentre cohort study

OBJECTIVE

To investigate the relationship between Ankle-Brachial Index (ABI) and renal function progression in patients with atrial fibrillation (AF).

DESIGN

Observational prospective multicentre cohort study.

SETTING

Atherothrombosis Center of I Clinica Medica of 'Sapienza' University of Rome; Department of Medical and Surgical Sciences of University Magna Græcia of Catanzaro; Atrial Fibrillation Registry for Ankle-Brachial Index Prevalence Assessment-Collaborative Italian Study.

PARTICIPANTS

897 AF patients on treatment with vitamin K antagonists.

MAIN OUTCOME MEASURES

The relationship between basal ABI and renal function progression, assessed by the estimated Glomerular Filtration Rate (eGFR) calculated with the CKD-EPI formula at baseline and after 2 years of follow-up. The rapid decline in eGFR, defined as a decline in eGFR >5 mL/min/1.73 m(2)/year, and incident eGFR<60 mL/min/1.73 m(2) were primary and secondary end points, respectively.

RESULTS

Mean age was 71.8±9.0 years and 41.8% were women. Low ABI (ie, ≤0.90) was present in 194 (21.6%) patients. Baseline median eGFR was 72.7 mL/min/1.73 m(2), and 28.7% patients had an eGFR<60 mL/min/1.73 m(2). Annual decline of eGFR was -2.0 (IQR -7.4/-0.4) mL/min/1.73 m(2)/year, and 32.4% patients had a rapid decline in eGFR. Multivariable logistic regression analysis showed that ABI ≤0.90 (OR 1.516 (95% CI 1.075 to 2.139), p=0.018) and arterial hypertension (OR 1.830 95% CI 1.113 to 3.009, p=0.017) predicted a rapid eGFR decline, with an inverse association for angiotensin converting enzyme (ACE) inhibitors/angiotensin receptor blockers (OR 0.662 95% CI 0.464 to 0.944, p=0.023). Among the 639 patients with AF with eGFR >60 mL/min/1.73 m(2), 153 (23.9%) had a reduction of the eGFR <60 mL/min/1.73 m(2). ABI ≤0.90 was also an independent predictor for incident eGFR<60 mL/min/1.73 m(2) (HR 1.851, 95% CI 1.205 to 2.845, p=0.005).

CONCLUSIONS

In patients with AF, an ABI ≤0.90 is independently associated with a rapid decline in renal function and incident eGFR<60 mL/min/1.73 m(2). ABI measurement may help identify patients with AF at risk of renal function deterioration.

TRIAL REGISTRATION NUMBER

NCT01161251.

Association Between Ankle-Brachial Index and Coronary Lesions Assessed by Coronary Angiography

Background

The ankle-brachial index (ABI) is a simple, non-invasive, and inexpensive method used in the diagnosis of peripheral arterial disease (PAD) and can identify individuals at risk for cardiovascular disease in other arteries of the body, especially the coronary and carotid arteries. The primary objective of this study was to assess whether patients with an ABI < 0.9 have more severe coronary artery disease detected on coronary angiography compared to patients with a normal ABI.

Methods

This is a prospective, analytical, cross-sectional study that was performed from July 1, 2013 to June 31, 2014 that recruited 163 patients (101 men (62%) and 62 women (38%)) according to the inclusion and exclusion criteria. All patients underwent coronary angiography, and then ABI measurements were performed. Pearson’s Chi-square and Student’s t-tests were used to compare variables between groups. The Poisson regression model was used to evaluate whether ABI was an independent predictor of stenoses > 50%.

Results

The prevalence of ABI < 0.9 was 9.8%. Patients with an ABI < 0.9 had a higher prevalence of stenoses ≥ 50% in the left anterior descendant (LAD) (68.7% vs. 36%, P = 0.02) and left main (8.7% vs. 0.6%, P < 0.001) than those with a normal ABI. On multivariate Poisson regression, an ABI < 0.9 was an independent predictor of stenosis ≥ 50% in the LAD (odds ratio (OR): 2.05 (1.39 - 3.04), P < 0.001).

Conclusions

Patients with an ABI < 0.9 had a higher prevalence of stenoses ≥ 50% in the LAD and left main than those with a normal ABI. An abnormal ABI was an independent predictor of lesions ≥ 50% in LAD.

Relationship between serum 25-hydroxyvitamin D and lower extremity arterial disease in type 2 diabetes mellitus patients and the analysis of the intervention of vitamin D

The aim of this study was to explore the relationship between serum 25-hydroxyvitamin D [25(OH)D] concentrations and lower extremity arterial disease (LEAD) in type 2 diabetes mellitus (T2DM) patients and to investigate the intervention effect of vitamin D. 145 subjects were assigned to a control group (Group NC), T2DM group (Group DM1), and T2DM complicated with LEAD group (Group DM2); then Group DM2 were randomly divided into Group DM3 who received oral hypoglycemic agents and Group DM4 who received oral hypoglycemic drugs and vitamin D3 therapy. Compared to Group NC, 25(OH)D was significantly lower in Group DM2 and marginally lower in Group DM1. In contrast to baseline and Group DM3, 25(OH)D rose while low density lipoprotein (LDL), retinol binding protein 4 (RBP4), and HbA1c significantly lowered in Group DM4. Statistical analysis revealed that 25(OH)D had a negative correlation with RBP4, duration, HbA1c, homeostasis model assessment for insulin resistance (HOMA-IR), and fasting plasma glucose (FPG). LDL, systolic blood pressure (SBP), FPG, and smoking were risk factors of LEAD while high density lipoprotein (HDL) and 25(OH)D were protective ones. Therefore, we deduced that low level of 25(OH)D is significantly associated with the occurrence of T2DM complicated with LEAD.