The Impact of the COVID-19 Pandemic and Associated Control Measures on the Mental Health of the General Population : A Systematic Review and Dose-Response Meta-analysis

BACKGROUND

To what extent the COVID-19 pandemic and its containment measures influenced mental health in the general population is still unclear.

PURPOSE

To assess the trajectory of mental health symptoms during the first year of the pandemic and examine dose-response relations with characteristics of the pandemic and its containment.

DATA SOURCES

Relevant articles were identified from the living evidence database of the COVID-19 Open Access Project, which indexes COVID-19-related publications from MEDLINE via PubMed, Embase via Ovid, and PsycInfo. Preprint publications were not considered.

STUDY SELECTION

Longitudinal studies that reported data on the general population's mental health using validated scales and that were published before 31 March 2021 were eligible.

DATA EXTRACTION

An international crowd of 109 trained reviewers screened references and extracted study characteristics, participant characteristics, and symptom scores at each timepoint. Data were also included for the following country-specific variables: days since the first case of SARS-CoV-2 infection, the stringency of governmental containment measures, and the cumulative numbers of cases and deaths.

DATA SYNTHESIS

In a total of 43 studies (331 628 participants), changes in symptoms of psychological distress, sleep disturbances, and mental well-being varied substantially across studies. On average, depression and anxiety symptoms worsened in the first 2 months of the pandemic (standardized mean difference at 60 days, -0.39 [95% credible interval, -0.76 to -0.03]); thereafter, the trajectories were heterogeneous. There was a linear association of worsening depression and anxiety with increasing numbers of reported cases of SARS-CoV-2 infection and increasing stringency in governmental measures. Gender, age, country, deprivation, inequalities, risk of bias, and study design did not modify these associations.

LIMITATIONS

The certainty of the evidence was low because of the high risk of bias in included studies and the large amount of heterogeneity. Stringency measures and surges in cases were strongly correlated and changed over time. The observed associations should not be interpreted as causal relationships.

CONCLUSION

Although an initial increase in average symptoms of depression and anxiety and an association between higher numbers of reported cases and more stringent measures were found, changes in mental health symptoms varied substantially across studies after the first 2 months of the pandemic. This suggests that different populations responded differently to the psychological stress generated by the pandemic and its containment measures.

PRIMARY FUNDING SOURCE

Swiss National Science Foundation. (PROSPERO: CRD42020180049).

The Role of Oedema Protective Drugs in the Treatment of Chronic Venous Insufficiency: A Review of Evidence Based on Placebo-Controlled Clinical Trials with Regard to Efficacy and Tolerance

Objective:

To review the therapeutic efficacy and tolerability of oedema protective agents such as diosmin, horse chestnut extract and O-(β-hydroxyethyl)-rutosides in the treatment of chronic venous insufficiency (CVI).

Data selection:

Relevant clinical studies were selected if they were performed using a double-blind, placebo-controlled design with validated instrument measurement of objective criteria and measurement of subjective criteria by standardized methods.

Data synthesis:

Judgement of clinical effectiveness of drug treatment with venoprotective/venotropic agents was based on the signs and symptoms of CVI. Measurements; Accepted for consideration included reduction of leg oedema, related subjective symptoms, improvement of haemodynamics and microcirculation, and improved healing of venous ulcers. Tolerability of the compounds in therapeutic use was assessed by comparing the frequency of side-effects in treatment and placebo groups.

Conclusion:

Oedema protective agents such as diosmin, horse chestnut extract and O-(β-hydroxyethyl)-rutosides are an appropriate option in the management of CVI. The clinical efficacy can be measured objectively and quantified by assessing oedema reduction or in the case of venous ulcers by ulcer healing rates. The extent of oedema reduction in patients with CVI is equivalent to the reduction achieved by compression therapy with elastic stockings as seen in a recent clinical study. Combined treatment of oedema protective agents and compression therapy has a better clinical benefit compared with treatment with either alone. The compounds have a favourable benefit/risk ratio. They combine proven therapeutic efficacy with excellent safety of use confirmed in a large number of patients treated in clinical trials.

[Cardiovascular prevention at the general practitioner? First results of a study on attitudes, services, success and barriers in practice]

BACKGROUND

There is a lack of detailed data about lifestyle counseling and other cardiovascular preventive services in primary care settings in Germany. The objectives of this study were to analyze the provision of these services and to identify associated factors.

METHODS

260 (13 %) out of 2,000 randomly selected general practitioners from Southern Germany, took part in this study and were asked about lifestyle counseling and other preventive services as well as barriers and attitudes. Factors associated with lifestyle counseling were analyzed using chi-square tests and logistic regression.

RESULTS

Participating physicians had positive attitudes towards health promotion and prevention. Four out of ten physicians counseled the majority of their patients about diet, physical activity, tobacco and alcohol consumption. Female physicians (odds ratio, OR: 1,98), physicians who were confident about their preventive services (OR: 3,55) and those having risk factor questionnaires in the waiting room (OR: 2,26; all p < 0,05) were more likely to counsel their patients. The most important barriers towards preventive services were patients' lack of adherence (91 %), inadequate reimbursement (80 %) and lack of time (70 %).

CONCLUSION

There is a discrepancy between the potential and the implementation of cardiovascular-preventive services in primary care settings. Special trainings of physicians as well as better financial and organizational conditions might help to improve the provision of preventive care.

Asymmetric dimethylarginine as an independent risk marker for mortality in ambulatory patients with peripheral arterial disease

BACKGROUND

Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of nitric oxide (NO) synthesis causing endothelial dysfunction, an early sign of atherogenesis. Symmetric dimethylarginine (SDMA) does not inhibit NO synthases. Peripheral arterial disease (PAD) is a systemic indication of atherosclerosis.

METHODS

We assessed the associations between both ADMA and SDMA blood levels and major cardiovascular and cerebrovascular events or death from any cause within a 5-year follow-up in the multicentre getABI trial. From a cohort of 6821 primary care patients, aged ≥65 years, all 1260 patients with prevalent PAD were compared with a random sample of 1187 non-PAD controls. A total of 11,544 patient-years were documented. Multivariate risks were calculated by Cox proportional hazard models, adjusting for PAD, renal dysfunction and other important cardiovascular risk factors.

RESULTS

We documented 390 deaths, 296 cardiovascular events and 98 cerebrovascular events. Increased ADMA levels in the 4th quartile were significantly associated with total mortality [hazard ratio (HR) 1.41; 95% CI 1.14-1.74] and with cardiovascular events (HR 1.32; 95% CI 1.03-1.69), but there was a nonsignificant association with cerebrovascular events (HR 1.50; 95% CI 0.98-2.29). Increased SDMA was only just significantly associated with mortality (HR 1.27; 95% CI 1.01-1.59). In PAD patients compared with non-PAD controls, only mean SDMA concentration was considerably increased (0.52 μmol L(-1) vs. 0.48 μmol L(-1); P < 0.001) mainly because of a highly significant association with impaired renal function.

CONCLUSION

These data suggest that ADMA but not SDMA is an independent risk marker for death from any cause or from cardiovascular events. The association between SDMA and mortality is in part explained by a close link between SDMA and renal function.

[Elastic compression stockings for prevention of deep vein thrombosis - is there any evidence?]

Elastic compression stockings (ECS) as a physical tool for prevention of deep vein thrombosis were introduced in the 70 s and 80 s of the last century and they are still used today. Two recent studies have arisen a discussion regarding the benefit of the combined used of ECS and pharmaceutical prophylaxis over pharmaceutical prophylaxis alone. One study on patients receiving total hip replacement and one study on patients suffering from stroke did not show an advantage of the combination. In addition the German, the American and the British Guidelines do not give precise and mandatory indication for the use of ECS in addition to pharmaceutical prophylaxis. They describe the lack of adequate data and the problems in patient care using ECS. Thus, due to the lack of evidence and the possibility of adverse events a routine use of ECS is not justified. The only generally accepted indication for ECS is in patients with moderate and high risk for venous thromboembolism when pharmaceutical prophylaxis is not possible.

[Deficits in adherence on all levels. Current need of interventions in primary, secondary, and tertiary prevention of cardiovascular diseases]

BACKGROUND AND OBJECTIVE

Previous studies often lack any differentiation between target groups for primary, secondary and tertiary prevention of cardiovascular disease (CVD). The aim of this study was to investigate the target group-specific adherence with lifestyle recommendations in different risk groups. This information may be useful in identifying better starting points for future CVD interventions.

METHODS

2,002 men and women aged 50 to 70 years were selected by random and interviewed about their health status, health behavior and health locus of control. Adherence was defined as regular physical activity, healthy diet, non-smoking, and moderate alcohol consumption. Differences between risk groups were determined using Chi-square tests and stratified logistic regression.

RESULTS

Health behavior only varied to a limited extent between the risk groups: physical activity (77.8%), healthy diet (62.2%), moderate alcohol consumption (74.4%), non-smoking (total: 75.7%; healthy respondents 70.9%; risk group 79.1%; CVD patients 74.7%). 29.6% were adherent to lifestyle recommendations. Women were more likely to be adherent than men (35.4% vs. 23.5%). In CVD patients, those living together with a partner were also more likely to have a healthy lifestyle (32.2% vs. 20.0%). Furthermore, health locus of control seems to be an important factor.

CONCLUSION

In the age group 50-70 adherence with lifestyle recommendations of almost 30% is rather low and not optimal. Health locus of control as motivational barrier should be taken into account particularly in secondary prevention. There is a need of health behavior interventions not only for persons at increased risk and CVD patients, but also for the (still) healthy. Men, singles and persons with external health locus of control should be particularly addressed by these interventions.

[Anticoagulation in the elderly]

The recommendations for anticoagulation in over 80 years old patients are based on the thromboembolic/bleeding risk relation. They add to the published recommendations for the specific indications. Low-molecular-weight heparin (LMWH) is used to prevent thromboembolism postoperatively. Compression stockings and/or intermittent pneumatic compression are used if bleeding risk is very high. The dose is increased starting at day two if the thromboembolic risk is very high. Bleeding and thromboembolic risks are re-evaluted daily. The antithrombotic therapy is adjusted accordingly. Prophylaxis of thromboembolism in patients with acute illnesses and bedrest is performed according postoperative care. Two-thirds of therapeutic doses of low-molecular-weight heparin are used to treat acute venous thromboembolism. Reduced renal function (creatinine clearance <30 ml/ min for most LMWHs or <20 ml/min for tinzaparin) should result in a further reduction of dose. Intensity and duration of prophylaxis of recurrent events with vitamin K antagonist or LMWH in malignancy follow current or herein described recommendations. Patients with atrial fibrillation are treated with vitamin K antagonists adjusted to an INR of 2-3 for prophylaxis of embolism. Further details of anticoagulant therapy should be in agreement with the national or international recommendations.

Results of the randomized, placebo-controlled clopidogrel and acetylsalicylic acid in bypass surgery for peripheral arterial disease (CASPAR) trial

OBJECTIVE

Dual antiplatelet therapy with clopidogrel plus acetylsalicylic acid (ASA) is superior to ASA alone in patients with acute coronary syndromes and in those undergoing percutaneous coronary intervention. We sought to determine whether clopidogrel plus ASA conferred benefit on limb outcomes over ASA alone in patients undergoing below-knee bypass grafting.

METHODS

Patients undergoing unilateral, below-knee bypass graft for atherosclerotic peripheral arterial disease (PAD) were enrolled 2 to 4 days after surgery and were randomly assigned to clopidogrel 75 mg/day plus ASA 75 to 100 mg/day or placebo plus ASA 75 to 100 mg/day for 6 to 24 months. The primary efficacy endpoint was a composite of index-graft occlusion or revascularization, above-ankle amputation of the affected limb, or death. The primary safety endpoint was severe bleeding (Global Utilization of Streptokinase and Tissue plasminogen activator for Occluded coronary arteries [GUSTO] classification).

RESULTS

In the overall population, the primary endpoint occurred in 149 of 425 patients in the clopidogrel group vs 151 of 426 patients in the placebo (plus ASA) group (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.78-1.23). In a prespecified subgroup analysis, the primary endpoint was significantly reduced by clopidogrel in prosthetic graft patients (HR, 0.65; 95% CI, 0.45-0.95; P = .025) but not in venous graft patients (HR, 1.25; 95% CI, 0.94-1.67, not significant [NS]). A significant statistical interaction between treatment effect and graft type was observed (P(interaction) = .008). Although total bleeds were more frequent with clopidogrel, there was no significant difference between the rates of severe bleeding in the clopidogrel and placebo (plus ASA) groups (2.1% vs 1.2%).

CONCLUSION

The combination of clopidogrel plus ASA did not improve limb or systemic outcomes in the overall population of PAD patients requiring below-knee bypass grafting. Subgroup analysis suggests that clopidogrel plus ASA confers benefit in patients receiving prosthetic grafts without significantly increasing major bleeding risk.

Management of patients with peripheral arterial disease in primary care: a cross-sectional study in Germany

BACKGROUND

Studies in the primary care setting are of high interest for assessing the management situation of patients with manifestations of atherothrombosis.

AIMS

Therefore, we documented diagnostic procedures, characteristics, and management of patients with symptomatic and asymptomatic peripheral arterial disease (PAD).

MATERIALS & METHODS

Prospective cross-sectional study in primary care practices throughout Germany.

RESULTS

A total of 671 patients with newly diagnosed PAD were included (mean age 69.1 years; 62.1% men). Cardiovascular risk factors were highly prevalent in the total PAD group: arterial hypertension in 84.2%, hyperlipidaemia in 75.5%, present smoking in 45.0% and diabetes mellitus in 47.3%. Atherothrombotic comorbidities were also frequent: coronary artery disease in 44.9% and cerebrovascular disease in 28.1%. For confirmation of diagnosis, patients were referred to specialists in 66.9% of cases. Overall, ankle brachial index was measured in 89.0%, and a clinical PAD score assessed in 66.6% (agreement of both measures with Cohen's kappa only, kappa = 0.039; p = 0.209). Drug treatment of risk factors (as secondary prophylaxis) in line with current guidelines was reported in a high percentage of patients: 88.6% with any antiplatelet drug, 69.3% with statins, 62.4% with angiotensin converting enzyme inhibitors, 23.5% with AT(1) receptor blockers and 43.9% with beta-blockers. Between asymptomatic and symptomatic PAD, differences in the risk factor/comorbidity profiles were small; however, the latter group received intensified treatment.

CONCLUSION

Our findings confirm that patients with PAD pose a substantial challenge to physicians because of their high number of comorbidities. Compared with previous studies, management of such patients appears to have improved.

Oscillometric measurement of ankle-brachial index in patients with suspected peripheral disease: comparison with Doppler method

QUESTION UNDER STUDY

Purpose was to validate accuracy and reliability of automated oscillometric ankle-brachial (ABI) measurement prospectively against the current gold standard of Doppler-assisted ABI determination.

METHODS

Oscillometric ABI was measured in 50 consecutive patients with peripheral arterial disease (n = 100 limbs, mean age 65 +/- 6 years, 31 men, 19 diabetics) after both high and low ABI had been determined conventionally by Doppler under standardised conditions. Correlation was assessed by linear regression and Pearson product moment correlation. Degree of inter-modality agreement was quantified by use of Bland and Altman method.

RESULTS

Oscillometry was performed significantly faster than Doppler-assisted ABI (3.9 +/- 1.3 vs 11.4 +/- 3.8 minutes, P <0.001). Mean readings were 0.62 +/- 0.25, 0.70 +/- 0.22 and 0.63 +/- 0.39 for low, high and oscillometric ABI, respectively. Correlation between oscillometry and Doppler ABI was good overall (r = 0.76 for both low and high ABI) and excellent in oligo-symptomatic, non-diabetic patients (r = 0.81; 0.07 +/- 0.23); it was, however, limited in diabetic patients and in patients with critical limb ischaemia. In general, oscillometric ABI readings were slightly higher (+0.06), but linear regression analysis showed that correlation was sustained over the whole range of measurements.

CONCLUSIONS

Results of automated oscillometric ABI determination correlated well with Doppler-assisted measurements and could be obtained in shorter time. Agreement was particularly high in oligo-symptomatic non-diabetic patients.

[Secondary prevention with clopidogrel or acetylsalicylic acid after acute cerebrovascular event. Health services research study of private primary care specialists]

BACKGROUND

Current guidelines on stroke prevention recommend long-term antiplatelet therapy. Clopidogrel is primarily indicated in patients at higher risk. This investigation documented the current situation of patients who are treated with clopidogrel and/or acetylicsalicylic acid (ASA) following an acute ischemic cerebrovascular event (stroke or transient ischemic attack, TIA) in a primary care setting.

PATIENTS AND METHODS

Prospective, cross sectional study with 2095 patients in 642 physician offices.

RESULTS

Patients were 69.0 +/- 10.2 years old (58.2% were men). Ischemic stroke was reported in 57.3% and TIA in 46.0% (several events in one given patient possible). Cardiovascular risk factors were frequent (arterial hypertension 87.6%, hyperlipidaemia 75.3%, diabetes mellitus 42.5%, and smoking in 27.2%) as were atherothrombotic comorbidities (stable coronary artery disease 23.3%, unstable CAD 11.6%, peripheral arterial hypertension 26.6%). A stratification according to the Essen Stroke Risk Score (ESRS) showed that 80.2% of the patients had a high risk of recurrent events. Patients with clopidogrel monotherapy or combination therapy (47.2% and 39.2% of the cohort) compared to ASA monotherapy (16.6%) were more frequently male, had more often a private insurance, a higher number of risk factors and comorbidities as well as a higher ESRS. Long-term antiplatelet therapy was planned by the treating physicians in 6.5% of patients on clopidogrel monotherapy in 33.6% on combination therapy and in 93.4% on ASA monotherapy.

CONCLUSION

Patients with an acute cerebrovascular event have multiple comorbidities and are therefore relatively frequently treated with clopidogrel. It is striking that in a number of patients no long-term anti-platelet therapy was recommended by the primary care physician.

Peripheral endovascular revascularization trials: high noon for uniform reporting standards

In the era of evidence based medicine, proof of clinical benefits and cost-effectiveness need to be firmly based on transparent comparisons between various therapeutic alternatives. Standards for reports are a prerequisite for comparisons across reports and should reflect the patient's perspective. According standards have been successfully introduced in many fields of modern medicine, but not yet for peripheral endovascular interventions. Given the overwhelmingly increasing importance of endovascular revascularization in patients with chronic lower limb ischemia, this report provides an updated outline of the heterogeneity of current reporting practice and highlights the need for uniform reporting standards.

[Diabetes, heart surgery and the peripheral arteries]

Peripheral arterial disease (PAD) is an under-recognized and underestimated complication of diabetes. Prevalence of PAD in diabetic patients is 25-30%. The main reason for underreporting is the largely asymptomatic nature of PAD in diabetes. It is important to diagnose PAD as soon as possible because PAD is an important marker for systemic atherosclerosis. Patients with claudication have approximately a 30% five-year mortality rate. PAD patients die 10 years earlier than patients without this atherothrombotic disease. About 70% of the PAD patients die from coronary heart disease, 5-11% die from stroke. PAD and diabetes are comorbid conditions and are associated with the risk of death from coronary artery bypass graft surgery. The prevalence of diabetes in patients who undergo cardiac surgery is 30% and the prevalence of PAD is 18%. The presence of PAD in diabetic patients had a similar 2-fold increase in the annual incidence of death compared with diabetic patients without PAD. The theory that diabetes and PAD together is associated with small vessel disease may play a role in the cause of the higher long-term mortality seen in at least two studies (Circulation 2004; suppl II: II/41-II/44).

[Metabolic syndrome and peripheral arterial occlusive disease as indicators for increased cardiovascular risk]

BACKGROUND AND AIMS

The usefulness of the metabolic syndrome (MetS) or a low ankle brachial index (ABI), respectively, to identify patients with high risk for cardiovascular events has repeatedly been postulated. However, robust data on the prevalence and prognosis of such patients are missing in the primary care setting.

PATIENTS AND METHODS

In the prospective, non-interventional "German epidemiological trial on Ankle Brachial Index (getABI) at total of 6880 unselected patients > or = 65 years were observed by their General Practitioners over 3 years. Death and cardiovascular events were recorded. The definition of MetS was similar to the one of NCEP ATP III (National Cholesterol Education Program--Adult Treatment Panel III). ABI (ratio of the systolic blood pressures measured at the distal part of the calf and at the upper arm) was measured with Doppler sonography. Peripheral arterial disease (PAD) was defined as ABI <0.9 or peripheral revascularization/amputation owing to PAD. Survival analyses were conducted with a Cox proportional hazard model. Hazard rate ratios (HRR, 95 % confidence intervals, CI) were multvariate adjusted.

RESULTS

The observation time for the total cohort was more than 20,000 patient years (PY). Cardiovascular mortality in patients with MetS (n = 3040, 44 %) compared to patients without MetS (n = 3795; 55 %) was doubled (8.5 vs. 4.0 per 1,000 PY; HRR: 2.0; CI 1.3 - 2.9). Concomitant presence of MetS and PAD (n = 651; 9.5 %) increased the mortality risk compared to patients without both conditions (n = 3194; 46.4 %) drastically (21.1 vs. 3.0 per 1000 PY; HRR: 5.7; CI: 3.5 - 9.4). Similar significant risk increases also were noted for all-cause mortality or a combined endpoint of mortality and vascular morbidity. Further, in lower ABI categories cardiovascular event rates increased.

CONCLUSIONS

Patients with MetS carry a substantially increased risk of premature death, especially cardiovascular death, and therefore require intensive treatment of their risk factors. This holds especially true if concomitant PAD is present.

[Self-management of anticoagulation therapy]

Patents on anticoagulation therapy benefit appreciably from so-called coagulation self-management. Thus, in comparison with patients receiving conventional management, self-managers showed a higher level of treatment quality, better compliance and a lower complication rate (ESCAT studies). In addition, self-monitoring permits greater flexibility and independence, quality of life improves, and the doctor-patient relationship benefits. Appropriate devices have been available in Germany since 1994. A prerequisite for the payment of the costs by health insurances is the participation of the patient in a theoretical and practical educational program, and his/her presumed life-long need for anticoagulation therapy.

Does calculation of ankle brachial pressure index need revision?

Peripheral arterial disease (PAD) is a commonly encountered but a commonly under-diagnosed condition in clinical practice. Ankle brachial pressure index (ABI) is a widely used procedure in its detection. It is also a very good prognostic marker not only of PAD but also of mortality. According to the current guidelines ABI of a side i.e. either the left or the right, is the quotient of the higher of the systolic blood pressures (SBP) of the two ankle arteries of that limb (either the anterior tibial artery or the posterior tibial artery) and the higher of the two brachial SBP of upper limbs. With the currently existing method of ABI calculation, considering only the higher of the SBP of the two ankle arteries, a distal stenosis of the ankle arterial system with the lower SBP, may be missed. We suggest a modification to the currently existing of calculating ABI. The method has been termed by us as the low ankle pressure method. In this method the lowest ankle pressure between the two ankle arteries of a particular side is to be the numerator and the denominator could be the same as before. A study or a series of studies comparing our proposed method with the current one are needed to test its clinical utility.

Epidemiology of peripheral arterial disease

Peripheral arterial disease (PAD) is not an uncommon but a commonly neglected condition by many medical practitioners. It is a disease that threatens not only the limb but also life itself! Atherosclerosis is the commonest cause of PAD in the western nations. The cardinal symptom is intermittent claudication (IC) but majority of the patients are asymptomatic. Ankle-brachial pressure index (ABI) is an effective screening tool for PAD. A diminished ABI (< 0.9) is a definite sign of PAD. Its prevalence steadily increases with age. In Germany almost a fifth of the patients aged over 65 years suffer from it. With increasing life expectancy the prevalence of PAD is on the increase. PAD is a manifestation of diffuse and severe atherosclerosis. It is a strong marker of cardiovascular disease; a very strong association exists between PAD and other atherosclerotic disorders such as coronary artery disease (CAD) and cerebrovascular disease (CVD). PAD is an independent predictor of high mortality in patients with CAD. Smoking, diabetes mellitus and advancing age are the cardinal risk factors. A relatively small number of PAD patients lose limbs by amputation. Most paitients with PAD die of either heart attacks or strokes and they die of the former conditions far earlier than controls. PAD still remains an esoteric disease and there is a significant lack of awareness of this condition by many physicians, and therefore under-diagnosed and underestimated. Measures to promote awareness of PAD among physicians and the society in general are needed. Since most patients are asymptomatic and carry potentially significant morbidity and mortality risks, screening for PAD should be made a routine practice at primary care level.

High Prevalence of Peripheral Arterial Disease and Low Treatment Rates in Elderly Primary Care Patients with Diabetes

Representative data on peripheral arterial disease (PAD) in community-based office practice are scarce while at the same time of high interest. Thus, we aimed to determine the prevalence of peripheral arterial disease (PAD), comorbidity of atherothrombotic manifestations, and treatment intensity among elderly diabetic patients in primary care. In this monitored cross-sectional study, 344 general practitioners throughout Germany determined the ankle-brachial index (ABI) of 6880 consecutive, unselected patients aged 65 years or older with bilateral Doppler ultrasound measurements. PAD was defined according to the recent American Heart Association guidelines (using the higher of the 2 systolic ankle pressures: ABI < 0.9) or peripheral revascularisation, or amputation because of PAD. Coronary events (CAD) and cerebrovascular events (CVD) were taken from the patient's history without additional diagnostic measures. Diabetes was defined according to the clinical diagnosis of the physician and/or HbA1c > or = 6.5 % and/or intake of oral antidiabetic medication and/or application of insulin. 1.743 patients were classified as diabetics: the median disease duration was 6 years (1st; 3rd quartile: 2; 11), median HbA1c 6.6 % (5.9; 7.3), mean age 72.5 +/- 5.4 years, and 51.4 % were females. Diabetics had in comparison with non-diabetics a higher prevalence of PAD defined as ABI < 0.9 (26.3 % vs. 15.3 %, univariate odds ratio 2.0 [95 % confidence interval: 1.7; 2.3]), intermittent claudication (5.1 % vs. 2.1 %, OR: 2.5 [1.9; 3.4]), known CAD (16.1 % vs. 10.6 %, OR: 1.6 [1.4; 1.9]), and known CVD (6.8 % vs. 4.8 %; OR: 1.4 [1.2; 1.8]). 57.4 % of the diabetics with previously known PAD (as only atherothrombotic manifestation) received antiplatelet therapy (vs. 75.1 % with CAD and/or CVD only). The ABI was suitable as screening measure in the primary care setting. In elderly diabetics in comparison to non-diabetics, the prevalence of PAD was very high. Despite the known benefits of antiplatelet therapy, PAD patients were less intensively treated than patients with CAD or CVD.