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Prevalence of coexistence of coronary artery disease, peripheral arterial disease, and atherothrombotic brain infarction in men and women > or = 62 years of age
Abstract
Our data showed that CAD, PAD, and ABI were more prevalent in men than in women aged ≥62 years. Of our 1,886 patients, only 705 (37%) had no CAD, PAD, or ABI. CAD was present in 43%, PAD in 25%, and ABI in 26% of our population. If ABI was present, CAD was also present in 53% and PAD in 33% of our population. If PAD was present, CAD was also present in 58% and ABI in 34% of our population. If CAD was present, ABI was also present in 32% and PAD in 33% of our population.
... The number of patients with PAD is estimated to be over 200 million worldwide, with symptoms ranging from none to severe [1][2][3]. Since PAD has risk factors in common with coronary artery disease (CAD) and cerebrovascular disease (CVD), patients with PAD are likely to have these other comorbid conditions [3,4]. Furthermore, patients with PAD, especially those with critical limb ischemia, have an increased risk of cardiovascular events, cerebrovascular events, lower limb amputations, and death compared to the general population [4][5][6][7]. ...
... Since PAD has risk factors in common with coronary artery disease (CAD) and cerebrovascular disease (CVD), patients with PAD are likely to have these other comorbid conditions [3,4]. Furthermore, patients with PAD, especially those with critical limb ischemia, have an increased risk of cardiovascular events, cerebrovascular events, lower limb amputations, and death compared to the general population [4][5][6][7]. Previous reports have revealed that approximately 40% of patients with critical limb ischemia require lower limb amputations within 6 months of their initial diagnosis, and 20-25% die within a year [8,9]. ...
... Patient prognosis in cases with PAD, especially with critical limb ischemia, is poor, as these patients are at increased risk of CAD, CVD, lower limb amputations, and death compared to the general population [4][5][6][7]. In this study, the proportion of patients who experienced MAE was significantly higher in the low LMBR group than in the high group (7 of 12 vs. 1 of 26 patients, p < 0.001). ...
PurposeThe purpose of this study was to estimate the severity of the participants’ lower limb ischemia by calculating the lower limb muscle-to-background ratio (LMBR) using lower limb perfusion single-photon emission computed tomography-computed tomography (SPECT/CT) and to evaluate the prognostic value of LMBR in peripheral artery disease (PAD) patients. Materials and methodsThis retrospective study consists of 38 patients with PAD (70 ± 12 years) and observed over 1 year who were included in the analysis. All participants underwent lower limb perfusion SPECT/CT. LMBR was calculated by dividing counts/volume in lower limb muscle by mean counts/volume of background. All patients were divided into two groups based on their LMBR value and observed for the occurrence of a major adverse event (MAE). ResultsThe high and low LMBR groups consisted of 26 and 12 patients, respectively. The median LMBR in the high group was 9.59 (6.11–11.87) while that in the low group was 4.35 (3.85–4.99). A significantly higher number of patients in the low LMBR group experienced MAE than in the high LMBR group (7 of 12 vs. 1 of 26, p < 0.001). Conclusion
This study demonstrated that the LMBR derived from lower limb perfusion SPECT/CT may have a high prognostic value in patients with PAD.
... Atherosclerosis is a systemic disease and around 60% of PAD patients are expected to have ischaemic heart disease and one third cerebrovascular disease [44]. Approximately 5 years after diagnosis, 10-15% of patients with IC are highly likely to die of CVD. ...
... TASC II. guidelines stated that diabetes puts patients at equal risk of developing PAD as smoking [44]. Studies mentioned above also found that patients with ABI < 0.90 were more likely to be smokers, to have hypertension and to suffer from symptomatic or asymptomatic CVD. ...
Past decades have witnessed a major epidemiologic transition with a considerable increase in the disease burden associated with atherosclerotic cardiovascular diseases (CVDs), with low-income and middle-income countries (LMICs) experiencing substantial increase in CVDs. As the global population is aging and peripheral artery disease (PAD) is strongly age-related, it is estimated to become increasingly prevalent in the future. PAD shares risk factors with coronary and cerebrovascular risk factors, particularly diabetes mellitus and smoking, and is associated with significant CVD morbidity and mortality. Despite advances in therapeutic modalities, 236 million people were estimated to be suffering from PAD worldwide in 2015, and numbers have been rising since. The prevalence of asymptomatic PAD has remained high; PAD prevalence seems higher among women and is related to ethnicity. Although several epidemiological studies have been published on PAD during the past decades, data from LMICs are scarce. Besides providing up-to-date epidemiological data retrieved from the literature and the Global Burden of Disease (GBD) study database, this narrative review also intends to draw attention to the substantial disease burden of PAD manifesting in more Years of Life Lost (YLL), age-adjusted mortality and amputation rates, with a special focus on some European countries and especially Hungary, i.e., the country with the highest amputation rate in Europe.
... 2 The disorder is most commonly caused by atherosclerosis, a systemic disease that leads to ischemic heart disease and cerebrovascular disease in about 60% and 30% of these patients, respectively. 3 Preoperative nutritional status is a well-known prognostic factor for surgical outcomes, and albumin level has long been one of the most commonly used measures for determining preoperative nutrition. 4 In a seminal Veterans Affairs (VA) study, researchers reported that for major surgical procedures, there is a large, graded increase in complications with declining albumin levels in addition to an exponential increase in mortality rates. ...
... Each model (Tables IV-VI) controlled for patient and hospital characteristics (age, sex, race, hospital bed size), procedure type, PAD severity (CLTI vs claudication), and chronic conditions or comorbidities (Charlson index, anemia, chronic heart/kidney disease, heart failure, and diabetes). Low albumin level was strongly associated with length of stay $10 days (OR, 3 ...
Objective
Low albumin has been associated with poor outcome, including death, in surgical patients. The mechanistic relationship, however, is more complex than simply nutritional. As studies are scant in the vascular population, we sought to examine the association of low albumin with outcomes in patients undergoing open and endovascular lower extremity procedures for peripheral arterial disease (PAD).
Methods
Patients with PAD undergoing lower extremity procedures (2008 to 2015) were selected from Cerner HealthFacts® database using ICD-9 diagnosis and procedure codes. Age, sex, disease severity and other comorbidities were captured. Outcomes were identified using ICD-9 codes and encounter data. Chi-square analysis and multivariable logistic regression were performed.
Results
6,170 patients were evaluated; 4,562 (74%) underwent endovascular procedures and 1,608 (26%) underwent open surgery. Low albumin (< 3.5 g/dL) was associated with age ≥80 years (23.1% vs. 16.3% normal; p < .0001), black race (21% vs. 11.6% normal; p < .0001), tissue loss (38% vs. 16.4% normal; p < .0001) and higher Charlson Index (mean = 3.1 vs. 2.2 in the normal group; p < .0001). Low albumin was also associated with longer length of stay (4.9 vs. 2.2 days normal; p < .0001), higher in-hospital mortality (1.9% vs. 0.3% normal; p < .0001) and higher thirty-day readmission (15% vs. 12.7% normal; p = .02). Multivariable analysis demonstrated that low albumin was strongly associated with in-hospital death (OR 5.23, 95% CI 2.00-13.70), infection (OR 2.51, 95% CI 1.96-3.22), renal failure (OR 2.61, 95% CI 1.79-3.79) and cardiac complications (OR 2.59, 95% CI 1.69-3.96). After multivariable adjustment, there was no association between albumin level and thirty-day readmission.
Conclusions
Low preoperative albumin levels are associated with in-hospital death, prolonged length of stay and severe morbidity following open and endovascular lower extremity procedures. As the majority of lower extremity procedures are elective, there should be serious consideration given to deferring elective procedures until albumin levels have been optimized. Due to the pleiotropic effects of albumin, including antiplatelet and inflammatory function, study of this complex relationship may offer insights into how best to integrate this novel biomarker into vascular surgery decision-making.
... The PAD is not just a disease of the peripheral arteries, but in addition, it is an indication of a high probability of generalized vascular atherosclerosis. 29 Our findings are a further evidence that the association between arterial disease, arterial stiffness, and myocardial perfusion indices beyond generalized atherosclerosis might be a potential hemodynamic link for cardiac events in PAD through plaque vulnerability and/or oxygen supply dysbalance. 6,[30][31][32] In this context, the observation by ...
... In this study, we used arterial tonometry to determine the subendocardial oxygen supply-demand ratio since this approach seems to provide a relatively reliable surrogate assessment of the real subendocardial oxygen supply-demand ratio. However, the assessment of DPTI:SPTI ratio based only on pulse waveforms is affected by several factors, including left ventricular mass, left ventricular diastolic pressure, 29 and data that were not available in our study. Finally, in a recent study SEVR presented a moderate correlation (r = .651) ...
Among patients with peripheral arterial disease (PAD) the risk of mortality remains extremely high. We investigated whether arterial stiffness evaluated by aortic Pulse Wave Velocity (aPWV) and Augmentation index normalized for a standard heart rate of 75 bpm (Aix@75), predict cardiovascular disease (CVD) and total mortality in PAD and No-PAD patients. In 231 PAD patients (ankle-brachial index-ABI ≤ 0.9) and 167 No-PAD (ABI ≥ 0.91 < 1.3) the aPWV and Aix @75HR were evaluated using arterial tonometry and ABI values were obtained using an 8-MHz Doppler probe. The CVD and total mortality rates in relation to aPWV and Aix@75HR were analyzed using Cox regression model. During a mean follow-up of 5.4 ± 2 years 39 (16.9%) deaths occurred in PAD patients and 8 (4.8%) in No-PAD. In the population study, the age was a predictor of CVD mortality (HR = 0.143, 95% CI, 0.06–0.23; p = 0.0004) while the aPWV, was a predictor of total mortality (HR = 1.18, 95% CI, 1.07–1.30; p = 0.0008). In the PAD group, the aPWV remained associated with an increased risk for total mortality (HR = 1.14, 95% CI, 1.03–1.27; p = 0.010). An increase of aPWV may be an indicator of total mortality in PAD patients.
... The assessment of this simple, non-invasive and inexpensive index allows for PAOD detection with acceptable sensitivity and high specificity [1]. There are multiple studies addressing the role of ABI in patients with PAOD and the significance of the index regarding general atherosclerotic burden [2][3][4][5]. Current guidelines on the diagnosis and treatment of PAOD focus mainly on the importance of ABI as a primary diagnostic tool [6,7]. ...
... Amputation-free survival at 6, 12, and 24 months was calculated to be 97.1, 94.8, and 91.7% in Group 1 and 87.7, 83.8, and 81.6% in Group 2 (logrank test: p < 0.0001). The rates were only drawn if the standard error was < 10% mortality between the groups during follow-up, despite the fact that a low ABI is co-prevalent with other atherosclerotic diseases and drastically worsens outcome in terms of morbidity and mortality [3,2]. ...
Purpose
To evaluate the significance of perioperative changes in ankle-brachial index (ABI) with regard to extremity-related outcome in non-diabetic patients with critical limb ischemia (CLI) following revascularization.
Methods
The study represents a subanalysis of the multicentric Registry of First-line Treatment in Patients with CLI (CRITISCH). After exclusion of diabetic patients, conservative cases, and primary major amputation, 563 of 1200 CRITISCH patients (mean age 74 ± 10.7 years) were analyzed. This population was divided into two groups regarding perioperative ABI changes ∆ + 0.15 (Group 1) or ∆ − 0.15 (Group 2). Study endpoints were reintervention and major amputation during a mean follow-up of 14.6 ± 9 months. Logistic regression was performed in order to identify factors for ABI group affiliation.
Results
There were 279 patients in Group 1 (49.5%) and 284 in Group 2 (51.5%). ABI sensitivity and specificity regarding vessel patency were calculated to be 54 and 87%. A preoperative ABI ≤ 0.4 [odds ratio (OR) 7.7], patent vessels at discharge (OR 12.2), and secondary interventions (OR 2.4) were identified as factors for Group 1 affiliation. Contrariwise, previous revascularization (OR 0.6), a glomerular filtration rate ≤ 15 ml/min/1.73 m² (OR 0.3), and TASC A lesions (OR 0.2) were associated with Group 2 affiliation. No statistical difference was found with regard to the need of reintervention. However, time to reintervention was significantly shorter in Group 2 compared to that in Group 1 (10.0 ± 9.5 months vs 12.1 ± 9.1 months; p = 0.005). Amputation rate in Group 2 was 14.4%, significantly higher compared to that in Group 1 (6.0%; p < 0.0001).
Conclusions
Failure of perioperative ABI improvement is associated with a higher probability for amputation and should be valued as prognostic factor in non-diabetic patients with CLI. Patients with no/marginal improvement in ABI after revascularization require close follow-up monitoring and may benefit from early reintervention.
... Temelde PAH'ın altında yatan aterosklerozun sistemik bir hastalık olarak ele alınması ve PAH ile ilişkili şikayetlerle kliniğe başvuran hastalarda serebrovasküler hastalık ve koroner arter hastalığının eşlik etme potansiyeli mutlaka göz önünde bulundurulmalıdır. [10] İlerleyen yaş ile birlikte aterosklerotik hastalıkların birlikte bulunma oranları giderek artmakta, ortalama 80 yaş civarındaki PAH populasyonunda eş zamanlı koroner arter hastalığı oranı %58, serebro-vasküler hastalık oranı %34'e ulaşmaktadır. [10] PAH saptanan yaşlı hastalarda, serebrovasküler sistem için asemptomatik dahi olsalar karotis ve vertebral arter sistemi renkli doppler dupleks ultrasonografi incelemesinin yapılması gerekir. ...
... [10] İlerleyen yaş ile birlikte aterosklerotik hastalıkların birlikte bulunma oranları giderek artmakta, ortalama 80 yaş civarındaki PAH populasyonunda eş zamanlı koroner arter hastalığı oranı %58, serebro-vasküler hastalık oranı %34'e ulaşmaktadır. [10] PAH saptanan yaşlı hastalarda, serebrovasküler sistem için asemptomatik dahi olsalar karotis ve vertebral arter sistemi renkli doppler dupleks ultrasonografi incelemesinin yapılması gerekir. PAH'da en önemli mortalite riski oluşturan neden eş zamanlı bulunan koroner arter hastalığıdır. ...
The prevalence of peripheral arterial disease, which usually develops on the basis of atherosclerosis and develops as a result of chronic arterial occlusive pathology, increases with age. Peripheral artery disease in the elderly patient population may be asymptomatic due to restrictive conditions associated with immobilization. Concurrent cerebrovascular disease and coronary artery disease risk and mortality rates are higher in elderly patients with peripheral artery disease. The life expectancy in patients with peripheral arterial disease is worse than in prostate cancer patients. Leading risk factors include advanced age, smoking, diabetes mellitus, hypertension, hyperlipidemia, hyperhomocysteinemia and hypothyroidism. The most important physical examination component is the palpation of the entire peripheral pulses. The cases in which the ankle-brachial systolic pressure index measurement for clinical diagnosis is below 0.9 are defined as peripheral arterial disease. It is aimed to completely correct or improve the existing clinical symptoms and to increase the survival rates of the patients. The existing risk factors are modified as the first step of the treatment. Smoking cessation, treatment of hypertension primarily with angiotensin-converting enzyme inhibitors, lowering of hemoglobin A1c levels below 7%, anti-hyperlipidemic treatment primarily with statin, antiaggregant therapy primarily with clopidogrel, cilostazol therapy, good foot care, controlled exercise program, if necessary, interventional or operational revascularization, amputation in the presence of irreversible effects are the main treatment components. Indications for major revascularization include the presence of resting pain in the limb and / or open and long-lasting unhealed wound in the extremity and / or severe complaints of intermittant claudication that will result in limitation in daily activities. It should not be forgotten that, all the clinical decisions to be taken in the treatment of elderly patients with peripheral arterial disease are determined by the patient's physical condition, current clinical condition and the expectation level of the patient.
... The PAD is not just a disease of the peripheral arteries, but in addition, it is an indication of a high probability of generalized vascular atherosclerosis. 29 Our findings are a further evidence that the association between arterial disease, arterial stiffness, and myocardial perfusion indices beyond generalized atherosclerosis might be a potential hemodynamic link for cardiac events in PAD through plaque vulnerability and/or oxygen supply dysbalance. 6,[30][31][32] In this context, the observation by ...
... In this study, we used arterial tonometry to determine the subendocardial oxygen supply-demand ratio since this approach seems to provide a relatively reliable surrogate assessment of the real subendocardial oxygen supply-demand ratio. However, the assessment of DPTI:SPTI ratio based only on pulse waveforms is affected by several factors, including left ventricular mass, left ventricular diastolic pressure, 29 and data that were not available in our study. Finally, in a recent study SEVR presented a moderate correlation (r = .651) ...
... The PAD is not just a disease of the peripheral arteries, but in addition, it is an indication of a high probability of generalized vascular atherosclerosis. 29 Our findings are a further evidence that the association between arterial disease, arterial stiffness, and myocardial perfusion indices beyond generalized atherosclerosis might be a potential hemodynamic link for cardiac events in PAD through plaque vulnerability and/or oxygen supply dysbalance. 6,[30][31][32] In this context, the observation by ...
... In this study, we used arterial tonometry to determine the subendocardial oxygen supply-demand ratio since this approach seems to provide a relatively reliable surrogate assessment of the real subendocardial oxygen supply-demand ratio. However, the assessment of DPTI:SPTI ratio based only on pulse waveforms is affected by several factors, including left ventricular mass, left ventricular diastolic pressure, 29 and data that were not available in our study. Finally, in a recent study SEVR presented a moderate correlation (r = .651) ...
An increase of arterial stiffness tend to coexists in peripheral arterial disease (PAD).We tested whether aortic Pulse Wave Velocity (aPWV) and Augmentation index (Aix @75HR) predict total mortality (all-cause and cardiovascular mortality) in patients with PAD. In 231 PAD (ABI ≤0.9) and 167 Non-PAD (ABI ≥ 0.91<1.3) the total mortality in relation to ABI, aPWV and Aix @75HR were analyzed using Cox regression models. During a mean follow-up of 5,4±2 years 39 (16,9%) deaths occurred in PAD patients and 8 (4,8%) in Non-PAD. In the whole population the ABI and aPWV were associated with total mortality (HR =0.18, 95% CI, 0.04-0.75; p=0.018), (HR=1.17, 95% CI, 1.06-1.28; p=0.001). In the PAD group, the aPWV remained associated with increased risk for total mortality (HR=1.14, 95% CI, 1.03-1.26; p=0.016) independently of cardiovascular risk factors and CAD history. In PAD patients also aPWV is an independent indicator of total mortality.
... Consequent-ly, cardiovascular events are the major cause of death among those patients. A long-term follow-up of 16,440 index patients showed that the annual mortality among patients diagnosed with PAD is higher than among patients with previous myocardial infarction (8,2% and 6,3%, respectively) [9]. Epidemiological data confi rm that PAD is undertreated, thus contributing to the increased incidence of cardiovascular events [10]. ...
... Similarly coronary artery disease is common in patients with PAD. CAD was present in 58-68% of PAD patients [15,16]. According to the REACH-Register, patients with CAD and PAD are at increased risk for one-year fatal and non fatal cardiac events compared to patients with CAD [17]. ...
Polyvascular presentation among patients with peripheral artery disease is common. The cardiovascular burden among those patients highlights the need of minimally invasive therapeutic techniques. Advances in endovascular technology and skills over the last decades offer an alternative to open surgery. This review discusses the cardiovascular morbidity in patients with peripheral artery disease and currently utilized endovascular management.
... The PAD is not just a disease of the peripheral arteries, but in addition, it is an indication of a high probability of generalized vascular atherosclerosis. 29 Our findings are a further evidence that the association between arterial disease, arterial stiffness, and myocardial perfusion indices beyond generalized atherosclerosis might be a potential hemodynamic link for cardiac events in PAD through plaque vulnerability and/or oxygen supply dysbalance. 6,[30][31][32] In this context, the observation by ...
... In this study, we used arterial tonometry to determine the subendocardial oxygen supply-demand ratio since this approach seems to provide a relatively reliable surrogate assessment of the real subendocardial oxygen supply-demand ratio. However, the assessment of DPTI:SPTI ratio based only on pulse waveforms is affected by several factors, including left ventricular mass, left ventricular diastolic pressure, 29 and data that were not available in our study. Finally, in a recent study SEVR presented a moderate correlation (r = .651) ...
... Ultrasonographic findings of carotid artery arteriosclerosis have proved to be a useful predictor of systemic atherothrombosis, especially coronary heart disease and cerebrovascular disease. [14,15,30,31] Hyperhomocysteinemia has been demonstrated to increase the risk of carotid stenosis by up to 25%. [8] To our knowledge, ours is the first study evaluating the extracranial carotid atherosclerosis in patients presenting with venous strokes. ...
Background:
Cerebral venous thrombosis (CVT) is an uncommon cause of stroke and shares common risk factors with arterial strokes such as hyperhomocysteinemia, tobacco, alcohol, drugs, and hypercoagulable state. These risk factors can alter both arterial and venous health leading to the occurrence of atherosclerosis in CVT patients.
Aims:
To evaluate carotid hemodynamics in CVT patients.
Settings and design:
Prospective hospital-based case-control study.
Methods:
This study included 50 consecutive CVT patients and 50 healthy controls. The demographic data, vascular risk factors, clinical data, biochemical, and radiological parameters were recorded. Carotid sonography was performed in CVT patients within the first 24 h of admission.
Statistical analysis:
MedCalc 17.
Results:
The age of the patients was 35.04 ± 9.48 years and the controls 38.88 ± 10.41 years with male preponderance in both groups. Risk factors for atherosclerosis among patients included hyperhomocysteinemia (40 patients), diabetes mellitus (4 patients), hypertension (9 patients), alcohol (17 patients), and tobacco (21 patients). Eight patients had abnormal carotid sonography. Six had nonflow-limiting plaques, one had carotid occlusion, two had increased intimal-medial thickness, and one had increased peak systolic velocity. Among the controls, three subjects had nonflow-limiting plaques. There was no difference in carotid hemodynamic parameters between controls and patients; and those with normal and elevated homocysteine.
Conclusion:
This is the first study to our knowledge looking at carotid health in venous strokes. The relative risk for carotid atherosclerosis in CVT patients is higher and requires long-term follow-up for the initiation of preventive measures.
... The majority of patients suffering from critical ischaemia of lower extremities are also affected with other diseases of the cardiovascular system. Critical ischaemia of lower extremities tends to be accompanied by concurrent ischaemic heart disease, scattered ischaemic lesions in the brain and hypertension (Aronow & Ahn, 1994;Hirsch et al., 2001). The often identified concurrent diseases include tobacco related neoplasms (Armstrong & Lavery, 1998). ...
Background
Critical lower limb ischaemia is associated with a 20% annual risk of amputation and death. It is necessary to activate pa-tients’ personal resources which comprise mental dispositions needed to effectively cope with the disease. The objective of the study was to evaluate the correlation between the attitude toward the vascular reconstruction and self-efficacy (SE), health locus of control (HLoC) and own life quality (QOL) assessment in patients with critical lower limb ischaemia.
Participants and procedure
The study involved 64 patients with critical lower limb ischaemia (Rutherford 4 and 5), 26 women and 38 men. Four scales were applied during primary admission: the Generalized Self-Efficacy Scale; the Satisfaction with Life Scale; the Multidimensional Health Locus of Control Scale; and the visual scale revealing attitude to vascular reconstruction.
Results
The attitude to the vascular reconstruction was positive (M = 8.50). The lowest grades were given by those hospitalised several times during follow-up (M = 8.30); women expressed low grades (M = 7.71). An overall positive correlation was found between the positive attitude to the surgery and self-efficacy (p = .012), internal HLoC (p = .041) and external locus (p = .026). In the patients who died within six months from baseline assessment, no correlations were found. In subjects with no readmission, a correlation was found between positive attitude to surgery and the external personal HLoC (p = .023). In patients with subsequent readmissions, a correlation was found between the originally positive attitude to the surgery and poor self-efficacy (p = .009).
Conclusions
Patients with weak mental dispositions cannot cope with difficult situations and show a tendency to experience strong emotions, concentrating on their deficiencies, resulting in decreased motivation and feeble engagement in treatment. Poor mental disposition influences the final outcome of the vascular reconstruction.
... 7 However, more than half of patients suffering from PAD that are approximately 80 years of age with, will also have concomitant CAD. 8,9 Understanding the relationship between CAD and PAD is essential as CADrelated complications are the leading cause of morbidity and mortality in patients undergoing surgery for PAD. 6 While epidemiology data provide an overview of the incidence and prevalence of CAD and PAD across Germany as a whole, various studies have shown that there is significant disparity in the rates of both CAD and PAD within the country. ...
Introduction
Coronary artery disease (CAD) and peripheral arterial disease (PAD) account for significant morbidity and mortality in Germany and are more prevalent in rural, non-metropolitan areas. The goal of this study is to screen patients for their current atherosclerotic status, initiate treatment according to the latest scientific findings using a standardised multimodal approach and track their atherosclerotic status over one year.
Methods and Analysis
This manuscript describes the study protocol of a prospective, multicentre registry of 500 sequential patients with CAD and/or PAD in rural, non-metropolitan regions of Germany. Patients, who visit the “WalkByLab” at the Brandenburg Medical School, Brandenburg, Germany, will be assessed by using our structured, multimodal risk factor management (SMART) tool to evaluate cardiovascular morbidity data, collect information on care and deliver multimodal therapy. The study’s primary objective is a cross-sectional examination of the risk profile, diagnostic and therapeutic status in this patient group. Secondary objectives include the assessment of risk factor correlations as well as changes in risk-factor profile and therapy adherence. Patients will be examined at baseline and followed up at three-monthly intervals for one year. Over this time, atherosclerotic risk factors and patient adherence to defined therapeutic strategies will be evaluated. Study completion is estimated to be December 2021. An expansion of this concept into other rural, non-metropolitan neighbouring regions is planned.
Ethics and Dissemination
This registry was assessed and approved by the ethics committee of the Brandenburg State Medical Association, Brandenburg, Germany, and conducted in accordance with the Declaration of Helsinki. The study findings will be disseminated through usual academic channels including meeting presentations and peer-reviewed publications.
Protocol Version
1.0.
... Vascular surgery is associated with a high risk of perioperative adverse events, in part due to the heavy burden of comorbidities in surgical candidates. [1][2][3] The incidence of surgical disease is increasing with growing life expectancy and cardiovascular disease globally. 4 Inexpensive and accessible perioperative biomarkers are crucial in improving the risk-stratification of these patients in order to optimize perioperative care. ...
Objective
The global burden of surgical vascular disease is increasing and with it, the need for cost-effective, accessible prognostic biomarkers to aid optimization of peri-operative outcomes. The neutrophil-lymphocyte ratio (NLR) is emerging as a potential candidate biomarker for perioperative risk stratification. We therefore performed this systematic review and meta-analysis on the prognostic value of elevated preoperative NLR in vascular surgery.
Methods
We searched Embase (Ovid), Medline (Ovid), and the Cochrane Library database from inception to June 2019. Screening was performed, and included all peer-reviewed original research studies reporting preoperative NLR in adult emergent and elective vascular surgical patients. Studies were assessed for bias and quality of evidence using a standardized tool. Meta-analysis was performed by general linear (mixed-effects) modelling where possible, and otherwise a narrative review was conducted. Between-study heterogeneity was estimated using the Chi-squared statistic and explored qualitatively.
Results
Fourteen studies involving 5,652 patients were included. The overall methodological quality was good. Elevated preoperative NLR was associated with increased risk of long-term mortality (HR 1.40 [95%CI: 1.13-1.74], Chi-squared 60.3%, 7 studies, 3,637 people) and short-term mortality (OR: 3.08; 95%CI: 1.91-4.95), Chi-squared 66.59%, 4 studies, 945 people). Outcome measures used by fewer studies such as graft patency and amputation free survival were assessed via narrative review.
Conclusions
NLR is a promising, readily obtainable, prognostic biomarker for mortality outcomes following vascular surgery. Heterogeneity in patient factors, severity of vascular disease, and type of vascular surgery performed renders direct comparison of outcomes from the current literature challenging. This systematic review supports further investigation for NLR measurement in pre-vascular surgical risk stratification. In particular, the establishment of a universally accepted NLR cut-off value is of importance in real-world implementation of this biomarker.
... It is estimated to affect between 4.5 % and 29 % of the population worldwide and more than 20 % of those over 75 years of age [1]. PAD significantly impairs functional capacity and quality of life and is an early indicator of future cardiovascular and cerebrovascular events; some 60 % of patients with PAD will have ischaemic heart disease, and 30 % have cerebrovascular disease [2]. Diabetes mellitus and smoking are the main risk factors for symptomatic PAD [3]. ...
Skin temperature has long been used as a natural indicator of vascular diseases in the extremities. Considerable correlation between oscillations in skin surface temperature and oscillations of skin blood flow has previously been demonstrated. We hypothesised that the impairment of blood flow in stenotic (subcutaneous) peripheral arteries would influence cutaneous temperature such that, by measuring gradients in the temperature distribution over skin surfaces, one may be able to diagnose or quantify the progression of vascular conditions in whose pathogenesis a reduction in subcutaneous blood perfusion plays a critical role (e.g. peripheral artery disease). As proof of principle, this study investigates the local changes in the skin temperature of healthy humans (15 male, 30.0 ± 5.2 years old, BMI 25.1 ± 2.2 kg/m
$^2$
) undergoing two physical challenges designed to vary their haemodynamic status. Skin temperature was measured in four central regions (forehead, neck, chest, and left shoulder) and four peripheral regions (left upper arm, forearm, wrist, and hand) using an infrared thermal camera. We compare inter-region patterns. Median temperature over the peripheral regions decreased from baseline after both challenges (maximum decrease: -2.09 ± 0.41 °C at 60 s after exercise; p = 0.0001 and -0.58 ± 0.14 °C at 180 s of cold-water immersion; p = 0.0013). Median temperature over the central regions showed no significant changes. Our results show that the non-contact measurement of perfusion-related changes in peripheral temperature from infrared video data is feasible. Further research will be directed towards the thermographic study of patients with symptomatic peripheral vascular disease.
... This study evaluated the sensitivity and specificity of ABI for predicting significant CAD in patients undergoing coronary angiography. CAD may be present in 58% of patients with PAD, 10 and such an association is related to a worse prognosis. The diagnosis and early treatment are critical in order to minimize cardiovascular events. ...
... [1][2][3][4] In previous epidemiological studies, 45% to 63% of patients with age over 60 years old had either CVD, CAD, or PAD. [5,6] Pharmacologic therapies for ASCVD including antiplatelet agents, angiotensin-converting enzyme inhibitors, ß blockers and lipid-lowing agents are the same between young and old patients. [7][8][9][10] Furthermore, clinical guidelines for evaluation and treatment of acute coronary syndrome, acute stroke, and PAD, are the same between men and women. ...
Atherosclerotic cardiovascular disease (ASCVD) including cerebrovascular disease (CVD), coronary artery disease (CAD), and peripheral arterial disease (PAD), contributes to the major causes of death in the world. Although several studies have evaluated the association between gender and major adverse cardiovascular outcomes in old ASCVD patients, the result is not consistent. Hence, we need a large-scale study to address this issue.
This retrospective cohort study included aged over 60 year-old patients with a diagnosis of ASCVD, including CVD, CAD, or PAD, from the database contained in the Taiwan National Health Insurance Bureau during 2001 to 2004. The matched cohort was matched by age, comorbidities, and medical therapies at a 1:1 ratio. A total of 9696 patients were enrolled in this study, that is, there were 4848 and 4848 patients in the matched male and female groups, respectively. The study endpoints included acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, in-hospital mortality, and so on. In multivariate Cox regression analysis in matched cohort, the adjusted hazard ratios (HRs) for female group in predicting acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, and in-hospital mortality were 0.67 (P < .001), 0.73 (P = .0015), 0.78 (P < .001), 0.59 (P < .001), and 0.77 (P = .0007), respectively.
In this population-based propensity matched cohort study, age over 60 year-old female patients with ASCVD were associated with lower rates of acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, and in-hospital mortality than male patients. Further prospective studies may be investigated in Taiwan.
... 36,37 This population of patients is also commonly found to have concurrent heart disease with a higher risk of cardiovascular mortality than those patients with primary coronary artery disease. [38][39][40] In addition to heart disease, there is a high prevalence of chronic health conditions, such as diabetes, cerebrovascular disease, and renal disease. 41,42 The presence of multiple comorbidities in patients with infrainguinal atherosclerosis leads to a high rate of perioperative morbidity and mortality. ...
Background:
Patients undergoing vascular operations face high rates of intraoperative and postoperative complications and delayed return to baseline. Enhanced recovery after surgery (ERAS), with its aim of delivering high-quality perioperative care and accelerating recovery, appears well suited to address the needs of this population.
Methods:
In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic review to characterize the use and effectiveness of ERAS in all types of vascular and endovascular operations. We queried MEDLINE (through PubMed), Embase, Web of Science, Scopus, ProQuest Dissertations and Theses Global, Cochrane Central Register of Controlled Trials, Prospero, and Google Scholar. Two reviewers independently completed screening, review, and quality assessment. Eligible articles described the use of ERAS pathways for vascular operations from January 1, 1997, through December 7, 2017. Details regarding patients' demographics and use of the ERAS pathway or selected ERAS components were extracted. When available, results including perioperative morbidity, mortality, and in-hospital length of stay were collected. The studies with control groups that evaluated ERAS-like pathways were meta-analyzed using random-effects meta-analysis.
Results:
In the final analysis, 19 studies were included: four randomized controlled trials and 15 observational studies. By Let Evidence Guide Every New Decision (LEGEND) criteria, the two good-quality studies are randomized controlled trials that evaluated a specific part of an ERAS pathway. All other studies were considered poor quality. Meta-analysis of the five studies describing ERAS-like pathways demonstrated a reduction in length of stay by 3.5 days (P = .0012).
Conclusions:
Based on systematic review, the use of ERAS pathways in vascular surgery is limited, and existing evidence of their feasibility and effectiveness is low quality. There is minimal poor- to moderate-quality evidence describing the use of ERAS pathways in open aortic operations. There is scarce, poor-quality evidence related to ERAS pathways in lower extremity operations and no published evidence related to ERAS pathways in endovascular operations. Although the risk of bias is high in most of the studies done to date, all of them observed improvements in length of stay, postoperative diet, and ambulation. It is reasonable to consider the implementation of ERAS pathways in the care of vascular surgery patients, specifically those undergoing open aortic operations, but many of the details will be based on limited data and extrapolation from other surgical specialties until further research is done.
... Así, en este estudio cerca del 65% de los sujetos con EAP presentaron evidencias clínicas de otra enfermedad vascular asociada (Bhatt et al., 2006, p. 9). Sin embargo, en un estudio prospectivo de 1889 individuos con una edad mayor o igual a 62 años, solo 37% de los sujetos no presento evidencia de la enfermedad en ningún otro de los tres territorios (Aronow & Ahn, 1994, p. 5). ...
In this work it was approached the Peripheral Arterial Disease (PAD) and its determinants in the general population of the urban area of Jardín (Antioquia) municipality from a bioanthropological perspective. It was assed the prevalence of PAD from the Ankle-Brachial Index (ABI) values of 345 individuals, 65.5% women and 34.5% men in an age range of 45 to 88 years, being the overall prevalence of 19,4%. Statistical analysis was performed to estimate if there was association between socio-demographic, biological and behavioural characteristic of the sample as risk factors for PAD. In addition, using a semistructured interview in 17 individuals selected from the initial epidemiological sample and with diagnosis of PAD, this work inquired for beliefs, conceptions, practices and therapeutic itineraries on vascular health. It was obtained, from the perspective of those interviewed, the conceptions of health, disease and healthy lifestyles in relation with the presence of PAD and other vascular diseases. On the other hand, practices related to the vascular health care –by example the use of plants, homemade remedies and Naturist Products- were recorded and reconstructed some explanatory models (EM’s) of the individuals on the aetiology, symptomatology and development course for PAD.
... [17][18][19] There is a significant variation in the prevalence of coronary artery disease in studies by Ness et al, Aronow et al and Sarraf-Zadegan et al where the prevalence was 34%, 43% and 19.4% respectively. [20][21][22] This variation is due to the socio-demographic characteristics of the study population. ...
Background: Cardio vascular disease (CVD) is the number 1 cause of death globally and an estimated 17.7 million people died from CVD in 2015, representing 31% of all global deaths. In India CVD accounts for 25% of all deaths. The objectives of the study was to estimate the prevalence of CVD among the study population and to determine the association between CVD and various risk factors.Methods: This is a cross sectional study carried out in the rural field practice area attached to SBMCH. The study group were 400 adults (20-60 years). The data was collected using a structured questionnaire containing socio-demographic particulars, details regarding CVD risk factors and physical measurements. Data was entered in MS Excel and analysed using SPSS 15 software.Results: Prevalence of CVD is 24.3% and of which hypertension (18%), coronary artery disease (6%), stroke (2.2%) and valvular heart disease (1%). The prevalence of risk factors are age >40 (63%), tobacco use (17.8%), alcohol use (22.3%), physical inactivity (52%), unhealthy diet (61.4%), obesity (19.7%), diabetes (13.6%) and positive family history (21.4%). There is a strong statistically significant association between CVD and age (p=0.008, OR-1.968), tobacco use (p<0.0001, OR-10.029), obesity (p<0.0001, OR-13.462) and positive family history (p<0.0001, OR-13.964).Conclusions: In this study prevalence of CVD is high. It is necessary to minimize the burden of growing CVD by controlling the rates of the risky behaviours by lifestyle modification and by increasing awareness regarding CVD.
... Several studies have demonstrated the strong association of lower limb atheromatous disease with coronary and Ankle-brachial index, mean ± SD 0.62+0.2 cerebrovascular arterial disease [4][5][6][7][8], which increases the mortality and the incidence of major cardiovascular events in this group of patients. The fi ve-year mortality of a patient with lower limb atheromatous disease is approximately 30%, mostly due to cardiovascular cause [9]. ...
... Several studies have demonstrated the strong association of lower limb atheromatous disease with coronary and Ankle-brachial index, mean ± SD 0.62+0.2 cerebrovascular arterial disease [4][5][6][7][8], which increases the mortality and the incidence of major cardiovascular events in this group of patients. The fi ve-year mortality of a patient with lower limb atheromatous disease is approximately 30%, mostly due to cardiovascular cause [9]. ...
... 10 Specifically, 30% of patients with PAD have or will develop cerebrovascular disease and 60% have or will develop ischaemic heart disease. 11 Furthermore, within 5 years of PAD diagnosis, 10-15% of patients with intermittent claudication will die from cardiovascular disease. 12 Given the similarity of aetiologic factors between PAD and carotid artery atherosclerosis, radiologists utilizing carotid ultrasonography have demonstrated that more than 60% of neurologically asymptomatic patients with PAD harbour carotid plaques causing ≥50% luminal reduction in the bifurcation region and that their presence signifies significant risk of future ischaemic cerebrovascular and cardiovascular events. ...
Objective:
Males with peripheral arterial disease (PAD) are at high risk of ischaemic stroke given that atherogenic risk factors for both diseases are similar. We hypothesized that neurologically asymptomatic males diagnosed with PAD would demonstrate calcified carotid artery plaques (CCAP) on panoramic images (PI) significantly more often than similarly aged males not having PAD.
Methods:
Investigators implemented a retrospective cross-sectional study. Subjects were male patients over age 50 diagnosed with PAD by ankle-brachial systolic pressure index results of
≤
0.9. Controls negative for PAD had an ankle-brachial systolic pressure index > 0.9. Predictor variable was a diagnosis of PAD and outcome variable was presence of CCAP. Prevalence of CCAP amongst the PAD+ patients was compared to prevalence of CCAP among PAD- patients. Descriptive and bivariate statistics were computed and p-value was set at 0.05.
Results:
Final sample size consisted of 234 males (mean age 72.68 ± 9.09); 116 subjects and 118 controls. Among the PAD+ cohort, CCAP+ prevalence rate (57.76%) was significantly (p = 0.001) greater than the CCAP+ rate (36.44%) of the PAD- (control). There was no significant difference in atherogenic "risk factors" in the PAD+ cohort between CCAP+ and CCAP- subjects.
Conclusion:
We demonstrated that CCAP, a "risk factor" for future stroke and "risk indicator" of future myocardial infarction is seen significantly more often detected on the PIs of older male patients with PAD than among those without. Dentists treating patients with PAD must be uniquely vigilant for the presence of CCAPs on their patients' PI.
... The cause for not seeing youthful subjects with PAD in this study may be attributed to that the bulk of our cases were of old age i.e. age > 40 years and held in hemodialysis for longer than a two-year continuation. The popular concept is that PAD is frequent in men in the general community [18][19][20] . The aforementioned concept was kept also in the present research. ...
The chronic renal disease is a principle common medical dilemma in Iraq. Peripheral arterial disease (PAD) is a prevalent infirmity in the hemodialysis people. The aim of present study was to estimate the prevalence of PAD in subjects with end-stage renal disease (ESRD). This cross-sectional study was done between January 2016 and May 2017 on ESRD subjects regularly attending renal dialysis unit in Al-Kindy teaching hospital in Baghdad, Iraq. PAD was diagnosed on the base of the ankle-brachial index (ABI) measured by using a hand-held Doppler ultrasound. Subjects with ABI =0.9 were supposed positive for PAD. A total of 150 ESRD cases were analyzed. The mean age of the subject was 49.52 15 years. Majority of them were males 87(58%). Most of the subjects were hypertensive 100(66.6%), while 39(26%) were diabetic. PAD was present in 79(52.7%) of cases. Intermittent claudication was the main manifestation in patients with PAD 57(72.15%) and only 3(3.8%) of the patients end with an amputation. The study revealed that only older age was significantly and individually linked with PAD, while additional determinants such as male gender, smoking, positive virology, hypertension, diabetes mellitus, hyperlipidemia, and IHD were not significant. We conclude that PAD prevalence is high among subjects with ESRD undergoing hemodialysis. The ABI should be routinely calculated for subjects with ESRD on usual hemodialysis.
... More than 70% of circulatory system deaths are attributable to coronary artery disease and cerebrovascular disease with the same pathogenesisatherothrombosis. 15 Atherothrombosis is a common pathophysiological process of morbid or fatal clinical ischemic events affecting cerebral, coronary, or peripheral arterial circulation. Therefore, we included specific CVD categories in this study, namely coronary heart disease, cerebrovascular disease, congestive heart failure, CVD-associated hypertensive diseases, and CVDassociated hyperlipidemia. ...
Aim:
We attempted to determine risk factors, particularly pathophysiological changes, for the early cardiovascular mortality in bipolar disorder.
Methods:
A total of 5416 in-patients with bipolar I disorder were retrospectively followed through record linkage for cause of death. A total of 35 patients dying from cardiovascular disease (CVD, ICD 9: 401-443) before the age of 65 years were identified. Two living bipolar patients and two mentally healthy adults were matched with each one deceased patient as control subjects according to age (±2 years), sex, and date (±3 years) of the final/index admission or the date of general health screening. Data were obtained through medical record reviews.
Results:
Eighty percent of CVD deaths occurred within 10 years following the index admission. Conditional logistic regression revealed that the variables most strongly associated with CVD mortality were the leukocyte count and heart rate on the first day of the index hospitalization, as the deceased bipolar patients were compared with the living bipolar controls. Systolic pressure on the first day of the index hospitalization can be substituted for the heart rate as another risk factor for CVD mortality.
Conclusion:
It is suggested that systemic inflammation and sympathetic overactivity during the acute phase of bipolar patients may be risk factors for the early CVD mortality.
... PAD affected 202 million people worldwide in 2010 [2,3], and in a database of over 9 million patients, PAD prevalence was 10.7% [4]. Furthermore, PAD patients have a high frequency of concomitant atherosclerotic disease, and risk factors for atherosclerosis such as arterial hypertension are common in this population [5,6]. Major PAD guidelines issued by ACC/AHA [7] and TASC [1], recommend strict control of cardiovascular risk factors in this group of patients, and the current European guidelines on treatment of hypertension recommend a blood pressure (BP) target of less than 140/90 mm Hg also in PAD patients [8]. ...
Peripheral artery disease (PAD) is defined as atherosclerotic arterial occlusive disease of the lower extremities, manifesting as intermittent claudication (IC, pain induced by walking) or critical limb ischaemia (CLI, rest pain or ulcerations). PAD guidelines recommend strict control of cardiovascular risk factors, and European guidelines on hypertension recommend a blood pressure (BP) target < 140/90 mm Hg also in PAD patients. As the pressure in the affected extremity might be of relevance for the prognosis concerning limb salvage in CLI, the traditional approach was to avoid beta-blockers and allow a slightly higher BP in CLI. Both theoretical considerations and observational data support aggressive BP lowering also in CLI; however, in the absence of randomized studies on BP lowering in this setting it cannot be definitely established that current recommendations on BP lowering apply also in CLI.
Critical limb ischemia (CLI) is the advanced stage of peripheral arterial disease, which impairs blood flow to the extremities due to occlusion of arteries, in which patients suffer from ischemic pain at rest and gangrene or ulcers. It is frequently accompanied by major adverse cardiac events, resulting in exceedingly high mortality from a cardiac or cerebrovascular event in this population. Although there have been considerable amounts of novel and costly revascularization and wound dressing technology, mortality is still high. Therefore, the risk factors for such high mortality need to be addressed. This review aimed to summarize the potential risk factors for mortality in patients with CLI of the lower extremities. There are several such risk factors, including modifiable and nonmodifiable risk factors. This review further discusses some highlighted major modified risk factors, including renal failure, cardiovascular, and diabetes. The strategy of regular surveillance and modification of such risk factors in any patients with CLI should be developed.
Background
Limited data exist regarding the significance of peripheral arterial disease (PAD) in patients with acute coronary syndrome (ACS).
Methods
We evaluated 16,922 consecutive ACS patients who were prospectively included in a national ACS registry. The co-primary endpoint included 30 days major adverse cardiovascular event (MACE) (re-infarction, stroke, and/or cardiovascular death) and 1-year mortality.
Results
PAD patients were older (70±11 vs 63±13; p<0.01), male predominance (80% vs 77%; p=0.01), and more likely to sustain prior cardiovascular events. PAD patients were less likely to undergo coronary angiography (69% vs 83%; p<0.001) and revascularisation (80% vs 86%; p<0.001). Patients with PAD were more likely to sustain 30-day MACE (22% vs 14%; p<0.001) and mortality (10% vs 4.4%; p<0.001), as well as re-hospitalisation (23% vs 19%; p=0.001). After adjusting for potential confounders, PAD remained an independent predictor of 30-day MACE (odds ratio [OR], 1.6 [95% confidence interval (CI), 1.24–2.06]).
Patients with compared to those without PAD had 2.5 times higher 1-year mortality rate (22% vs 9%; p<0.001). Co-existence of PAD remained an independent predictor of 1-year mortality after adjustment for potential confounders by multivariable regression analysis (OR, 1.62; 95% CI, 1.4–1.9). PAD was associated with a significant higher 1-year mortality rate across numerous sub-groups of patients including type of myocardial infarction (ST-elevation myocardial infarction vs non-ST-elevation myocardial infarction), and whether the patient underwent revascularisation.
Conclusions
Acute coronary syndrome with concomitant PAD represents a high-risk subgroup that warrants special attention and a more tailored approach.
The stent-implantation process during angioplasty procedures usually involves clamping the stent onto a catheter to a size that allows delivery to the place inside the artery. Finding the right geometrical form of the stent to ensure good functionality in the open form and to enable the clamping process is one of the key elements in the stent-design process. In the first part of the work, an original two-step procedure for stent-geometry design was proposed. This was due to the necessary selection of a geometry that would provide adequate support to the blood-vessel wall without causing damage to the vessel. Numerical simulations of the crimping and deployment processes were performed to verify the method. At the end of this stage, the optimal stent was selected for further testing. In addition, numerical simulations of selected experimental tests (catheter-crimping process, compression process) were used to verify the obtained geometrical forms. The results of experimental tests on stents produced by the microinjection method are presented. The digital image correlation (DIC) method was used to compare the results of numerical simulation and experimental tests. The two-step modeling approach was found to help select the appropriate geometry of the expanded stent, which is an extremely important step in the design of the crimping process. In the part of the paper where the results obtained by numerical simulation were compared with those gained by experiment and using the DIC method, a good compatibility of the displacement results can be observed. For both longitudinal and transverse (pinch) stent compression, the results practically coincide. The paper presents also the application of the DIC method which significantly expands the research possibilities, allowing for a detailed inspection of the deformation state and, above all, verification of local dangerous areas. This approach significantly increases the possibility of assessing the quality of the stents.
Peripheral artery disease (PAD) is a serious public health issue, characterized by circulation disorder of the lower extreme that reduces the physical activity of the lower extremity muscle. The artery narrowed by atherosclerotic lesions initiates limb ischemia. In the progression of treatment, reperfusion injury is still inevitable. Ischemia-reperfusion injury induced by PAD is responsible for hypoxia and nutrient deficiency. PAD triggers hindlimb ischemia and reperfusion (I/R) cycles through various mechanisms, mainly including mitochondrial dysfunction and inflammation. Alternatively, mitochondrial dysfunction plays a central role. The I/R injury may cause cells’ injury and even death. However, the mechanism of I/R injury and the way of cell damage or death are still unclear. We review the pathophysiology of I/R injury, which is majorly about mitochondrial dysfunction. Then, we focus on the cell damage and death during I/R injury. Further comprehension of the progress of I/R will help identify biomarkers for diagnosis and therapeutic targets to PAD. In addition, traditional Chinese medicine has played an important role in the treatment of I/R injury, and we will make a brief introduction.
Background:Cerebrovascular disease often coexists with coronary artery disease (CAD), and it has been associated with worse clinical outcomes in CAD patients. However, the prognostic effect of prior stroke on long-term outcomes in patients with acute coronary syndrome (ACS) is still unclear.
Methods and Results:An observational cohort study of ACS patients who underwent emergency percutaneous coronary intervention (PCI) between January 1999 and May 2015 was conducted. Patients were divided into 2 groups according to their history of stroke. We evaluated both all-cause death and cardiac death. Of the 2,548 consecutive ACS patients in the current cohort, 268 (10.5%) had a history of stroke at the onset of ACS. Patients with a history of stroke were older and had a higher prevalence of comorbidities such as hypertension or renal deficiency. The cumulative incidences of all-cause death and cardiac death were significantly higher in patients with a history of stroke (both log-rank P<0.0001). Multivariate Cox hazard regression analysis showed that a history of stroke was significantly associated with the incidences of all-cause death (hazard ratio [HR] 1.49, 95% confidence interval [CI] 1.20–1.85, P=0.0004) and cardiac death (HR 1.41, 95% CI 1.03–1.93, P=0.03).
Conclusions:About 10% of the ACS patients had a history of stroke and had worse clinical outcomes.
Introduction
Peripheral artery disease (PAD) is a prevalent but underdiagnosed manifestation of atherosclerosis that has a worse prognosis than coronary artery disease. Patients with PAD are at heightened risk of both systemic cardiovascular adverse events and limb-related morbidity. There is insufficient awareness of its clinical manifestations, including intermittent claudication and critical limb ischemia and of its risk of adverse cardiovascular and limb outcomes.
Areas covered
The authors present the current knowledge concerning medications and their mechanism of action, landmark trials, and the evidence base behind the most commonly utilized pharmacological therapy including but not limited aspirin, clopidogrel, ticagrelor, warfarin, rivaroxaban, statins, angiotensin-converting enzyme inhibitors, Evolocumab and Ezetimibe.
Expert opinion
Relative to coronary artery disease, peripheral artery disease is an undertreated and under-investigated condition. The majority of the evidence base in the management of PAD is extrapolated from data subsets of large trials examining different conditions. This creates a paucity of management decisions based on trials powered for outcomes in PAD.
Enhanced recovery after surgery (ERAS) pathways have been beneficial for many surgical specialties, but these coordinated care pathways have yet to be developed for patients undergoing vascular operations. Vascular surgery patients present specific challenges due to their advanced age, frailty, and multiple comorbidities as well as the highly invasive operations that are sometimes required. This combination of factors results in complex management strategies, increased utilization of healthcare resources, and high rates of postoperative complications leading to prolonged hospitalizations, chronic pain, rehabilitation needs, and frequent hospital readmissions. ERAS, with its aim of delivering high-quality perioperative care and accelerating recovery, appears well-suited to address the needs of this demanding population.
Introduction: Single arm measurement of Blood Pressure (BP) is routinely done in clinical practice. Significant difference in the interarm BP is related to various risk factors of cardiovascular disease Prevalence of Peripheral Arterial Disease (PAD) is high, but the awareness about the disease and its symptoms are relatively low. Aim: To assess the prevalence of inter-arm difference in systolic blood pressure in people without any cardiovascular risk factors and to relate the inter-arm BP difference with both symptomatic and asymptomatic peripheral arterial disease. Materials and Methods: It was a comparative study in which 260 subjects in the age group of 40-70 years participated. Systolic Blood Pressure (SBP) inter-arm difference was measured and SBP Inter-Arm Difference (IAD), non-invasive Doppler test was done to diagnose PAD. The results were analysed using t-test. Results: It was found that 33.08% (86 out of 260) of the subjects had inter-arm SBP difference above 10 mmHg. The total number of subjects diagnosed with PAD were 33.84% (88 out of 260). The odds of patients with IAD to have PAD is 102.6 times higher than patients without IAD {OR=102.6 (42.46-247.94)}. The odds of patients with 15-20 mmHg IAD to have PAD was 6.53 times higher than patients with 10-15 mmHg IAD {OR=6.53 (1.49- 28.57)}. IAD in SBP is significantly related to PAD. Conclusion: It is important to diagnose the PAD at the earlier stage and also measurement of BP on both the arms is one of the costeffective tool for screening patients with risk factors for PAD.
Patients with peripheral artery disease (PAD) are at high risk for ischemic cardiovascular complications. While single antiplatelet therapy (SAPT), predominantly aspirin, has long been the standard antithrombotic treatment in stable PAD, there have now been greater than 40,000 PAD patients randomized to varying antiplatelet and/or anticoagulant regimens. In this review, we provide a summary of the current evidence for antithrombotics in stable PAD, focusing on the rates of major adverse cardiovascular events (MACE), major adverse limb events (MALE), and major bleeding. SAPT has a limited role in the treatment of asymptomatic PAD, particularly in the absence of concomitant coronary artery disease. In symptomatic PAD, SAPT is effective in preventing MACE, though treatment with a thienopyridine appears marginally superior to aspirin. Dual antiplatelet therapy (DAPT) suggests benefit over SAPT in reducing MACE and MALE, though studies to date are not conclusive and/or are associated with excess major bleeding. Combining moderate to high intensity vitamin K antagonists with antiplatelet therapy does not reduce MACE or MALE and increases life-threatening bleeding. Rivaroxaban 2.5 mg BID in addition to aspirin reduces the incidence of both MACE and MALE as compared to aspirin alone, without increasing life-threatening bleeding. This regimen is associated with a reduced severity of MALE when it does occur. Comparisons across antithrombotic trials in PAD are challenging given the heterogeneity of patient populations and the differing assessment of outcomes. The vascular medicine practitioner can reduce ischemic cardiac and limb events, as well as minimize life-threatening bleeding, by choosing the optimal antithrombotic regimen in their PAD patients.
p> Introduction : Atherosclerosis is a systemic disease which may affect coronary arteries, carotid arteries and peripheral arteries. Patients having coronary artery disease may also have lower limb peripheral arteries involvement due to atherosclerosis. This study is to see the prevalence and pattern of lower limb arteries involvement in patients having CAD.
Methods : Duplex ultrasonic evaluation of peripheral arteries were done in 210 patients of CAD. Ultrasonic evaluation was done by B Mode image and on the basic of haemodynamic change.
Result : Mean age of respondents was was 51.3 ± 10.4 years. 90% patient did not show any clinical sign or symptoms of PAD. 5.2% of patient has critical level of stenosis in one or multiple segments of lower limb arteries, 0.5 % patients had stenosis below the critical level. All the patients suffering from PAD were male patients. No statistical significant relation was found between occurrence of PAD and severity of CAD.
Conclusion : Patient of CAD may have hidden PAD without any clinical presentation. Duplex ultrasonography can be a non invasive initial study to rule out the possibility of lower limb arterial insufficiency.
TAJ 2016; 29(2): 62-65</p
Background:
Atherosclerosis is the leading cause of death worldwide. Ischaemic stroke, coronary heart disease (CHD), and peripheral artery disease (PAD) are different forms of atherosclerotic disease. Knowledge among general practitioners (GPs) about the three main locations of atherosclerosis has never been conjointly explored in a single study. The aim of this survey was to compare GP awareness on the subject of these three different clinical presentations.
Materials and methods:
Between February 2017 and May 2017, a self-administered survey was emailed to 18,500 French GPs. The questionnaire comprised three clinical cases involving cases of transient ischaemic attack (TIA), stable angina (SA), and intermittent claudication (IC). Each case was explored with seven similar questions. The primary endpoint was the number of physicians who correctly answered five questions for each clinical case.
Results:
The survey was completed by 1,724 GPs. TIA knowledge (48.2 %) was significantly higher than the SA knowledge (3.0 %) and IC knowledge (0.4 %). We also found a significant difference between SA knowledge and IC knowledge. The percentages of GPs who correctly diagnosed TIA, SA or IC were 96.7, 89.7, and 96.5 %, respectively (p < 0.0001). Poor knowledge ratings for all three locations were observed for inadequate prescription of supplementary investigations and treatments.
Conclusions:
Our study demonstrates that GPs' knowledge about atherosclerosis disease varies significantly depending on disease location. GPs diagnose correctly but need to be backed up for their management of patients with atherosclerosis.
The ankle-brachial index (ABI) plays a key role in diagnosis of peripheral arterial disease (PAD) in clinical practice. Moreover, pulse wave velocity (PWV), upstroke time (UT), percent mean arterial pressure (%MAP), and toe-brachial index (TBI) are useful indices of predicting the presence of PAD even if ABI at rest is still within the normal range, thus improving patients risk stratification and helping in clinical decisions, especially in circumstances of discrepancy between symptoms and ABI at rest. The aim of this review is to investigate how to interpret the results of these indices for understanding of etiology, diagnosis, and severity in evaluation of PAD. Case 1: a discrepancy between PWV and pulse waveform in a patient with bilateral common femoral artery stenosis; Case 2: a discrepancy between ABI and TBI in a patient with bilateral diffuse stenosis of infra-popliteal artery; Case 3: a discrepancy within the normal range ABI between left and right in a patient with left superficial femoral artery occlusion; Case 4 and 5: a discrepancy between ABI and clinical symptoms in a patient with scleroderma and Buerger’s disease.
Background
Mortality in patients with type 2 diabetes and diabetic foot osteomyelitis (DFO) have been explored in few small studies with a short follow-up. Aim of the present study is to assess all-cause and cardiovascular mortality and predictors of mortality in a consecutive series of patients with DFO.
Research Design and Methods
Patients with a diagnosis of DFO, attending the Diabetic Foot Unit of San Donato Hospital in Arezzo between January 1st, 2012 and December 31st, 2013, were included in this retrospective study. Information on all-cause mortality up to December 1st, 2016, was obtained from the registry of the Local Health Unit of Arezzo, which contains updated records of all persons living in Tuscany.
Results
One hundred ninety four patients were included in the study. During a mean period of observation of 2.8±1.4 years, 73 (37.6%) died, with a yearly rate of 13.2%. Of the 73 deaths, 59 were attributable to cardiovascular causes. After adjusting for possible confounders in a Cox analysis, site of osteomyelitis (hindfoot vs mid/forefoot) was associated with a higher mortality, and surgical treatment with a lower mortality.
Conclusions
Mortality in patients with DFO appears to be much higher than that reported in clinical series of patients with diabetic foot ulcers, particularly when hindfoot is affected.
Background
Outpatient ascertainment of peripheral artery disease (PAD) is rarely considered in the measurement of PAD clinical burden; therefore, the clinical burden of PAD likely has been underestimated while contributing to a decreased awareness of PAD in comparison to other circulatory system disorders.
Methods and Results
The purpose of this study was to estimate the age‐standardized annual period prevalence and incidence of PAD in the outpatient and inpatient settings using data from the Atherosclerosis Risk in Communities (ARIC) study linked with Centers for Medicare and Medicaid Services claims. The majority (>70%) of all PAD encounters occurred in the outpatient setting. The weighted mean age‐standardized prevalence and incidence of outpatient PAD was 11.8% (95% CI 11.5–12.1) and 22.4 per 1000 person‐years (95% CI 20.8–24.0), respectively. Black patients had higher weighted mean age‐standardized prevalence (15.6%; 95% CI 14.6–16.4) compared with white patients (11.4%; 95% CI 11.1–11.7). Black women had the highest weighted mean age‐standardized prevalence (16.9%; 95% CI 16.0–17.8). Black patients also had a higher incidence rate of PAD (31.3 per 1000 person‐years; 95% CI 27.3–35.4) compared with white patients (25.4 per 1000 person‐years; 95% CI 23.5–27.3). PAD prevalence and incidence did not differ by sex alone.
Conclusions
This study provides comprehensive estimates of PAD in the inpatient and outpatient settings where the majority of PAD burden was found. PAD is an important circulatory system disorder similar in prevalence to stroke and coronary heart disease.
Background:
In all, 68% of all lower limb amputees experience residual limb pain. More than 95% of all lower limb amputations in developed countries are due to peripheral artery occlusive disease in combination with diabetes mellitus. Therefore, claudication, which is one of the most common manifestations of peripheral artery occlusive disease, should be taken into consideration in making a differential diagnosis of residual limb pain. Case description and methods: We present a case study of a 60-year-old diabetic patient who underwent a transfemoral amputation due to peripheral artery occlusive disease and who experiences residual limb pain. A computed tomography angiography was performed, and we searched for relevant literature on claudication pain after lower limb amputation.
Conclusion:
Little research has explored claudication as a cause of residual limb pain. More research will lead to a decrease in unnecessary prosthetic fittings and adjustments give more insight into the treatment and management of residual limb pain and prevent a decrease in mobility in amputees. Clinical relevance Claudication due to peripheral artery occlusive disease should be included as a possible cause of residual limb pain to prevent unnecessary prosthetic fittings and adjustments and to minimize psychological effects and limitations in activities and participation.
Most patients with lower extremity peripheral arterial disease (PAD) are asymptomatic. Approximately 30-50% have intermittent claudication or atypical leg symptoms. In comparison to isolated coronary artery disease (CAD), the mortality and event rate is doubled in patients with combined CAD and PAD. Aggressive risk-factor modification and CAD therapy is expected to improve cardiovascular events in PAD. There are three clinical forms of PAD: asymptomatic PAD, claudication, and critical limb ischemia (CLI). If PAD is suspected in a symptomatic patient with an abnormal pulse exam, ankle-brachial index (ABI) is first performed, followed by a lower extremity arterial Doppler study if revascularization is considered. There are two major forms of renal artery stenosis (RAS): atherosclerotic RAS; and fibromuscular dysplasia (FMD). The success rate of percutaneous intervention is higher for FMD than for atherosclerotic RAS. Also, RAS is more likely the sole cause of hypertension in FMD than in atherosclerotic RAS.
Above the knee peripheral artery intervention presents a myriad of anatomic and histopathologic challenges and considerations. An in-depth understanding of this vascular bed, inflow and outflow and therapeutic and interventional approaches, tools, and goals is necessary in order for the vascular interventionalist to be successful in caring for patients with peripheral arterial disease (PAD).
El Doctor Valencia realiza el abordaje mas interesante de la coagulacion para todas aquellas personas que trabajan en el area de medicina critica. Los hematologos ven la coagulacion de una forma muy diferente, el Doctor Valencia lo ve por patologias, el plantea que los problemas de coagulacion no son iguales en un paciente con patologia de SNC, o una paciente obstetrica o un paciente con enfermedades tropicales. El diferencia las caracteristicas de cada enfoque por patologias, pero lo hace con base en examenes de coagulacion pedidos en las unidades de cuidados intensivos y trae conocimientos aprendidos en las unidades de cuidado intensivo del Reino Unido y un capitulo de CID por el profesor Marcel Levi, de Holanda.
• Coronary angiography was performed during the evaluation of a prospective series of 506 patients (mean age, 65 years) presenting with extracranial cerebrovascular disease and previous neurologic symptoms (N =288) or asymptomatic carotid bruits (N = 218). Severe, surgically correctable coronary artery disease was documented in 37% of patients suspected to have coronary artery disease by conventional clinical criteria, compared with 16% of those who were not. Severe inoperable coronary disease was present in 9.8% and 1.5% of these respective subsets and was especially common (14%) among diabetics. As the result of this investigation, an algorithm for perioperative cardiac screening has been developed in an attempt to reduce the eventual mortality caused by myocardial infarction in patients who require extracranial reconstruction.(Arch Intern Med 1985;145:849-852)
In 26 patients (mean age at death 68 +/- 9 years) who had undergone amputation (at mean age 63 +/- 12 years) of 1 or both lower extremities due to severe peripheral arterial atherosclerosis, the amounts of narrowing at necropsy in the 4 major (left main, left anterior descending, left circumflex, and right) epicardial coronary arteries were determined. During life, 15 of the 26 patients (58%) had symptoms of myocardial ischemia: angina pectoris alone in 1, acute myocardial infarction alone in 5, and angina and/or infarction plus congestive heart failure or sudden coronary death in 9. Twelve of the 26 patients (42%) died from consequences of myocardial ischemia: acute myocardial infarction in 5, sudden coronary death in 3, chronic congestive heart failure in 3, and shortly after coronary bypass surgery in 1. Grossly visible left ventricular necrosis or fibrosis, or both, was present in 21 patients (81%). Of the 26 patients, 24 (92%) had narrowing 76 to 100% in cross-sectional area of 1 or more major coronary arteries by atherosclerotic plaque. The mean number of coronary arteries per patient severely (> 75%) narrowed was 2.3 +/- 1.0/4.0. Of the 104 major coronary arteries in the 26 patients, 60 (58%) were narrowed > 75% in cross-sectional area by plaque. The 4 major coronary arteries in the 26 patients were divided into 5-mm segments and a histologic section, stained by the Movat method, was prepared from each segment.(ABSTRACT TRUNCATED AT 250 WORDS)
The frequency of angiographically defined asymptomatic CAD in patients with carotid disease is 40%. Although the prognosis of patients with asymptomatic 1-vessel or 2-vessel CAD is good (annual cardiac mortality rate less than 2%), the prognosis of asymptomatic 3-vessel disease or left main CAD is substantially less favorable (annual cardiac mortality 5-8%). Preliminary data from nonrandomized studies suggest that coronary artery bypass surgery significantly lowers cardiac mortality in patients with asymptomatic 3-vessel or left main CAD. Further studies are needed to determine 1) vascular risk factor profiles that are predictive of asymptomatic CAD in patients with cerebrovascular disease and 2) the prevalence of asymptomatic CAD, especially 3-vessel and left main CAD, in patients with a variety of subtypes of cerebrovascular disease (e.g., carotid disease, atherosclerotic vertebrobasilar disease, cardioembolism, penetrating artery disease, stroke of undetermined cause). If the prevalence of asymptomatic 3-vessel or left main CAD is high in a subset of patients with cerebrovascular disease, a randomized study comparing coronary artery bypass surgery with best medical therapy (anti-ischemic agents, lipid-lowering therapy, and aspirin) may be warranted.
Early postoperative silent myocardial ischemia detected by ambulatory electrocardiography (ECG) in patients undergoing peripheral vascular surgery for occlusive peripheral arterial disease (PAD) is associated with clinical ischcmic events after surgery.1 Patients undergoing peripheral vascular surgery who had silent myocardial ischemia before surgery detected by ambulatory ECG had an increased incidence of major postoperative cardiac events after surgery.2 At a mean follow-up of 615 days after peripheral vascular surgery, cardiac events occurred in 12 of 32 (38%) patients with ischemia before surgery detected by ambulatory ECG and in 10 of 144 (7%) without myocardial ischemia (relative risk 5.4).3 We are reporting data from a prospective study correlating silent myocardial ischemia detected by 24-hour ambulatory ECG with the incidence of new coronary events at a 43-month mean follow-up in elderly patients with PAD and coronary artery disease (CAD) and in those with PAD and hypertension, valvular heart disease or cardiomyopathy without CAD.
In the Whitehall study, 18,388 subjects aged 40-64 years completed a questionnaire on intermittent claudication. Of these subjects, 0.8% (147) and 1% (175) were deemed to have probable intermittent claudication and possible intermittent claudication, respectively. Within the 17-year follow-up period, 38% and 40% of the probable and possible cases, respectively, died. Compared with subjects without claudication, the probable cases suffered increased mortality rates due to coronary heart disease and cerebrovascular disease, but the mortality rate due to noncardiovascular causes was not increased. Possible cases demonstrated increased mortality rates due to cardiovascular and noncardiovascular causes. This difference in mortality pattern may be due to chance. Possible and probable cases still showed increased cardiovascular and all-cause mortality rates after adjusting for coronary risk factors (cardiac ischemia at baseline, systolic blood pressure, plasma cholesterol concentration, smoking behavior, employment grade, and degree of glucose intolerance). Intermittent claudication is independently related to increased mortality rates. It is not a rare condition, and simple questionnaires exist for its detection. The latter can be usefully incorporated in cardiovascular risk assessment and screening programs.
Coronary angiography was performed during the evaluation of a prospective series of 506 patients (mean age, 65 years) presenting with extracranial cerebrovascular disease and previous neurologic symptoms (N = 288) or asymptomatic carotid bruits (N = 218). Severe, surgically correctable coronary artery disease was documented in 37% of patients suspected to have coronary artery disease by conventional clinical criteria, compared with 16% of those who were not. Severe inoperable coronary disease was present in 9.8% and 1.5% of these respective subsets and was especially common (14%) among diabetics. As the result of this investigation, an algorithm for perioperative cardiac screening has been developed in an attempt to reduce the eventual mortality caused by myocardial infarction in patients who require extracranial reconstruction.
In an attempt to reduce early and late mortality caused by myocardial infarction, coronary angiography was performed in 1000 patients (mean age, 64 years) under consideration for elective peripheral vascular reconstruction since 1978. Those found to have severe, surgically correctable coronary artery disease (CAD) were advised to undergo myocardial revascularization (CABG), usually preceding other vascular procedures. The primary vascular diagnosis was abdominal aortic aneurysm (AAA) in 263 patients (mean age, 67 years), cerebrovascular disease (CVD) in 295 (mean age, 64 years), and lower extremity ischemia (ASO) in 381 (mean age, 61 years). Severe correctable CAD was identified in 25% of the entire series (AAA, 31%; CVD, 26%; and ASO, 21%). Surgical CAD was documented in 34% of patients suspected to have CAD by clinical criteria (AAA, 44%; CVD, 33%; and ASO, 30%) and in 14% of those without previous indications of CAD (AAA, 18%; CVD, 17%; and ASO, 8%). Cardiac procedures (216 CABG) were performed in 226 patients (AAA, 30%; CVD, 22%; and ASO, 19%), with 12 (5.3%) postoperative deaths. A total of 796 patients underwent 1066 peripheral vascular operations with an early mortality of 2.0% (AAA, 3.4%; ASO, 1.9%; and CVD, 0.3%), but only one death (0.8%) occurred in the group of 130 patients having preliminary CABG. The overall operative mortality for 1292 cardiac and peripheral vascular procedures was 2.6%.
Patients with extracranial carotid disease (ECD) have an increased incidence of coronary events.1-3 We are reporting data from a prospective study correlating silent myocardial ischemia detected by 24-hour ambulatory electrocardiography with the incidence of new coronary events at 43-month mean follow-up in elderly patients with 40 to 100% ECD with and without coronary artery disease (CAD).
Black men are 2.5 times as likely to die of stroke as white men.1 Black women are 2.4 times as likely to die of stroke as white women.1 In Los Angeles County, stroke accounted for a greater percentage of the deaths from cardiovascular disease among blacks and Hispanics than among non-Hispanic whites and Asians.2 Elderly blacks have a higher prevalence of atherothrombotic brain infarction (ABI) than elderly whites or Hispanics. 3 Patients with extracranial carotid arterial disease (ECAD) diagnosed by carotid duplex ultrasonography have at follow-up an increased incidence of ABI.4–8 We are reporting data from a prospective study investigating the prevalence of ECAD with 40 to 100% arterial luminal diameter decrease and of ABI, and their association in 1,063 elderly blacks, Hispanics and whites.