Risk factors and haemodynamic variables in patients with low toe-brachial index but normal ankle-brachial index.

BACKGROUND AND AIMS: Classically, peripheral arterial disease (PAD) is diagnosed by a low ankle-brachial index (ABI), but the diagnosis can also be made based on toe-brachial index (TBI) measurements. The objective of this study was to characterize patients with low TBI but normal ABI, and chart potential underestimation of PAD prevalence by solitary use of ABI. METHODS: A total of 3739 consecutive patients with known or suspected PAD referred for ABI and TBI measurements in a four-year period were compared to an age- and gender matched control group (n = 17,340). RESULTS: In the patient cohort, 65.0% had low ABI, 20.5% had low TBI but normal ABI, and 14.5% had normal indices. When comparing the frequencies of comorbidities related to atherosclerotic disease (myocardial infarction, congestive heart failure, cerebrovascular disease, diabetes mellitus, chronic kidney failure), there were no significant differences among patients with low ABI or low TBI with normal ABI in any of the variables (all p > 0.06). Of the patients with low TBI and normal ABI, 18.7% were diagnosed with diabetes mellitus type I or II, and 8.2% with chronic kidney disease. CONCLUSIONS: Patients with low TBI but normal ABI represented 20.5% of patients referred with the suspicion of PAD. Furthermore, patients with low TBI but normal ABI presented similar comorbid characteristics to patients with low ABI, who have a well-described increased risk of cardiovascular morbidity and mortality. The solitary use of ABI underestimated the prevalence of PAD in the population, and PAD screening could potentially be improved by routine application of TBI.

The use of secondary medical prevention after primary vascular reconstruction: studies on usage and effectiveness.

Peripheral arterial disease (PAD) is a common manifestation of symptomatic atherosclerosis that leads to a significantly elevated risk of cardiovascular events, including major limb loss, myocardial infarction, stroke and death. The prevalence proportions of PAD increase dramatically with age and appear to progress more aggressively in women than in men. Several studies have indicated that the use of secondary medical prevention is generally insufficient among PAD patients. However, current national and international guidelines recommend lipid-lowering and anti-platelet therapy, supplemented with aggressive blood pressure lowering treatment. We aimed to determine whether there were age-, gender-, geography or time related differences in the use of secondary medical prevention, following primary vascular reconstruction. We also sought to describe the prognoses for the same population, according to the association between the use of ACE/ATII inhibitors (angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists) or beta blockers and clinical outcomes (all cause mortality, myocardial infarction, stroke, major amputation and/or recurrent vascular surgery) in a population-based, long-term follow-up study. We established a data base by linking four population based administrative and health-care registries. All Danish patients undergoing primary vascular surgical reconstruction due to atherosclerotic disease between 1997 and 2007 were included and identified in the Danish Vascular Registry; a total of 20,761 patients were followed during a median of 582 days (range of 30 to 4,379 days). Data regarding all prescriptions filled by the study population were obtained from the Medical Registry of the Danish Medicines Agency. Study I: Age- and gender-related differences. We found moderate to low use of secondary medical prevention. However, this use has increased in recent years and the age- and gender-related differences in use have been reduced or eliminated. Study II: Geographic or time related differences. The use of evidence-based secondary medical prevention, especially lipid-lowering drugs, increased substantially over time, regardless of socio-demographic and clinical factors. No substantial differences in pharmacological use according to location of residence were observed. Study III: Use of ACE/ATII and prognosis. We found the use of ACE inhibitors to be associated with lower all cause mortality but also an increased long-term risk of recurrent vascular reconstruction and myocardial infarction. Study IV: Use of beta blockers and prognosis. We found beta blocker use to be associated with a lower risk of major amputation, but also an increased risk of new myocardial infarction and stroke. No association were found regarding all cause mortality or the risk of recurrent vascular surgery. In conclusion, the use of secondary medical prevention following primary vascular surgery (between 1996 and 2006 in Denmark) shifted towards a more evidence-based treatment, as reduction in age-, gender- and geography related differences were observed early in the study period. However, recommendations for the current clinical guidelines suggest that additional improvement can be made. The treatment of hypertension in PAD patients is complex, and our results are also complex but indicate that ACE/ATII and beta blockers are safe for use in symptomatic PAD patients.

C-reactive protein predicts future arterial and cardiovascular events in patients with symptomatic peripheral arterial disease.

High-sensitivity C-reactive protein is associated with increased risk of cardiovascular events. Consequently, the predictive value of this protein in patients with symptomatic peripheral arterial disease was examined. In all, 452 patients with symptomatic peripheral arterial disease had high-sensitivity C-reactive protein measured at baseline (mean follow-up = 2.1 +/- 1.4 years). Events were defined as primary (death, amputation, or peripheral revascularization) or secondary (lower limb thrombosis, myocardial infarction, or stroke).The level of high-sensitivity C-reactive protein was significantly higher among those dying (P = .04), those who needed amputation (P = .01), and those developing an overall secondary endpoint (P = .02). By receiver-operating characteristic curve analysis, the optimal cutoff point was constantly approximately 10 to 20 mg/L with a sensitivity and specificity of 56% to 63% and 54% to 56%, respectively. Baseline levels of high-sensitivity C-reactive protein are associated with future arterial events in symptomatic peripheral arterial disease patients but cannot stand alone as a predictive tool.