PAD screening: why? whom? when? how? - a systematic review.

An estimated 237 million people suffer from peripheral arterial disease (PAD), which is associated with high morbidity and mortality, and prevalence is still increasing. Currently, we do not have any randomized trials that compare screening to no screening specifically for PAD in the general population. Presently, PAD screening is not generally established. This systematic review gives an overview of relevant literature and guidelines. Screening usually focuses on ankle-brachial index (ABI)-measurement, which enables detection of asymptomatic and symptomatic PAD, but has limitations in diabetics. There are no sufficient data on PAD screening. Guideline recommendations are heterogeneous. While some advocate no screening until better data are available, most recommend selective screening despite insufficient data on morbidity and mortality reduction in consequence of screening. We support the only evidence-based screening strategy for PAD: combined screening for abdominal aortic aneurysm (AAA), PAD and arterial hypertension in men aged 65-74 according to the VIVA study. We additionally suggest a new simple three-step screening strategy for symptomatic PAD in all individuals aged 40 and older, who see a general practitioner: Asking one question ("Do you have pain or cramps in the legs during normal walking?") followed by physical examination (normal lower extremity pulse status?) in those, whose answer is "yes", and ABI measurement unless all pulses are normal.

Claudication, in contrast to angina pectoris, independently predicts mortality risk in the general population.

BACKGROUND: The aim of our analyses was to investigate whether claudication and angina pectoris, each defined and based on the answer to a single question, are predictive of future mortality. PROBANDS AND METHODS: The study population consisted of 3995 subjects selected from the population-based Study of Health In Pomerania (SHIP). Kaplan-Meier analysis and multivariable Cox proportional hazards regression analysis were used to analyze the association of angina pectoris and claudication with all-cause and cardiovascular mortality adjusted for major cardiovascular risk factors. RESULTS: At baseline, 417 individuals had symptoms of angina pectoris, and 323 had symptoms of claudication. During a median follow-up of 8.5 years, 277 individuals died. Individuals with claudication had a higher fully-adjusted all-cause mortality rate (Hazard Ratio (HR) 1.79; 95 % CI 1.34, 2.39, p < 0.001) and a higher sex- and age-adjusted cardiovascular mortality rate (HR 1.76; 95 % CI 1.03, 2.99, p = 0.038) compared to subjects without claudication. In contrast, subjects with angina pectoris had neither an elevated fully-adjusted all-cause mortality rate (HR 1.15; 95 % CI 0.82, 1.61, p = 0.413) nor sex- and age-adjusted cardiovascular mortality rate (HR 0.71; 95 % CI 0.34, 1.48, p = 0.363) compared to those without this symptom. CONCLUSIONS: Claudication, in contrast to angina pectoris, is a strong, independent predictor of all-cause mortality.

Impedance cardiography versus invasive measurements of stroke volume index in patients with chronic heart failure.

We assessed the hypothesis that non-invasive measurement of stroke volume index can replace invasive measurements in patients with chronic heart failure. Non-invasive impedance cardiography (ICG) measurements together with invasive hemodynamic thermodilution (TD) measurements were performed in 13 patients with severe chronic heart failure (NYHA III-IV). Agreement between ICG and TD regarding stroke volume index was poor. Correlation between non-invasive and invasive hemodynamic measurements was low (r=0.29). In conclusion, non-invasive measurements of stroke volume index using impedance cardiography did not result in sufficient agreement with invasive thermodilution measurements in this study with patients suffering from severe chronic heart failure.

Haemodynamic effects of intravenous quinaprilat in comparison to sodium nitroprusside in patients with chronic heart failure.

We compared the haemodynamic effects of intravenous boluses of the ACE inhibitor quinaprilat with an intravenous infusion of sodium nitroprusside in 23 patients with chronic heart failure (NYHA Class III or IV). At the highest drug doses, sodium nitroprusside significantly increased stroke volume index (+6.63 ml/m(2), p=0.045), whereas quinaprilat induced only a minor increase (+1.79 ml/m(2), n.s.).

Hemodynamic effects of alpha1-adrenoceptor antagonist, doxazosin, in patients with chronic congestive heart failure.

PURPOSE: Non-selective alpha-adrenoceptor antagonists have not demonstrated significant beneficial effects in chronic heart failure. Previous studies with the selective alpha1-adrenoceptor antagonist, doxazosin, led to conflicting results. We assessed the hypothesis that treatment with doxazosin adjuvant to standard oral therapy results in significant increase in cardiac index in patients with chronic heart failure. METHODS: A double-blind, randomized study was conducted on 30 patients with chronic congestive heart failure (NYHA III-IV), with cardiac index<2.5 l/minxm, and/or with pulmonary capillary wedge pressure>16 mm Hg. Of the 30 patients, 15 were treated with doxazosin and 15 with placebo, both adjuvant to stable oral therapy, which included a minimum of an ACE inhibitor and a diuretic. Hemodynamic measurements were performed on days 1 and 2, and after 12 weeks on study medication. On day 1, patients were treated with 4 mg doxazosin or placebo. On day 2 and throughout the following 12 weeks, the patients were treated with 4 mg or 8 mg doxazosin/d (the latter, if 4 mg/d did not induce an increase >0.75 l/minxm in cardiac index), or with placebo. RESULTS: Six patients were treated with 4 mg doxazosin/d (group A), 9 patients with 8 mg doxazosin/d (group B), and 15 with placebo. Baseline values for the cardiac index on day 1, day 2, and after 12 weeks failed to disclose significant differences between patient groups and between the days of study. On day 1, the increase in cardiac index compared with baseline was significantly higher in group A than in the placebo group (P=0.004) and group B (P=0.001). On day 2, the increase in cardiac index compared with baseline on day 1 was significantly higher in group A than in group B (P=0.003) (with reference to alpha/3=0.0167 according to Bonferroni). This was no longer observed after 12 weeks. In the placebo group, following significant changes occurred in baseline values, heart rate was lower (P=0.023) and stroke volume index was higher after 12 weeks in comparison to day 1 (P=0.032). CONCLUSIONS: In conclusion, oral application of doxazosin supplementary to standard oral medication did not induce sustained hemodynamic benefit. Significant acute increase in cardiac index was observed in a minority (40%) of patients, whereas favorable changes in baseline hemodynamic parameters after 12 weeks occurred in the placebo group.