Post-exercise ankle-brachial index is not an indispensable tool for the detection of peripheral arterial disease in an epidemiological survey. A post-hoc analysis of the Athens Study.

AIM: Previous studies have estimated the sensitivity, specificity and predictive value of non-invasive methods for the detection of peripheral arterial disease (PAD). The aim of our study was to evaluate the performance of non-invasive diagnostic tools and more specifically ankle-brachial index (ABI) at rest and after exercise for the detection of PAD in an epidemiological survey conducted in Greece. METHODS: Overall, a representative sample of 2089 adults (911 men and 1178 women), 18-90 years old (mean age 46.88+14.98 years) living in the greater Athens area, participated in the study. For the detection of intermittent claudication, the Rose questionnaire (RQ) was used. Moreover, physical examination (PE) of the lower extremities was performed, ABI both at rest and after exercise was measured. RESULTS: Thirty subjects were diagnosed with PAD, corresponding to a prevalence of 1.43%. Sensitivity and specificity of RQ, PE, ABI at rest and one minute after stress test were 53.33%, 66.67%, 100%, 64.71% and 98.79%, 97.77%, 99.81%, 94.94%, respectively. The combination of RQ with PE and ABI at rest yielded a 41.18% sensitivity, but a very high specificity (100%) and positive predictive value (100%). CONCLUSION: ABI at rest detected PAD in the epidemiological setting, and its combination with RQ and PE attained a very high specificity. Intermittent claudication and physical examination, while easier to evaluate, were considerably less sensitive. Finally, inclusion of postexercise ABI did not increase sensitivity which leads to the conclusion that this diagnostic tool is not needed for the detection of PAD in large epidemiological surveys.

Differential impact of angiotensin receptor blockers and calcium channel blockers on arterial stiffness.

AIM: Arterial stiffness, assessed by ambulatory arterial stiffness index (AASI), is an independent predictor of cardiovascular disease (CVD) mortality in hypertensives. However, it is unclear whether certain antihypertensive drugs are conducive to the reduction in CVD morbidity and mortality through their beneficial effect on arterial stiffness. Therefore, we compared the effect of angiotensin receptor blockers (ARBs) and calcium channel blockers (CCBs) on AASI in a hypertensive population. METHODS: We studied 188 individuals with newly-diagnosed essential hypertension without organ damage or CVD. AASI was calculated from twenty-four-hour ambulatory blood pressure monitoring (ABPM) readings at baseline and after twelve weeks of antihypertensive treatment. Therapy was initiated with a low-dose of CCB (group A) or ARB (group B). After six weeks, subjects with poor office blood pressure (BP) control were further randomized to high-dose monotherapy (CCB in group C or ARB in group D) or low-dose combination therapy (CCB plus ARB, group E). RESULTS: Groups A and B showed similar reductions in systolic and diastolic BP (r=-0.12, P=0.92 and r=-0.07, P=0.58 in group A and r=-0.06, P=0.67 and r=-0.04, P=0.73 in group B, respectively). However, only subjects in group B achieved significant AASI decrease (P<0.001). Similarly, subjects in groups C, D and E also displayed a comparable BP reduction, but only those in group E attained significant AASI decrease (P=0.001). CONCLUSION: ARB treatment, either as low-dose monotherapy or in combination with a CCB in hypertensives who do not achieve BP control with monotherapy, has a beneficial effect on arterial stiffness. As arterial stiffness is an important modifiable risk factor, our findings highlight the value of ARBs beyond their BP lowering properties.

High-dose monotherapy vs low-dose combination therapy of calcium channel blockers and angiotensin receptor blockers in mild to moderate hypertension.

The objectives of the study were to compare long-acting dihydropyridine calcium channel blockers (CCBs) with angiotensin II receptor blockers (ARBs) according to the ambulatory blood pressure monitoring (ABPM) profile in stage 1 and 2 newly diagnosed hypertensives and also to evaluate the efficacy of high-dose monotherapy vs low-dose combination therapy of the two drug categories among the subjects with inadequate blood pressure (BP) control after conventional low-dose monotherapy. We obtained 24-h ABPM readings from 302 subjects with newly diagnosed stage 1 or 2 essential hypertension. The study protocol consisted of initial drug treatment with a low dose of either CCBs or ARBs. Hypertensives who did not achieve BP control were randomized to high-dose monotherapy of either category of drug or low-dose combination therapy. CCBs and ARBs in low-dose monotherapy achieved BP control in 53.8 and 55.3% of the cases, respectively. However, subjects under treatment with CCBs experienced side effects more often and required that treatment be discontinued. Hypertensives who failed to control their BP with low-dose monotherapy did significantly better with low-dose combination treatment (61.6%) than with high-dose CCBs (42.8%) or ARBs (40.5%) monotherapy (P<0.05). In terms of ABPM, low-dose combination therapy exhibited better 24-h BP profile according to trough-to-peak ratio, hypertensive burden and BP variability. In conclusion, low-dose ARBs and CCBs have a comparable effect in subjects with grade 1 and 2 arterial hypertension. In hypertensives who are not controlled by low-dose monotherapy, low-dose combination therapy proves be more efficacious than high-dose monotherapy.

Intermittent claudication unmasking underlying Fabry's disease.

In a 53-year-old woman, admitted to our Department with leg pain, peripheral arterial occlusive disease (PAOD) was diagnosed. The absence of cardiovascular risk factors in this middle-aged woman, the unexplained burning pain during both effort and rest of the lower extremities mimicking severe ischemia, decreased sweating and cold induced Raynaud's phenomenon raised the suspicion of an underlying predisposing disease. The coexistence of painful acroparesthesias, angiokeratomas, left ventricular hypertrophy (LVH), corneal opacities and lenticular lesions suggested the diagnosis of Fabry's disease, which was confirmed by low serum levels of a-galactosidase-A activity. This case, presented with intermittent claudication due to generalized atherosclerosis, is quite unusual, since Fabry's disease rarely produces symptoms in female carriers.