Prognostic value of a low post-exercise ankle brachial index as assessed by primary care physicians.

OBJECTIVE: We aimed to investigate whether the post-exercise ankle brachial index (ABI) performed by primary care physicians offers useful information for the prediction of death or cardiovascular events, beyond the traditional resting ABI. An additional focus was on patients with intermittent claudication and normal resting ABI. METHODS: Using data from the 5-year follow-up of 6468 elderly patients in the primary care setting in Germany (getABI study) we used multivariate Cox regression models adjusted for age, gender and conventional risk factors to determine the association of resting ABI and/or post-exercise ABI and all-cause mortality/morbidity. RESULTS: Mean post-exercise ABI in the total cohort was 0.977 and resting ABI was 1.034. For post-exercise ABI, a threshold value of 0.825 had nearly the same sensitivity (28.6%) and specificity (85.7%) as the conventionally used resting ABI with a cut-off value of 0.9 to predict death. Compared to patients with normal post-exercise ABI, a low post-exercise ABI was associated with an almost identical risk increase for mortality (hazard ratio [HR] 1.56, 95% confidence interval [CI] 1.30-1.86) as a low resting ABI (HR 1.65; CI 1.39-1.97) and/or myocardial infarction/stroke. Slight differences were observed for coronary/carotid revascularisation and peripheral revascularisation/amputation. In combined models it could not be shown that post-exercise ABI yielded relevant additional information for the prognosis of mortality and/or myocardial infarction/stroke, not even in the subgroup analysis of patients with intermittent claudication and normal resting ABI. CONCLUSIONS: It could not be shown that the post-exercise ABI is a useful tool for the prognosis of mortality and/or myocardial infarction/stroke beyond the resting ABI.

Peripheral arterial disease as an independent predictor for excess stroke morbidity and mortality in primary-care patients: 5-year results of the getABI study.

BACKGROUND: There is controversial evidence with regard to the significance of peripheral arterial disease (PAD) as an indicator for future stroke risk. We aimed to quantify the risk increase for mortality and morbidity associated with PAD. METHODS: In an open, prospective, noninterventional cohort study in the primary care setting, a total of 6,880 unselected patients > or =65 years were categorized according to the presence or absence of PAD and followed up for vascular events or deaths over 5 years. PAD was defined as ankle-brachial index (ABI) <0.9 or history of previous peripheral revascularization and/or limb amputation and/or intermittent claudication. Associations between known cardiovascular risk factors including PAD and cerebrovascular mortality/events were analyzed in a multivariate Cox regression model. RESULTS: During the 5-year follow-up [29,915 patient-years (PY)], 183 patients had a stroke (incidence per 1,000 PY: 6.1 cases). In patients with PAD (n = 1,429) compared to those without PAD (n = 5,392), the incidence of all stroke types standardized per 1,000 PY, with the exception of hemorrhagic stroke, was about doubled (for fatal stroke tripled). The corresponding adjusted hazard ratios were 1.6 (95% confidence interval, CI, 1.1-2.2) for total stroke, 1.7 (95% CI 1.2-2.5) for ischemic stroke, 0.7 (95% CI 0.2-2.2) for hemorrhagic stroke, 2.5 (95% CI 1.2-5.2) for fatal stroke and 1.4 (95% CI 0.9-2.1) for nonfatal stroke. Lower ABI categories were associated with higher stroke rates. Besides high age, previous stroke and diabetes mellitus, PAD was a significant independent predictor for ischemic stroke. CONCLUSIONS: The risk of stroke is substantially increased in PAD patients, and PAD is a strong independent predictor for stroke.

Mortality and vascular morbidity in older adults with asymptomatic versus symptomatic peripheral artery disease.

BACKGROUND: Our aim was to assess the mortality and vascular morbidity risk of elderly individuals with asymptomatic versus symptomatic peripheral artery disease (PAD) in the primary care setting. METHODS AND RESULTS: This prospective cohort study included 6880 representative unselected patients >or=65 years of age with monitored follow-up over 5 years. According to physician diagnosis, 5392 patients had no PAD, 836 had asymptomatic PAD (ankle brachial index <0.9 without symptoms), and 593 had symptomatic PAD (lower-extremity peripheral revascularization, amputation as a result of PAD, or intermittent claudication symptoms regardless of ankle brachial index). The risk of symptomatic compared with asymptomatic PAD patients was significantly increased for the composite of all-cause death or severe vascular event (myocardial infarction, coronary revascularization, stroke, carotid revascularization, or lower-extremity peripheral vascular events; hazard ratio, 1.48; 95% confidence interval, 1.21 to 1.80) but not for all-cause death alone (hazard ratio, 1.13; 95% confidence interval, 0.89 to 1.43), all-cause death/myocardial infarction/stroke (excluding lower-extremity peripheral vascular events and any revascularizations; hazard ratio, 1.18; 95% confidence interval, 0.92 to 1.52), cardiovascular events alone (hazard ratio, 1.20; 95% confidence interval, 0.89 to 1.60), or cerebrovascular events alone (hazard ratio, 1.33; 95% confidence interval, 0.80 to 2.20). Lower ankle brachial index categories were associated with increased risk. PAD was a strong factor for the prediction of the composite end point in an adjusted model. CONCLUSIONS: Asymptomatic PAD diagnosed through routine screening in the offices of primary care physicians carries a high mortality and/or vascular event risk. Notably, the risk of mortality was similar in symptomatic and asymptomatic patients with PAD and was significantly higher than in those without PAD. In the primary care setting, the diagnosis of PAD has important prognostic value.

Profound influence of different methods for determination of the ankle brachial index on the prevalence estimate of peripheral arterial disease.

BACKGROUND: The ankle brachial index (ABI) is an efficient tool for objectively documenting the presence of lower extremity peripheral arterial disease (PAD). However, different methods exist for ABI calculation, which might result in varying PAD prevalence estimates. To address this question, we compared five different methods of ABI calculation using Doppler ultrasound in 6,880 consecutive, unselected primary care patients > or = 65 years in the observational get ABI study. METHODS: In all calculations, the average systolic pressure of the right and left brachial artery was used as the denominator (however, in case of discrepancies of > or = 10 mmHg, the higher reading was used). As nominators, the following pressures were used: the highest arterial ankle pressure of each leg (method #1), the lowest pressure (#2),only the systolic pressure of the tibial posterior artery (#3), only the systolic pressure of the tibial anterior artery (#4),and the systolic pressure of the tibial posterior artery after exercise (#5). An ABI < 0.9 was regarded as evidence of PAD. RESULTS: The estimated prevalence of PAD was lowest using method #1 (18.0%) and highest using method #2 (34.5%),while the differences in methods #3-#5 were less pronounced. Method #1 resulted in the most accurate estimation of PAD prevalence in the general population. Using the different approaches, the odds ratio for the association of PAD and cardiovascular (CV) events varied between 1.7 and 2.2. CONCLUSION: The data demonstrate that different methods for ABI determination clearly affect the estimation of PAD prevalence, but not substantially the strength of the associations between PAD and CV events. Nonetheless, to achieve improved comparability among different studies, one mode of calculation should be universally applied, preferentially method #1.

Association of low ankle brachial index with high mortality in primary care.

AIMS: We aimed to assess the increased risk of death and severe vascular events in elderly individuals with subclinical or manifest peripheral arterial disease (PAD), evidenced by low ankle brachial index (ABI < 0.9) in primary care. METHODS AND RESULTS: In this monitored prospective observational study, 6880 representative unselected patients aged >or=65 years were followed up over 3 years by 344 primary care physicians. Main outcome measures were mortality or a combined endpoint of mortality and severe vascular events. In total, 20 127 patient-years were observed. In the group of PAD patients (n=1230), 134 patients died; in the group without PAD (n=5591), 237 patients died [multivariate hazard ratio (HR) 2.0; 95% confidence interval 1.6-2.5, P<0.001]. Compared with an ABI>or=1.1, the risk of death increased linearly in the lower ABI categories: ABI 0.7-0.89, HR 1.7 (1.2-2.4, P<0.001); ABI<0.5, HR 3.6 (2.4-5.4, P<0.001). CONCLUSION: Patients with a low ABI (PAD), who can be readily identified in a primary care setting, have a substantially increased risk of death and severe vascular events. Patients with an ABI between 1.1 and 0.9 should be considered and followed up as borderline PAD cases. Particular attention should be paid to patients with PAD and previous vascular events, as their risk is markedly increased.

Excess 1-year cardiovascular risk in elderly primary care patients with a low ankle-brachial index (ABI) and high homocysteine level.

Previous studies in selected patient samples suggested a high risk for total mortality and cardiovascular (CV) morbidity associated not only with symptomatic, but also with asymptomatic peripheral arterial disease (PAD). Our aim was to assess the 1-year risk of death and CV morbidity associated with PAD in primary care. Furthermore, we quantified the strength of association between low ankle-brachial index (ABI, as indicator for PAD), plasma homocysteine (HC) levels, and various accepted PAD risk factors, and death and outcomes. In a prospective cohort study, 6880 unselected patients > or =65 years were followed up by 344 primary care physicians in Germany. At 1 year, all-cause mortality was 2.8% in patients with PAD and 0.9% in patients without PAD (odds ratio [OR] adjusted for age and gender: 2.7 [95% confidence interval: 1.7; 4.2]; multivariate adjusted OR: 2.0 [1.3; 3.3]). Mortality due to CV events was 1.6 versus 0.4% (OR: 3.7 [2.0; 6.9], adjusted OR: 2.5 [1.3; 4.9]). Patients with PAD and high HC values (> or =fourth quintile) had a markedly increased risk of premature death: OR versus no PAD/low HC level (

High prevalence of peripheral arterial disease and co-morbidity in 6880 primary care patients: cross-sectional study.

We aimed to obtain reliable data on the epidemiology, co-morbidities and risk factor profile of peripheral arterial disease (PAD) in general medical practise. In the cross-sectional part of the observational German Epidemiological Trial on Ankle Brachial Index (getABI study), 344 general practitioners throughout Germany determined the ABI of consecutive, unselected patients aged 65 years or older with bilateral Doppler ultrasound measurements. Additional assessments comprised patient history with the focus on atherothrombotic diseases, physical examination, and the WHO questionnaire on intermittent claudication. A total of 6880 patients were included (42.0% male, mean age 72.5 years, mean body mass index 27.3 kg/m(2), mean systolic/diastolic blood pressure 143.7/81.3 mmHg). The prevalence of PAD for men/women as indicated by an ankle brachial index (AB1)<0.9 was 19.8/16.8%. Patients with PAD were slightly older than patients without PAD, suffered more frequently from diabetes (36.6 vs. 22.6%; adjusted OR: 1.8), hypertension (78.8 vs. 61.6%; OR: 2.2), lipid disorders (57.2 vs. 50.7%; OR: 1.3) and other coexisting atherothrombotic diseases (any cerebrovascular event: 15.0 vs. 7.6%; OR: 1.8; any cardiovascular event: 28.9 vs. 17.0%; OR: 1.5). The data highlight the high prevalence of PAD in primary care. PAD patients are characterised by a high co-morbidity, particularly with regard to other manifestations of atherothrombosis. Doppler ultrasound measurement for ABI determinations is a non-invasive, inexpensive, reliable tool in primary care and enables GPs to identify patients at risk of PAD.

Relationship between lipid parameters and the presence of peripheral arterial disease in elderly patients.

OBJECTIVE: To investigate the relationship between various lipid parameters and the presence of peripheral arterial disease (PAD). METHODS: Cross-sectional analysis of the observational epidemiological getABI study (German epidemiological trial on Ankle Brachial Index) with 6,880 unselected elderly patients in 344 primary care centers. RESULTS: In the multivariate analysis, the strength of the association between the various lipid parameters and PAD was found to be generally limited, when accounting for other risk factors. CONCLUSION: These findings are in contrast to previous studies. While lipid levels alone cannot be used for supporting the PAD diagnosis or the risk factor for these patients, this should not preclude PAD patients from receiving adequate lipid lowering treatment.