[Physical trainings in peripheral atherosclerosis: problems and ways of solution].

Physical trainings (PT) in patients with peripheral atherosclerosis (PA) improve quality of life and the prognosis. They are accompanied and followed by favourable shifts in metabolism of peripheral tissues. The currently existing guidelines are unequivocally in favour of the necessity of physical trainings in patients with signs of intermittent claudication (class I, level A evidence). However, there is a considerable gap between efficacy of regular physical exercises and readiness of patients to participate in them, with only a sparse number of patients with PA actually performing these programmes. The review gives a detailed consideration of both subjective and objective factors limiting the participation of PA patients in PT programmes. New approaches for solving this problem have recently been proposed. In order to prevent the development of painful sensations during PT, they propose to use low-intensity loads, also performing training of other muscular groups, integral trainings, including those using electrostimulation of skeletal muscles. Mention should be made of the beginning of PT in patients with subclinical manifestations of PA, behavioural therapy in PA patients. Revealing early forms of PA and carrying out active rehabilitative measures are more convenient to be performed by physicians specializing in neurosurgery, thus requiring new organizational approaches.

Effect of intensive rehabilitation on physical function and arterial function in community-dwelling chronic stroke survivors.

BACKGROUND: Atherothrombosis due to arteriosclerosis is a risk factor for recurrence of stroke. Although exercise therapy is essential to prevent progression of arteriosclerosis and to improve endothelial function, little is known about the effect of rehabilitation in chronic stroke survivors. OBJECTIVE: The purpose of this study was to investigate the effect of intensive rehabilitation on physical and arterial function among community-dwelling stroke survivors. METHODS: Forty-four community-dwelling stroke survivors participated in the study. The experimental group (n = 22) received primarily intensive strengthening exercise and the control group (n = 22) received standard physical therapy consisting mainly of stretching and gait training. Both groups underwent the rehabilitation program for 12 weeks. Physical function was evaluated using 10-m gait velocity, the 30-s chair stand test, Timed Up and Go test, and grip strength. Arterial function of the affected and unaffected sides was evaluated using the cardio-ankle vascular index (CAVI) as an index of arterial stiffness and the ankle-brachial pressure index (ABI) as an index of arterial occlusion. RESULTS: After the 12-week rehabilitation period, improvement in physical function did not differ between the 2 groups; whereas with regard to arterial function, a significant improvement in the CAVI for the affected side was observed in the experimental group (P < .001). Also, the ABI for the unaffected side in the experimental group was significantly improved after intervention (P < .001). No significant differences were found for the unaffected-side CAVI and affected-side ABI between the 2 groups. CONCLUSIONS: These findings suggested that intensive rehabilitation for stroke patients during the chronic stage preserved physical function and improved arterial function.

Automatic referral to cardiac rehabilitation.

OBJECTIVES: Cardiac rehabilitation (CR) remains underused and inconsistently accessed, particularly for women and minorities. This study examined the factors associated with CR enrollment within the context of an automatic referral system through a retrospective chart review plus survey. Through the Behavioral Model of Health Services Utilization, it was postulated that enabling and perceived need factors, but not predisposing factors, would significantly predict patient enrollment. SUBJECTS: A random sample of all atherosclerotic heart disease (AHD) patients treated at a tertiary care center (Trillium Health Centre, Ontario, Canada) from April 2001 to May 2002 (n = 501) were mailed a survey using a modified Dillman method (71% response rate). MEASURES: Predisposing measures consisted of sociodemographics such as age, sex, ethnocultural background, work status, level of education, and income. Enabling factors consisted of barriers and facilitators to CR attendance, exercise benefits and barriers (EBBS), and social support (MOS). Perceived need factors consisted of illness perceptions (IPQ) and body mass index. RESULTS: Of the 272 participants, 199 (73.2%) attended a CR assessment. Lower denial/minimization, fewer logistical barriers to CR (eg, distance, cost), and lower perceptions of AHD as cyclical or episodic reliably predicted CR enrollment among cardiac patients who were automatically referred. CONCLUSION: Because none of the predisposing factors were significant in the final model, this suggests that factors associated with CR enrollment within the context of an automatic referral model relate to enabling factors and perceived need. A prospective controlled evaluation of automatic referral is warranted.

[Cardiovascular prevention and rehabilitation]. / Kardiovaskuläre Prävention und Rehabilitation.

The distinction between primary and secondary prevention has been abandoned in favor of cardiovascular prevention, mandating individual risk assessment. First, the individual cardiovascular risk of a person is determined by index diseases like myocardial infarction, peripheral arterial disease or other, or, if absent, by a score consisting of a number of conventional risk factors. According to current guidelines, cardiovascular prevention is indicated, as soon as the risk for fatal cardiovascular disease is > or = 5 %, equivalent to a risk for a major cardiovascular event of > or = 20 %. Non-pharmaceutical approaches are: refraining from smoking, mediterranean diet with fatty fish, physical activity and normal body weight. Blood pressure and diabetes mellitus are optimized. In addition, the following agents are used: platelet inhibitors, beta-blockers, ACE-inhibitors, statins and omega-3 fatty acids. A number of structural problems add to individual factors impeding optimal implementation of cardiovascular prevention in Germany.

Improvement of insulin resistance and early atherosclerosis in patients after gastric banding.

OBJECTIVE: To evaluate the effect of massive weight loss on insulin sensitivity, soluble adhesion molecules, and markers of the insulin resistance syndrome (IRS). RESEARCH METHODS AND PROCEDURES: Eighteen morbidly obese patients underwent gastric banding and were evaluated before and 6 and 12 months after surgery. Total insulin secretion, hepatic insulin extraction, and insulin sensitivity were analyzed by oral glucose-tolerance test model analysis. In addition, soluble intercellular adhesion molecule-1, vascular cell adhesion molecule-1, E-selectin, leptin, high-sensitivity C-reactive protein, plasminogen activating factor-1 (PAI-1), and tissue plasminogen activator were measured. RESULTS: BMI dropped from 45.22 +/- 5.62 to 36.99 +/- 4.34 kg/m(2) after 6 months and 33.72 +/- 5.55 kg/m(2) after 12 months (both p < 0.0001). This intervention resulted in a significant reduction of blood pressure (p < 0.00001), triglycerides (p < 0.01), fasting blood glucose (p = 0.03), basal insulin (p < 0.001), and basal C-peptide (p = 0.008) levels. Total insulin secretion decreased (p < 0.05), whereas hepatic insulin extraction (p < 0.05) and oral glucose insulin sensitivity index (p < 0.0001) increased compared with baseline. Leptin (p < 0.0001) and E-selectin levels decreased significantly after 6 and 12 months (p = 0.05), whereas significantly lower levels of intercellular adhesion molecule-1 and PAI-1 were only seen after 6 months. Subclinical inflammation, measured by high-sensitivity C-reactive protein, was lowered to normal ranges. No changes were observed in vascular cell adhesion molecule-1 and tissue plasminogen activator levels. DISCUSSION: Although gastric banding ameliorates several features of the IRS, including 29.05% improvement in insulin sensitivity and blood pressure and reduction of soluble adhesion molecules and PAI-1, considerable weight loss did not normalize all components of the IRS in morbidly obese patients.

Changes of cerebral blood flow velocities during enhanced external counterpulsation.

OBJECTIVES: Intra-aortic counterpulsation is the most frequently used cardiac assist device. However, there are only few studies of the effects of counterpulsation on cerebral blood flow and these report conflicting outcomes. The new enhanced external counterpulsation (EECP) technique reproduces non-invasively the effects of intra-aortic counterpulsation. In this study, we evaluated effects of EECP on blood pressure (BP) and on cerebral flow velocity (CBFV). SUBJECTS AND METHODS: Twenty-three healthy controls and 15 atherosclerotic patients each underwent a 5-min session of EECP. Before, during and after EECP we monitored heart rate, beat-to-beat radial artery BP and CBFV. RESULTS: EECP induced a second increase in BP and CBFV during diastole with a significant increase of mean BP and a decrease of systolic BP in patients and controls. Mean CBFV increased in both groups during the first 5 s of EECP. After 3 min of EECP, diastolic CBFV was still higher than at baseline, but systolic CBVF was lower than at baseline; mean CBFV was as low as before EECP in the patients and lower than the baseline values in the controls. Three minutes after ending EECP, mean and systolic BP were lower in the patients than the corresponding baseline values. Otherwise, CBFV and BP values did not differ from baseline in patients and controls. CONCLUSION: Cerebral autoregulation ensures the constancy of cerebral blood flow even though EECP creates marked systemic changes. In the patients, the decrease of BP after EECP with maintained CBFV indicates an improved BPCBFV relation and a more economic autoregulation.

Vertebral artery atherosclerosis: a risk factor in the use of manipulative therapy?

BACKGROUND AND PURPOSE: Vertebrobasilar insufficiency, a direct result of compromised blood flow in the vertebrobasilar circulation, may be caused by stretching and/or compression of the vertebral arteries, particularly if superimposed on underlying atherosclerosis of the vessels. This is an important consideration when using manipulative therapy techniques. The aim of the present study was to investigate the incidence of atherosclerosis and to calculate the relative associated decrease in blood flow in the third and fourth parts of the vertebral artery, in a sample of the adult population. METHOD: A laboratory-based experimental investigation was used to study 362 vertebral arteries from embalmed adult cadavers that were routinely processed for light microscopic study. The incidence of each grade of atherosclerosis in the vessels was recorded. Atherosclerosis was classified as grades 0-5, where Grade 0 represented no atherosclerosis and Grade 5 a fully developed plaque occluding more than 75% of the vessel lumen. From mean measurements of 188 of these arteries, the estimated decrease in luminal cross-sectional area and the relative decrease in blood flow in the atherosclerotic vessels were calculated. RESULTS: The highest incidence of atherosclerosis found was Grade 3 (third part of the vertebral artery (VA3): 42.0%; fourth part of the vertebral artery (VA4): 35.2%). An estimated decrease in artery luminal cross-sectional area to 6.2% of normal in Grade 5 atherosclerosis was found. Because blood flow is proportional to the fourth power of the vessel radius, relative decreases in blood flow in grades 1-5 atherosclerosis from 100% to 0% (with critical closing pressure in vessels), respectively, are likely to occur. CONCLUSIONS: These data suggest that, as significant numbers of the sample showed marked (Grade 3+) atherosclerosis, concomitant with decreased blood flow in the vertebral arteries, this population is at risk for developing vertebrobasilar insufficiency. Because other Western populations may be similarly at risk, particular care should be taken when considering the use of rotational manipulative therapy techniques in treatments of the cervical spine.

[Recovery processes in the cerebral cortex, myocardium and thymus of rats with experimental atherosclerosis exposed to low-frequency electromagnetic fields on the head]. / Vosstanovitel'nye protsessy v kore golovnogo mozga, miokarde i timuse krys s éksperimental'nym aterosklerozom pri vozdeistviiakh nizkochastotnymi élektromagnitnymi poliami na golovu.

Studies of animals with experimental sclerosis has shown that a course of 10 procedures of alternative magnetic field (AMF) (50 Hz, 30 mT, 3 min daily) promotes partial recovery of the lipid spectrum and corrects vasomotor-metabolic disturbances in the cerebral cortex, myocardium and thymus caused by atherosclerosis. Combination of AMF with constant magnetic field in the same regime and location does not produce a hypolipidemic effect in atherosclerotic animals and this, in combination with increased vascular permeability may aggravate the condition. Activated microcirculation, antioxidant and antiproteinase effects in activation of biosynthetic processes in the cerebral cortex reflect inhibition in the CNS in this combined effect and create conditions for a hypotensive effect.

[Survey on adherence to hygiene and dietary rules in patients with arterial occlusive disease]. / Enquête sur les conditions de suivi des règles hygiéno-diététiques chez l'artériopathe.

OBJECTIVE: Chronic arterial occlusive disease of the lower limbs, a common (800,000 patients in France) invalidating condition, can involve one or more arterial territories. In 90% of the cases, it is related to a more general disease, atherosclerosis. The risk factors are the same as for atherosclerosis and can be classed into three distinct groups: pathological conditions, constitutional characteristics, and lifestyle. Besides age and gender, smoking habits are by far the most predominant vascular risk factor for chronic arterial occlusive disease. Other factors include diabetes, known to play a particular role in diabetic arteriopathy, generally with more distal and quite severe lesions, high blood pressure, a less evident but certain risk factor, and hyperlipidemia, whole role in the pathogenesis of chronic arterial occlusive disease is well recognized though not predominant. These different data led us to analyze a cohort of patients with chronic arterial occlusive disease of the lower limbs to ascertain the cause of success or failure of hygiene and diet counseling. PATIENTS AND METHODS: The study protocol included three steps. We first established the profile of a typical arteriopathy patient based on demographic data, history of the arterial disease, personal and familial medical history and lifestyle: smoking habits, physical exercise, diet. The second step was to estimate the proportion of patients following hygiene and dietary rules. Finally, we looked for the reasons why the patients succeeded or failed in following these rules. This cross-sectional study involved 1,500 practitioners. Each physician selected 3 patients, men or women aged 40 to 80 years whose arteriopathy had reached the stage of intermittent claudication. Evaluation criteria were based on the demographic data and conditions of adherence to advice as well as conditions leading to success or failure: personal motivation, familial support, the patient's knowledge of the disease, its pathophysiological mechanisms, and the way the risk factors contribute to its genesis and aggravation. RESULTS: The sex ratio of the 3,294 recruited patients was 4.3 (2,672 men and 622 women). Disease duration and walking distance were 8.6 +/- 6 years and 418 +/- 297 meters respectively. Thirty-eight percent of the patients had undergone surgery of the lower limbs. One thousand four hundred ninety-four patients (45%) had undergone surgery for their arterial disease (lower limbs, coronary or cerebral arteries). Forty-nine percent were aware of the risk of amputation. Overall adherence to drug therapy was good for 82% of the patients. Patients were treated basically with vasoactive and platelet antiaggregates (95 and 82% of the patients respectively). Seventy-nine percent of the patients were former smokers (38% continued to smoke). Fifty-six percent had a specific regular physical activity compared with 42% prior to their disease. Seventeen percent of the patients had already tried a Mediterranean type diet (with a success rate of 69%). Among the 3, 294 patients, 950 (28.8%) followed hygiene and dietary rules well. The main reasons and/or conditions differentiating those who were successful and those who were not were, for each item: personal motivation, family support, and perception of the influence of lifestyle on disease course. These differences were highly significant (p <0.001). CONCLUSION: Considering the importance of following good hygiene and dietary rules for secondary prevention of chronic arterial occlusive disease of the lower limbs, it was interesting to assess with precision the percentage of diseased patients who follow such rules. Only about 30% of the patients were successful in correcting all behaviors.

[The combined action of infrared radiation and permanent and alternating magnetic fields in experimental atherosclerosis]. / Kombinirovannoe deistvie infrakrasnogo izlucheniia, postoiannogo i peremennogo magnitnykh polei pri éksperimental'nom ateroskleroze.

Paravertebral exposure to infrared radiation (0.87 micron, 5 mW) and permanent magnetic field in combination with one- and two-semiperiodic alternative magnetic fields (50 Hz, 15-30 mT) was studied in respect to the action on adaptive reactions in animals with experimental atherosclerosis. Complex consisting of infrared radiation, permanent magnetic field and one-semiperiodic pulse alternative magnetic field was most effective in restoration of vasomotor-metabolic and immune disturbances accompanying development of atherosclerosis.

[Medico-social expert evaluation and rehabilitation of patients after reconstructive surgery for atherosclerosis of the leg vessels]. / Mediko-sotsial'naia ékspertiza i reabilitatsiia bol'nykh posle rekonstruktivnykh operatsii pri ateroskleroze sosudov nizhnikh konechnostei.

The study was aimed at defining the sociomedical criteria of disability after reconstructive surgery for atherosclerosis obliterans of the lower limbs, in connection with the creation of Federal Service of Sociomedical Expert Evaluations and with the crucial changes in methodological approaches to expert evaluations and its functional tasks; one more purpose of the study was to outline approaches to sociomedical rehabilitation.

The differential effect of the level of spinal cord stimulation on patients with advanced peripheral vascular disease in the lower limbs.

Percutaneous spinal cord stimulation (SCS) (Medtronic model 3487A PISCES-Quad lead) was carried out in 10 patients with rest pain from advanced peripheral vascular disease of the lower limb, who were unsuitable for conventional treatment. Trial stimulation ranged from 1-20 weeks and was associated with pain relief in nine of the patients. Claudication distance was improved in six patients. Trophic lesions improved in one patient with small artery disease. Spinal cord stimulation did not reverse the course of acute gangrenous lesions. The distal arterial pressure measured by Doppler Ankle/Brachial Pressure Index, (ABPI), showed no change. The capillary blood flow and skin temperature of both feet, measured, respectively, by Laser Doppler flowmetry and skin thermistor, showed a tendency to decrease when the stimulation was at the higher level, above T10, compared with an increase when the stimulation was at the lower level T12. Transcutaneous oxygen tension monitoring of the symptomatic foot showed an increase in four out of five patients. Pain relief was not dependent on circulatory changes, but it was more significant when the circulatory changes showed an impressive increase in the blood flow. The mechanism of these circulatory changes is probably by modulation of the sympathetic nervous system. Recognition of the optimal sitting of SCS may be critical in the clinical use of this technique, which seems to be a valuable option in the treatment of patients with advanced peripheral vascular disease (PVD).

Exercise rehabilitation for patients with peripheral arterial disease.

Intermittent claudication, resulting from PAD, impairs functional status. Reducing the disability result from the disease is therefore an important goal of treatment. To evaluate the efficacy of an intervention designed to improve functional status requires that appropriate outcome measures be developed to assess all treatments. Such outcome measures include graded treadmill testing and questionnaire assessment. These methodologies are important because they have a high degree of precision and accuracy and are practical and reproducible. Thus, functional status changes resulting from any intervention can be evaluated, and interventions can be compared with one another using the same methodologies. Currently, interventional therapies are often used to treat a portion of patients with claudication [49]. Such therapies restore blood flow and improve functional status, but with a high associated cost: morbidity and mortality. Pharmacological therapies currently are being developed, but the role of drugs in the overall management of claudication needs further study. Importantly, exercise therapy has been shown in numerous studies to be efficacious and very well tolerated by patients. Patients improve both their walking ability in the laboratory and their community-based functional status. Because of the efficacy of this treatment, in addition to the low associated morbidity, exercise therapy is recommended as a major treatment option for persons with intermittent claudication due to PAD.

Lower limb ischaemia in the octogenarian: is limb salvage surgery worthwhile?

Vascular surgeons are being asked to manage vascular disease in an increasingly elderly population, and advanced age may be considered a relative contraindication to limb salvage surgery with an amputation seeming the preferred option. We present a review of 50 patients over the age of 80 years, presenting with ischaemic rest pain, ulceration or gangrene of the lower extremity. Six patients were treated conservatively, four of whom died during the same admission. Only two patients proved suitable for transluminal angioplasty as the sole curative procedure. Twelve patients (24%) underwent primary amputation with a perioperative mortality of 3/12 (25%). Five patients (10%) had an iliac bypass procedure, and 25 patients (50%) were considered suitable for infrainguinal bypass. Of the latter group 14 had femoropopliteal bypasses, and 11 had femorodistal bypasses with an overall perioperative mortality of 3/25 (12%). Mortality at 6 months was high (33%) and was similar in both the grafted and amputation groups. Patients having reconstruction fared well in terms of independent mobility, use of long-term care, and length of hospital stay. Patients over 80 years of age with critical ischaemia should not be denied the opportunity of vascular reconstruction.

Microvascular pedal bypass for salvage of the severely ischemic limb.

Bypass to the pedal arteries was performed with use of the operating microscope and standard microsurgical technique in 37 patients with severe, chronic ischemia of a lower extremity. Twenty-one patients (57%) had three or more cardiovascular risk factors, and 22 (59%) had diabetes. Preoperative arteriography identified a pedal artery suitable for bypass in all but one patient. The greater or lesser saphenous vein was used in all patients, most frequently as a nonreversed, translocated vein graft. An arm vein was used as part of a composite graft in only one patient. No early deaths occurred, and only one patient had a perioperative myocardial infarction. Although five grafts occluded within 30 days, four were successfully revised, and 36 patients had a patent graft at the time of dismissal from the hospital. At 1 year, the primary graft patency rate (patency without revision) was 60.8%, and the secondary patency rate was 68.8%. One early and six late amputations were performed; the cumulative 1-year limb salvage rate was 82.4%. Grafts with an intraoperative flow rate of 50 ml/min or more had a better patency rate than those with a lower flow rate. The presence of diabetes did not adversely affect long-term patency. Of the 34 patients who were alive at the time of this report, 27 (79%) had a functional foot that allowed ambulation, had no rest pain, and had no substantial loss of tissue. Pedal bypass should be considered for critical, chronic ischemia, even if the patient has an increased surgical risk and advanced distal atherosclerotic disease.

Prediction of the effect of training on the walking tolerance in patients with intermittent claudication.

The possibility of predicting the effect of training on the walking tolerance in intermittent claudication has been studied. After three months of supervised training in 54 patients, the maximal walking distance (MWD) increased by 67% and the painfree walking distance (PFD) by 91%. The analysis of the relation between tested background variables and the effect of training showed covariation only in 14% of the increase in MWD and in 19% of the increase in PFD. The possibility of predicting the effect of training on the walking tolerance in the individual patient with intermittent claudication is limited.