Cardiovascular outcome stratification using the ankle-brachial pressure index.

OBJECTIVES: To investigate, in patients with peripheral arterial disease (PAD), the association between the level of the Ankle-Brachial Pressure Index (ABPI) at time of diagnosis and clinical outcome. METHODS: The data set of the Limburg PAOD Longitudinal Study (n=3649, mean follow-up time 7.2 years) was analyzed for this purpose. The ABPI was measured by trained personnel using handheld Doppler devices. Subjects were classified into 6 baseline ABPI categories ranging from ABPI > or = 1.10 ('certainly normal') to ABPI<0.50 ('seriously reduced'). Outcome measures were progressive limb ischaemia, cardiovascular morbidity and cardiovascular mortality. Cox proportional hazard models were used to investigate the associations (including hazard ratio's, HR) between different ABPI categories and outcome events. RESULTS: As compared to persons with an ABPI > or = 1.10 ('certainly normal'), patients with a baseline ABPI <1.00 (categories 'probably normal' and worse) were at high risk to develop progressive limb ischaemia (HR 3.3 - 9.0). Additionally, patients with a baseline ABPI <0.90 (categories 'moderately reduced' and worse) were at higher risk to experience a non-fatal cardiovascular disease (HR 1.5 - 1.7). Moreover, patients with a baseline ABPI <0.70 ('clearly' and 'seriously' reduced ABPI) were at high risk to die from a cardiovascular or other cause (HR 2.3). CONCLUSION: The ABPI can be helpful in identifying subjects at high risk for a poor cardiovascular outcome, in whom strict cardiovascular risk management would be appropriate.

A multidisciplinary guideline for the acute phase of stroke: barriers perceived by Dutch neurologists.

RATIONALE, AIMS AND OBJECTIVES: Guidelines for stroke management should improve quality of care. Dissemination of guidelines, however, does not guarantee guideline adherence. The aim of this paper is to investigate barriers for guideline adherence to bring about suggestions for possible implementation strategies. METHOD: Questionnaire survey among all Dutch neurologists working on neurology wards in general hospitals during the year 2000 in The Netherlands. RESULTS: The neurologists expressed a high degree of agreement with the diagnostic and preventive recommendations, but expressed doubts with regard to the therapeutic recommendations, especially for the recombinant tissue plasminogen activator therapy. In general, barriers at the organizational and the multidisciplinary team level were most prominent. CONCLUSIONS: Active implementation of the guidelines seems necessary. Implementation strategies should be focused on the different sources of barriers: the caregiver, the patient and the organization of care.

Peripheral arterial occlusive disease: prognostic value of signs, symptoms, and the ankle-brachial pressure index.

OBJECTIVES: To determine whether different levels of the ankle-brachial pressure index (ABPI) are associated with an increased risk for progressive limb ischemia, nonfatal and fatal cardiovascular events. To investigate the prognostic value of signs and symptoms associated with peripheral arterial occlusive disease (PAOD). DESIGN: Prospective follow-up study. SETTING: Eighteen general practice centers in the Netherlands. PARTICIPANTS: Three thousand six hundred forty-nine participants (53% female) with a mean age of 59 years (range: 40-78 years). MAIN OUTCOME MEASURES: Progressive limb ischemia, cardiovascular morbidity and mortality. RESULTS: At baseline, 458 participants had PAOD, defined as an ABPI < 0.95. Among these, 148 (32.2%) had an ABPI < 0.70. Cox proportional hazards models showed that after a mean follow-up period of 7.2 years, PAOD patients with an ABPI < 0.70 were at higher risk for cardiovascular death, compared with participants with a moderately reduced ABPI (< 0.95 - > or = 0.70): HR 2.3 versus 1.2. Older age, complaints of intermittent claudication, abnormal pedal pulses, elevated blood pressure, and coexisting cardiovascular disease at baseline were also significant independent prognostic factors for one or more of the adverse outcome events in these patients. CONCLUSION: The ABPI is inversely associated with cardiovascular mortality in PAOD patients. A low ABPI is an independent predictor for cardiovascular mortality in PAOD patients.