An unfavorable dietary pattern is associated with symptomatic peripheral artery disease.

BACKGROUND AND AIMS: Diet has an essential role in primary and secondary cardiovascular prevention by modulating various cardiovascular risk factors. The need to have easily useable tools seems essential to facilitate the daily practice of clinicians in order to propose the most optimal management of their patients' diet. The aim of this study was to compare the diet assessed with a simple food frequency questionnaire (FFQ) between patients with symptomatic peripheral artery disease (PAD) and healthy subjects. MATERIALS AND RESULTS: In this ancillary study (ELECTRO-PAD study), we included symptomatic PAD patients and healthy participants. All participants filled a FFQ previously validated called Cardiovascular-Dietary-Questionnaire 2 (CDQ-2). CDQ-2 allows the calculation of different scores: global food score, saturated fatty acids score (SFA), unsaturated fatty acids score (UFA), fruit and vegetable score. The higher the score, the better the diet. We compared the different scores between PAD patients and healthy participants. We included 37 PAD patients and 40 healthy subjects. Mean global score was significantly lower in PAD patients compared to the healthy participants (5.35 ± 7.65 vs 10.60 ± 5.81; p = 0.0011). Similarly, the sub-scores concerning unsaturated fatty acids and fruits-vegetables were significantly lower in PAD patients (p < 0.010). Only the sub-score concerning saturated fatty acids was not significantly different (p = 0.8803) between PAD patients and healthy participants. CONCLUSION: CDQ-2 highlights that PAD patients have an unfavorable diet compared with healthy participants. CDQ-2 is a tool of interest to help the clinicians for dietary advice of PAD patients.

Test-retest Reliability and Minimal Detectable Change in Exercise Oximetry in Claudicants.

BACKGROUND: Exercise transcutaneous oxygen pressure measurement (Exercise-TcPO2) can be used to diagnose Lower Extremity Artery Disease (LEAD) and allows the quantification of limb ischemia during exercise on treadmill. Exercise-TcPO2 test-retest reliability in patients with LEAD and severe walking impairment is unknown. The aim of this study was to evaluate the test-retest reliability, standard error of measurement (SEM), and Minimal Detectable Change (MDC) of exercise-TcPO2 in patients with claudication. METHODS: Data were collected from patients that performed 2 treadmill tests within a 1-month interval. Delta from Rest of Oxygen Pressure (DROP) values were measured at both buttocks (proximal) and both calves (distal). Test-retest reproducibility was assessed by recording transcutaneous oximetry measurements twice and expressed as SEM and intra-class correlation coefficients. MDC was calculated using the formula MDC = SEM x 1.96 x √ 2. RESULTS: Twenty eight LEAD patients (61 ± 9 years old) were included. Intra-class correlation coefficients were 0.66 [0.50, 0.79] and 0.65 [0.49, 0.79] for the proximal and distal levels, respectively. The SEM of DROP at the proximal and distal levels were 7 [6, 9] mm Hg and 9 [8, 11] mm Hg, respectively. The SEM for all (proximal and distal) DROP values was 8 [7, 10] mm Hg and the MDC of DROP was 23 mm Hg. CONCLUSIONS: Exercise-TcPO2 with measurement of DROP values has a moderate test-retest reliability in LEAD patients with a maximal walking distance ≤ 300m. For an individual, an improvement or deterioration in DROP of ≥ 23 mm Hg after an intervention would be required to be 95% confident that the change is significant. It should be considered in evaluating the impact of treatment in patients with claudication.

Use of the Walking Impairment Questionnaire and Walking Estimated-Limitation Calculated by History questionnaire to detect maximal walking distance equal to or lower than 250 m in patients with lower extremity arterial disease.

Objective: The objective was to assess the accuracy and optimal threshold of the Walking Impairment Questionnaire (WIQ) and the Walking Estimated-Limitation Calculated by History (WELCH) questionnaire in identifying patients with a maximal walking distance (MWD) below or equal to 250 m. Methods: This retrospective study screened 388 consecutive patients with suspected symptomatic lower extremity arterial disease (LEAD). Collected data included the patient's history, resting ankle-brachial index, WIQ, and WELCH. MWD was assessed with a treadmill test at 2 mph (3.2 km/h) with a 10% grade. An optimized threshold for detection of MWD ≤ 250 m was determined for each questionnaire via receiver operating characteristic (ROC) curves. Subsequently, multivariate analysis was performed to build a new simple score to detect MWD ≤ 250 m. Results: The study included 297 patients (63 ± 10 years old). With a threshold of ≤ 64%, the WIQ predicted MWD ≤ 250 m with an accuracy of 71.4% (66.2, 76.5%). With a threshold of ≤ 22, the WELCH predicted a treadmill walking distance of ≤ 250 m with an accuracy of 68.7% (63.4, 74.0%). A new score with only four "yes or no" questions had an accuracy of 71.4% (66.3, 76.6%). Items on this new score consisted of the level of difficulty of walking 1 block, declared maximum walking distance, usual walking speed, and maximum duration of slow walking. Conclusion: A WIQ score ≤ 64% and a WELCH score ≤ 22 help to predict a walking distance of ≤ 250 m in a treadmill test at 2 mph (3.2 km/h) with a 10% grade. A 4-item score could be used for rapid evaluation of walking distance among patients with LEAD, but the validity of this 4-item score requires further confirmation studies.

A Multicenter, Investigator-Blinded, Randomized Controlled Trial to Assess the Efficacy of Calf Neuromuscular Electrical Stimulation Program on Walking Performance in Peripheral Artery Disease: The ELECTRO-PAD Study Protocol.

This paper describes a currently on-going multicenter, randomized controlled trial designed to assess the efficacy of calf neuromuscular electrical stimulation (NMES) on changes in maximal walking distance in people with lower extremity peripheral artery disease (PAD), compared with a non-intervention control-group. This study (NCT03795103) encompasses five participating centers in France. PAD participants with a predominant claudication at the calf level and a maximal treadmill walking distance ≤300 m are randomized into one of the two groups: NMES group or Control group. The NMES program consists of a 12-week program of electrical stimulations at the calf-muscle level. The primary outcome of the study is the change in maximal treadmill walking distance at 12 weeks. Main secondary outcomes include changes in the pain-free treadmill walking distance; 6 min total walking distance; global positioning system (GPS)-measured outdoor walking capacity; daily physical activity level by accelerometry; self-reported walking impairment; self-reported quality of life; ankle-brachial index; and skin microvascular function, both at the forearm and calf levels. Recruitment started in September 2019 and data collection is expected to end in November 2022.

Simplification of ankle-brachial-index measurement using Doppler-waveform classification in symptomatic patients suspected of lower extremity artery disease.

Objectives: Ankle-brachial index (ABI) is commonly used for screening lower extremity peripheral artery disease (PAD) according to the international guidelines. Arterial Doppler waveform recordings is a tool to diagnose and assess PAD severity. We hypothesized that ABI measurement could be simplified by measuring only the pressure where the best arterial flow is recorded. The aim of this study was to evaluate the concordance between ABI performed according to the American Heart Association guidelines (AHA-ABI) and ABI measured according to best arterial waveform (FLOW-ABI). Design: This was a monocentric cross-sectional study. Methods: We included patients with exertional limb symptoms suspected of PAD. Arterial Doppler waveforms and ABI were acquired on both lower extremities at the pedis and tibial posterior arteries. Each arterial waveform was classified using the Saint-Bonnet classification. Concordances were analyzed with the kappa coefficient (confidence interval 95%). Exercise PAD study was registered n° NCT03186391. Results: In total, one hundred and eighty-eight patients (62+/-12 years and 26.8+/-4.5 kg/m2) with exertional limb symptoms were included from May 2016 to June 2019. On each extremity, FLOW-ABI had excellent concordance for the diagnosis of PAD with the AHA-ABI with a kappa of 0.95 (95% CI: 0.90, 0.99) in the right extremity and 0.91 (95% CI: 0.86, 0.97) in the left extremity. Conclusion: There is almost perfect concordance between AHA-ABI and FLOW-ABI. Thus, ABI can be simplified into five pressure measurements instead of seven in patient suspected of PAD with exertional limb symptoms. The question remains in patients with chronic limb ischemia.

Agreement Between StepWatch3 and ActiGraph wGT3X+ for Measuring Step-Based Metrics in People With Peripheral Artery Disease.

The authors investigated the agreement between StepWatch3™ (SW3) and ActiGraph™ wGT3X+ monitors for measuring step-based metrics in patients with peripheral artery disease and older adults. In 23 patients with peripheral artery disease and 38 older participants, the authors compared the metrics obtained during an outdoor (400-m track) walking session (step count) and a 7-day free-living period (step count and 60/30/5/1-min maximal or peak step accumulation) using the SW3 (ankle) and the wGT3X+ (hip) with the low-frequency extension filter enabled (wGT3X+/LFE) or not (wGT3X+/N). During outdoor walking session, agreement was high, particularly for wGT3X+/LFE: correlations ≥.98, median absolute percentage errors <1%, and significant equivalence using a ± 15% equivalence zone or narrower. In free living, no wGT3X+ method was equivalent to SW3 for step count. The wGT3X+/LFE was equivalent to SW3 regarding all step accumulation metrics using a ± 20% equivalence zone or narrower, with median absolute percentage errors <11%. The wGT3X+/LFE method is the best option for comparisons with SW3 in peripheral artery disease and older adults.

Combination of Exercise Testing Criteria to Diagnose Lower Extremity Peripheral Artery Disease.

Objectives: Nothing is known about the interest of the combination of exercise tests to diagnose Lower-extremity Peripheral Artery Disease (LEPAD). The aim of this study was to assess if combining exercise testing criteria [post-exercise Ankle-Brachial Index (ABI) + exercise-oximetry (exercise-TcPO2)] improves the detection of lower limbs arterial stenoses as compared with post-exercise ABI using American Heart Association (AHA) criteria, or exercise-TcPO2 alone. Material and Methods: In a prospective monocentric study, consecutive patients with exertional-limb pain and normal resting-ABI referred to our vascular center (Rennes, France) were assessed from May 2016 to February 2018. All included patients had a computed tomography angiography (CTA), a resting-ABI, a post-exercise ABI and an exercise-TcPO2. AHA post-exercise criteria, new validated post-exercise criteria (post-exercise ABI decrease ≥18.5%, post-exercise ABI decrease <0.90), and Delta from Rest of Oxygen Pressure (Total-DROP) ≤-15mmHg (criterion for exercise-TcPO2) were used to diagnose arterial stenoses ≥50%. For the different combinations of exercise testing criteria, sensitivity or specificity or accuracies were compared with McNemar's test. Results: Fifty-six patients (mean age 62 ± 11 years old and 84% men) were included. The sensitivity of the combination of exercise testing criteria (post-exercise ABI decrease ≥18.5%, or post-exercise ABI decrease <0.90 or a Total-DROP ≤-15mmHg) was significantly higher (sensitivity = 81% [95% CI, 71-92]) than using only one exercise test (post-exercise AHA criteria (sensitivity = 57% [43-70]) or exercise-TcPO2 alone (sensitivity = 59% [45-72]). Conclusions: Combination of post-exercise ABI with Exercise-TcPO2 criteria shows better sensitivity to diagnose arterial stenoses compared with the AHA post-exercise criteria alone or Exercise-TcPO2 criteria used alone. A trend of a better accuracy of this combined strategy was observed but an external validation should be performed to confirm this diagnostic strategy.

Corrigendum: Arterial Doppler Waveforms Are Independently Associated With Maximal Walking Distance in Suspected Peripheral Artery Disease Patients.

[This corrects the article DOI: 10.3389/fcvm.2021.608008.].

Arterial Doppler Waveforms Are Independently Associated With Maximal Walking Distance in Suspected Peripheral Artery Disease Patients.

Objective: Arterial Doppler waveform recordings are commonly used to assess lower extremity arterial disease (LEAD) severity. However, little is known about the relationship between arterial Doppler waveform profiles and patients' walking capacity. The purpose of this study was to assess whether arterial Doppler waveforms are independently associated with maximal walking distance (MWD) in patients experiencing exertional limb symptoms. Materials and Methods: This cross-sectional study included suspected LEAD patients experiencing exertional limb symptoms. In both lower extremities, arterial Doppler waveforms and ankle-brachial index (ABI) values were obtained from the pedis and tibial posterior arteries. Each arterial flow measurement was ranked using the Saint-Bonnet classification system. Treadmill stress testing (3.2 km/h, 10% slope) coupled with exercise oximetry (Exercise-TcPO2) were used to determine MWD. Delta from rest oxygen pressure (DROP) was calculated. Following treadmill stress testing, post-exercise ABI values were recorded. Univariate and multivariate analyses were used to determine the clinical variables associated with MWD. Results: 186 patients experiencing exertional limb symptoms (62 ± 12 years and 26.8 ± 4.5 kg/m2) were included between May 2016 and June 2019. Median [25th; 75th] treadmill MWD was 235 [125;500]m. Better arterial Doppler waveforms were associated with better walking distance (p = 0.0012). Whereas, median MWD was 524 [185;525]m in the group that yielded the best Doppler waveforms, it was 182 [125,305]m in the group with the poorest Doppler waveforms (p = 0.0012). MWD was significantly better (p = 0.006) in the patients with the best ABIs. However, arterial Doppler waveforms alone were significantly associated with MWD (p = 0.0009) in the multivariate model. When exercise variables (post-exercise ABI or DROP) were incorporated into the multivariate model, these were the only variables to be associated with MWD. Conclusion: Of the various clinical parameters at rest, Doppler flow waveform profiles were associated with MWD in suspected LEAD patients. A stronger link was however found between exercise variables and MWD.

"Should I stay or should I go now?" Recovery time effect on walking capacity in symptomatic peripheral artery disease.

The objective of the study was to investigate the effect of recovery time on walking capacity (WC) throughout repeated maximal walking bouts in symptomatic lower-extremity peripheral artery disease (PAD). The effect of recovery time on WC (maximal walking time) was determined in 21 participants with PAD in three experimental conditions [recovery time from 0.5 to 9.5 min + a self-selected recovery time (SSRT)]: 1) 11 repeated sequences of two treadmill walking bouts (TW-ISO); 2) a single sequence of seven treadmill walking bouts (TW-CONS); 3) a single sequence of seven outdoor walking bouts (OW-CONS). Exercise transcutaneous oxygen pressure changes were continuously recorded as an indirect measure of ischemia. An individual recovery time (IRT) beyond which WC did not substantially increased was determined in participants with a logarithmic fit. At the group level, mixed models showed a significant effect (P < 0.001) of recovery time on WC restoration. At the participant level, strong logarithmic relationships were found (median significant R2 ≥ 0.78). The median SSRT corresponded to a median work-to-rest ratio >1:1 (i.e., a lower recovery time in view of the corresponding previous walking time) and was related to unrecovered ischemia and a WC restoration level of <80%. A median work-to-rest ratio of ≤1:2 allowed full recovery of ischemia and full restoration of WC. The IRT ratio was between 1:1 and 1:2 and corresponded to the start of recovery from ischemia. Recovery time affects the restoration level of WC during repeated maximal walking bouts in symptomatic PAD. Meaningful variations in WC restoration were related to specific levels of work-to-rest ratios.NEW & NOTEWORTHY This study demonstrated that there is a significant and mostly logarithmic effect of recovery time on walking capacity in people with symptomatic PAD. This study revealed that a median work-to-rest ratio >1:1 leads to the resumption of walking with unrecovered ischemia and precludes the restoration of full walking capacity, whereas a work-to-rest ratio ≤1:2 allowed walking capacity to fully be restored.

Comparison of Activity Monitors Accuracy in Assessing Intermittent Outdoor Walking.

PURPOSE: This study aimed to determine and compare the accuracy of different activity monitors in assessing intermittent outdoor walking in both healthy and clinical populations through the development and validation of processing methodologies. METHODS: In study 1, an automated algorithm was implemented and tested for the detection of short (≤1 min) walking and stopping bouts during prescribed walking protocols performed by healthy subjects in environments with low and high levels of obstruction. The following parameters obtained from activity monitors were tested, with different recording epochs0.1s/0.033s/1s/3s/10s and wearing locationsscapula/hip/wrist/ankle: GlobalSat DG100 (GS) and Qstarz BT-Q1000XT/-Q1000eX (QS) speed; ActiGraph wGT3X+ (AG) vector magnitude (VM) raw data, VM counts, and steps; and StepWatch3 (SW) steps. Furthermore, linear mixed models were developed to estimate walking speeds and distances from the monitors parameters. Study 2 validated the performance of the activity monitors and processing methodologies in a clinical population showing profile of intermittent walking due to functional limitations during outdoor walking sessions. RESULTS: In study 1, GS1s, scapula, QS1s, scapula/wrist speed, and AG0.033s, hip VM raw data provided the highest bout detection rates (>96.7%) and the lowest root mean square errors in speed (≤0.4 km·h-1) and distance (<18 m) estimation. Using SW3s, ankle steps, the root mean square error for walking/stopping duration estimation reached 13.6 min using proprietary software and 0.98 min using our algorithm (total recording duration, 282 min). In study 2, using AG0.033s, hip VM raw data, the bout detection rate (95% confidence interval) reached 100% (99%-100%), and the mean (SD) absolute percentage errors in speed and distance estimation were 9% (6.6%) and 12.5% (7.9%), respectively. CONCLUSIONS: GPS receivers and AG demonstrated high performance in assessing intermittent outdoor walking in both healthy and clinical populations.

A systematic review of lower extremity electrical stimulation for treatment of walking impairment in peripheral artery disease.

Lower extremity peripheral artery disease (PAD) induces an ischemic pain in the lower limbs and leads to walking impairment. Electrical stimulation has been used in patients with PAD, but no systematic review has been proposed to address the efficacy of the technique as a treatment for walking impairment in PAD. A systematic search was performed to identify trials focused on electrical stimulation for the treatment of walking impairment in patients with PAD in the Cochrane Central Register, PubMed, Embase, and the Web of Science. Studies were included where the primary outcomes were pain-free walking distance and/or maximal walking distance. When appropriate, eligible studies were independently assessed for quality using the Cochrane Collaboration's tool for assessing risk of bias. Five studies eligible for inclusion were identified, of which only two were randomized controlled studies. Trial heterogeneity prevented the use of the GRADE system and the implementation of a meta-analysis. Three types of electrical stimulation have been used: neuromuscular electrical stimulation (NMES, n = 3), transcutaneous electrical stimulation (n = 1), and functional electrical stimulation (n = 1). The two available randomized controlled studies reported a significant improvement in maximal walking distance (+40 m/+34% and +39 m/+35%, respectively) following a program of NMES. Owing to the low number of eligible studies, small sample size, and the risk of bias, no clear clinical indication can be drawn regarding the efficacy of electrical stimulation for the management of impaired walking function in patients with PAD. Future high-quality studies are required to define objectively the effect of electrical stimulation on walking capacity.

Using wearable monitors to assess daily walking limitations induced by ischemic pain in peripheral artery disease.

PURPOSE: To develop, assess the feasibility of, and determine the clinical validity of an event-based analysis method using wearable monitors to quantify walking pain manifestations (WPMs) and stops induced by walking pain (SIWPs) during daily life walking in people with peripheral artery disease (PAD). METHODS: The following two conditions were studied: a standardized outdoor walking session (OWS) and a seven-day free-living measurement (FLM) period. The PAD participants (n = 23) wore an accelerometer and a watch. They were asked to press the event marker button on the watch to indicate events related to WPMs and SIWPs. To assess the clinical validity of the method, the computed pain-free walking time (PFWT) and maximal walking time (MWT) were compared with the PFWT and MWT assessed using standard treadmill walking protocols, respectively. RESULTS: Following OWSs, the PFWT[OWS] and MWT[OWS] were significantly correlated with the PFWT[Strandness] (r = .955, P < .001) and MWT[Strandness] (r = .821, P < .001), respectively. During the FLM, PAD participants experienced only 2 WPMs/day and 1 SIWP/day, although severely limited on the treadmill and during the OWS. The average WPMs/day were moderately correlated with the PFWT[Strandness] (r = -.54, P = .016). The PFWT[FLM] was on average 12 times longer than the PFWT[Strandness] . Interestingly, the intensity of the walking bouts as assessed by the accelerometer counts during the FLM was significantly lower than that during the OWS (45 ± 15 vs 66 ± 20 counts/s, P < .001). CONCLUSION: This new method offers opportunities for studies investigating the experience of living with PAD and the assessment of daily life walking capacity for both diagnostic and therapeutic purposes.

Atherosclerosis knowledge - diagnosis and management in primary care.

BACKGROUND: Atherosclerosis is the leading cause of death worldwide. Ischaemic stroke, coronary heart disease (CHD), and peripheral artery disease (PAD) are different forms of atherosclerotic disease. Knowledge among general practitioners (GPs) about the three main locations of atherosclerosis has never been conjointly explored in a single study. The aim of this survey was to compare GP awareness on the subject of these three different clinical presentations. MATERIALS AND METHODS: Between February 2017 and May 2017, a self-administered survey was emailed to 18,500 French GPs. The questionnaire comprised three clinical cases involving cases of transient ischaemic attack (TIA), stable angina (SA), and intermittent claudication (IC). Each case was explored with seven similar questions. The primary endpoint was the number of physicians who correctly answered five questions for each clinical case. RESULTS: The survey was completed by 1,724 GPs. TIA knowledge (48.2 %) was significantly higher than the SA knowledge (3.0 %) and IC knowledge (0.4 %). We also found a significant difference between SA knowledge and IC knowledge. The percentages of GPs who correctly diagnosed TIA, SA or IC were 96.7, 89.7, and 96.5 %, respectively (p < 0.0001). Poor knowledge ratings for all three locations were observed for inadequate prescription of supplementary investigations and treatments. CONCLUSIONS: Our study demonstrates that GPs' knowledge about atherosclerosis disease varies significantly depending on disease location. GPs diagnose correctly but need to be backed up for their management of patients with atherosclerosis.

How to become proficient in performance of the resting ankle-brachial index: Results of the first randomized controlled trial.

The resting ankle-brachial index (ABI) is a first-line test to diagnose peripheral artery disease (PAD). No randomized controlled trial (RCT) has yet been conducted to determine the best teaching method to become proficient in the ABI procedure. We conducted a monocentric RCT to determine whether didactic learning alone or didactic learning combined with experiential learning improved proficiency in the ABI procedure. Medical students ( n = 30) received didactic learning, including (i) a presentation of the ABI guidelines and (ii) a video demonstration. Each student was then randomized into two groups ('no experiential learning group' and 'experiential learning group'). An initial evaluation was performed after the didactic learning and a final evaluation at the end of the intervention. A student was considered to be proficient when he or she performed a correct ABI procedure on a healthy individual and a patient. The correct procedure corresponds to (i) following guidelines and (ii) a difference in ABI measurement between a vascular specialist and a student of ≤ 0.15. No student was proficient at the initial evaluation. At the final evaluation, in the didactic learning group, the number of proficient students was not improved compared with the initial evaluation (0/10 vs 1/10). In the experiential learning group, the number of proficient students was significantly improved (0/20 vs 11/20; p < 0.05). At the final evaluation, there was a significant difference between the number of proficient students depending on their learning group. In conclusion, didactic learning alone is insufficient to gain proficiency in the ABI procedure. Combining didactic learning with experiential learning significantly improved the students' proficiency.

A minimal resting time of 25 min is needed before measuring stabilized blood pressure in subjects addressed for vascular investigations.

Blood pressure (BP) measurement is a central element in clinical practice. According to international recommendations 3 to 5 minutes of resting is needed before blood pressure measurement. Surprisingly, no study has modelled the time course of BP decrease and the minimum resting-time before BP measurement. A cross-sectional bicentric observational study was performed including outpatients addressed for vascular examination. Using two automatic BP monitors we recorded the blood pressure every minute during 11 consecutive minutes. The data was analyzed by non-linear mixed effect regression. Systolic (SBP) and diastolic BPs were studied and we tested the effect of covariates on its evolution through log-likelihood ratio tests. We included 199 patients (66+/-13years old). SBP was found to decrease exponentially. Simulations based on the final model show that only half the population reaches a stabilized SBP (defined as SBP + 5 mmHg) after 5 min of resting-time while it takes 25 min to ensure 90% of the population has a stabilized SBP. In conclusion, our results and simulations suggest that 5 minutes are not enough to achieve a stabilized SBP in most patients and at least 25 minutes are required. This questions whether the diagnosis of hypertension can be reliably made during routine visits in general practitioners' offices.