外周动脉疾病与高血压

外周动脉疾病是一种系统性动脉硬化疾病,它和颈动脉、冠状动脉及其他血管床的动脉粥样硬化有着相同的主要危险因素.高血压作为其中主要的危险因素和外周动脉疾病有着密切的联系.现就二者的关系作一简单综述.     

Office Management of Peripheral Arterial Disease

Patients with peripheral arterial disease are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from coronary artery disease. Smoking should be stopped, and hypertension, diabetes mellitus, and dyslipidemia should be treated. Statins reduce the incidence of intermittent claudication and increase exercise duration until the onset of intermittent claudication in patients with peripheral arterial disease and hypercholesterolemia. Antiplatelet drugs, such as aspirin or clopidogrel, angiotensin-converting enzyme inhibitors, and statins, should be given to all patients with peripheral arterial disease. Beta-blockers should be given if coronary artery disease is present. Exercise rehabilitation programs and cilostazol improve exercise time until the onset of intermittent claudication. Indications for lower-extremity angioplasty, preferably with stenting, or bypass surgery are incapacitating claudication interfering with work or lifestyle in patients; limb salvage in patients with limb-threatening ischemia as manifested by rest pain, nonhealing ulcers, infection, or gangrene; and vasculogenic impotence.     

Prevalence and Clinical Characteristics of Peripheral Arterial Disease in the Study Population Hermex

INTRODUCTION AND OBJECTIVES: To estimate the prevalence of peripheral arterial disease as measured on ankle-brachial index and evaluate the associated risk, clinical, and diagnostic factors. METHODS: Cross-sectional study conducted in a random population-based sample of 2833 individuals aged 25 to 79 years from Don Benito health area (Badajoz). Peripheral arterial disease was considered for ankle-brachial index<0.90. To identify symptomatic disease we used the Edinburgh questionnaire. The current screening recommendations, changes to other categories of estimated coronary risk associated with index measurements, and the association with risk factors were assessed. RESULTS: The prevalence of peripheral arterial disease was 3.7% (95% confidence interval, 3.0%-4.5%), 5.0% (3.9%-6.3%) in men and 2.6% (1.8%-3.5%) in women (P=.001). The cumulative prevalence in those aged 50, 60 and 70 years were 6.2%, 9.1%, and 13.1% respectively. The disease was symptomatic in 13.3% (6.8%-19.8%) of cases and 29.6% of asymptomatic patients were not detected as recommended for high-risk groups. The use of ankle-brachial index increased the number of individuals with high coronary risk by 32.7%. Peripheral arterial disease was positively associated with age, smoking, hypercholesterolemia, sedentary lifestyle, microalbuminuria and history of cardiovascular disease, and negatively with alcohol consumption. CONCLUSIONS: The use of ankle-brachial index for peripheral arterial disease diagnosis is advisable because of the low prevalence of symptomatic cases and the associated change in estimated coronary risk. Screening groups should be adapted to the Spanish population. Smoking and hypercholesterolemia are major associated risk factors.     

Management of Infrapopliteal Peripheral Arterial Occlusive Disease

The management of infrapopliteal peripheral arterial occlusive disease (PAD) is challenging. For patients with asymptomatic disease or claudication, exercise and optimal medical management, including antiplatelet agents, blood pressure control, statin therapy and tight glucose control for patients with diabetes mellitus, are the mainstays of therapy. However, patients with isolated tibial artery occlusive disease often have diabetes mellitus or renal insufficiency and present with critical limb ischemia (CLI). CLI is advanced occlusive disease marked by the development of rest pain, ischemic ulceration, or gangrene and is associated with a high mortality rate. Limb salvage requires an intervention in cases of CLI, but careful operative planning is required as patients often have multilevel disease and limited options for revascularization. A surgical bypass with a vein graft remains the best treatment for infrapopliteal PAD, especially in patients with a life expectancy of over 2 years. Balloon angioplasty can play an important role in limb salvage, especially for patients lacking adequate vein for bypass, at high operative risk, or with a life expectancy of less than 2 years. However, a lack of rigorous trials has left unanswered questions as to the efficacy of infrapopliteal angioplasty with or without stents compared to bypass surgery. As such, endovascular therapy is currently not a proven treatment for intermittent claudication. Patients who are unable to undergo a revascularization procedure for infrapopliteal CLI have few options besides amputation or palliation. New therapies, such as drug-eluting stents, drug-coated balloons, and stem cell therapy are under development, but their efficacy and effectiveness remain unproven.     

Process of Care and Outcomes in Patients with Peripheral Arterial Disease

Background We investigated the association of process of care measures with adverse limb and systemic events in patients with peripheral arterial disease (PAD). Methods We conducted a retrospective cohort study of patients with PAD, as defined by an ankle-brachial index (ABI) <0.9. The index date was defined as the date, during 1995 to 1998, when the patient was seen in the Michael E. DeBakey VA Medical Center noninvasive vascular laboratory and found to have PAD. We conducted a chart review for process of care variables starting 3 years before the index date and ending at the time of the first event or the final visit (December 31, 2001), whichever occurred first. We examined the association between PAD process of care measures, including risk factor control, and prescribing of medication, with time of the patient’s first major limb event or death. Results Of the 796 patients (mean age, 65 ± 9.9 years), 230 (28.9% experienced an adverse limb event (136 lower-extremity bypass, 94 lower-extremity amputation), and 354 (44.5%) died. Of the patients who died, 247 died without a preceding limb event. Glucose control was protective against death or a limb event with a hazard ratio (HR) of 0.74 (95% confidence limits [CL] 0.60, 0.91, P = 0.004). African Americans were at 2.8 (95% CL 1.7, 4.5) times the risk of Whites or Hispanics for an adverse limb event. However, this risk was no longer significant if their glucose was controlled. For process measures, the dispensing of PAD specific medication (HR 1.4, 95% CL 1.1, 1.7) was associated an increased risk for an adverse outcome. Conclusions Our data suggest that glucose control is key to reducing the risk for adverse outcomes, particularly limb events in African Americans. Certain process of care measures, as markers of disease severity and disease management, are associated with poor outcomes in patients with PAD. Further work is needed to determine the role of early disease intervention to reduce poor outcomes in patients with PAD. This work was conducted by Dr. Collins while at the Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey VA Medical Center, and Section of Health Services Research, Baylor College of Medicine, Houston, Texas.     

外周动脉粥样硬化与冠心病相关性研究

研究证实,外周动脉粥样硬化与冠心病的发生发展关系密切。颈动脉内膜-中层厚度、踝-肱动脉压力指数、肱动脉依赖性血流介导的血管舒张反应、脉压、动脉弹性功能的测定可以作为非侵入性的检查方法,在一定程度上预测冠状动脉疾病的发生和发展。     

慢性肾脏病与外周动脉疾病研究进展

慢性肾脏病患者外周动脉疾病发生率远高于普通人群,且和患者的心血管事件的危险性及病死率相关。现简述近年来有关慢性肾脏病患者中外周动脉疾病的流行病学、危险因素、临床表现的特点,并提出适合其特点的诊断和治疗方法。     

Subclinical Peripheral Arterial Disease in Renal Transplantation

BackgroundPeripheral arterial disease (PAD) is a common finding in patients at various stages of chronic kidney disease; however, there has only been a limited amount of data that have been published regarding the prevalence and associated risk factors of subclinical PAD in renal transplant recipients.MethodsThe authors cross sectionally investigated the prevalence of PAD using ankle-brachial index (ABi) in 304 renal transplant recipients with no previous diagnosis of PAD. Patients were considered to have subclinical PAD when ABI < 0.9. The authors also determined the associated risk factors for subclinical PAD.ResultsThe mean age of the 304 patients was 53 years, and 30 patients (9.9%) had a history of atherosclerotic event (including past cardiovascular and cerebrovascular events). Twenty-five of the 304 patients (8%) had ABI < 0.9 and 1 had (0.3%) ABI > 1.3. Compared to patients with normal ABI, a history of atherosclerotic events is the only independent risk factor for patients with subclinical PAD (P = 0.0468).Conclusionssubclinical PAD is an inadvertent issue in renal transplant patients, especially those with a history of atherosclerotic events. Further research is needed on the long-term clinical impact and optimal treatment of subclinical PAD among renal transplant patients.     

Clinical Worsening During Long-Term Follow-Up in Inoperable Chronic Thromboembolic Pulmonary Hypertension

Background  

Pulmonary endarterectomy is the treatment of choice in chronic thromboembolic pulmonary hypertension (CTEPH). Modern pulmonary vasoactive medication (like endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, and prostacyclins) is used in patients with an inoperable disease and improved prognosis. We evaluate mortality and time to clinical worsening (TtCW) in inoperable CTEPH patients during long-term follow-up.