Worse blood pressure control in patients with cerebrovascular or peripheral arterial disease compared with coronary artery disease

Abstract. Mechtouff L, Touzé E, Steg PG, Ohman EM, Goto S, Hirsch AT, Röther J, Aichner FT, Weimar C, Bhatt DL, Alberts MJ, Mas J‐L, on behalf of the REACH Registry Investigators (Paris‐Descartes University; Université Paris 7; Paris, France, Duke University, Durham NC, USA, Tokai University, Isehara, Japan, University of Minnesota, Minneapolis, MN, USA, Academic Teaching Hospital Hannover Medical School, Minden, Germany, Academic Teaching Hospital Wagner‐Jauregg, Linz, Austria, University of Duisburg‐Essen, Essen, Germany, VA Boston Healthcare System, and Brigham and Women’s Hospital, Boston, MA; and Northwestern University Medical School, Chicago, IL; USA). Worse blood pressure control in patients with cerebrovascular or peripheral arterial disease compared with coronary artery disease. J Intern Med 2010; 267 :621–633. Objectives. Poor blood pressure (BP) control is common amongst patients with symptomatic atherothrombotic disease. It is unclear whether BP control and management differ across atherothrombotic disease subtypes. Methods. We analysed the baseline data of 44 984 patients with documented coronary artery disease (CAD) only (n = 30 414), cerebrovascular disease (CVD) only (n = 11 359) and peripheral arterial disease (PAD) only (n = 3211) from the international REduction of Atherothrombosis for Continued Health Registry and investigated the impact of atherothrombotic disease subtype on BP control and use of antihypertensive drugs. Results. The proportion of patients with BP controlled (<140/90 mmHg) was higher in CAD (58.1%) than in CVD (44.8%) or PAD (38.9%) patients (P < 0.001). Amongst patients with treated hypertension, CAD patients were more likely to have BP controlled than were CVD patients [odds ratio (OR) = 1.67; 95% confidence interval (CI) = 1.59–1.75] or PAD (OR = 2.30; 95% CI = 2.10–2.52). These differences were smaller in women than in men and decreased with age. Amongst treated patients, CAD patients were more likely to receive ≥3‐drug combination therapies than were CVD (OR = 1.73; 95% CI = 1.64–1.83) or PAD (OR = 1.64; 95% CI = 1.49–1.80) patients. Adjustment for age, gender, waist obesity, diabetes, education level and world region did not alter the results. Conclusions. Coronary artery disease patients are more likely than CVD or PAD patients to have BP controlled and to receive antihypertensive drugs, particularly combination therapies. Promotion of more effective BP control through combination antihypertensive therapies could improve secondary prevention and therefore prevent complications in CVD and PAD patients.     

Arm exercise testing for coronary artery disease in patients with peripheral vascular disease

We evaluated 74 peripheral vascular disease (PVD) patients (54 men, age 61 +/- 7 years and 17 women, age 63 +/- 7 years) for potential coronary heart disease (CAD) using an arm exercise test (AET) protocol. All patients performed upright two-arm cranking using discontinuous stages of 2 minutes of exercise separated by 2 minutes of rest. Exercise intensity was increased by +100 or 200 kpm (kilopond meters) with each stage. ECG was monitored continuously and blood pressure and 12-lead ECG tracings were obtained at the end of each exercise stage. All patients reached an endpoint of subjective exhaustion. Men achieved 91 +/- 14% of age-predicted heart rate at 597 +/- 167 kpm, while women achieved 86 +/- 14% of age-predicted heart rate at 335 +/- 117 kpm. Ischemic ECG responses (+AET) defined as new or additional ST depression greater than 1.0 mm X 80 ms, occurred in 35 men (65%) and 7 women (42%). Coronary angiography was performed in a subset of 22 patients (15 males and 7 females). CAD (greater than 70% stenosis) was found in 11 of 12 men and 4 of 5 women who showed positive or strongly positive AET responses (overall predictive value for AET = 88%). We conclude that arm exercise stress testing is safely performed in PVD patients who cannot complete treadmill exercise. In this limited series of PVD patients, the predictive value of a +AET response for diagnosis of CAD is similar to established values for treadmill exercise.     

The ankle—brachial index as a predictor of survival in patients with peripheral vascular disease

Objective: To determine whether the ankle—brachial index (ABI) predicts survival rates among patients with peripheral vascular disease. Design: A retrospective survival analysis of patients with abnormal ABIs who visited the authors’ blood-flow laboratory during 1987. The National Death Index was used to ascertain survival status for all patients up to January 1, 1992. Kaplan-Meier and Cox proportional hazards analyses were used to determine the relationship between increasing lower-extremity ischemia, measured by ABI, and survival time. Clinical characteristics controlled for included age, smoking history, gender, and comorbidities, as well as the presence of lower-extremity rest pain, ulcer, or gangrene. Setting: A university hospital blood-flow laboratory. Patients/participants: Four hundred twenty-two patients who had no prior history of lower-extremity vascular procedures and who had ABIs < 0.92 in 1987. Results: Cumulative survival probabilities at 52 months’ (4.3 years’) follow-up were 69% for patients who had ABIs =0.5–0.91, 62% for patients who had ABIs =0.31–0.49, and 47% for patients who had ABIs ≤0.3. In multivariate Cox proportional hazard analysis, the relative hazard of death was 1.8 (95% confidence interval =1.2–2.9, p<0.01) for the patients who had ABIs ≤0.3 compared with the patients who had ABIs 0.5–0.91. Other independent predictors of poorer survival included age >65 years (p<0.001); a diagnosis of cancer, renal failure, or chronic lung disease (p<0.001); and congestive heart failure (p<0.04). Conclusion: The ABI is a powerful tool for predicting survival in patients with peripheral vascular disease. Patients with ABIs ≤ 0.3 have significantly poorer survival than do patients with ABIs 0.31–0.91. Further study is needed to determine whether aggressive coronary risk-factor modification, a work-up for undiagnosed coronary or cerebrovascular atherosclerotic disease, or aggressive therapy for known atherosclerosis can improve survival of patients with ABIs ≤ 0.3. Presented at the annual meeting of the Society of General Internal Medicine, April 27–29, 1994, Washington, DC. Supported in part by grant number 1R01HS07184-01A2 from the Agency for Health Care Policy and Research to Northwestern University Medical School.     

The relationship of renal function to segmental vascular stiffness,ankle‐brachial index,and peripheral artery disease

The authors consecutively assessed various arterial pulse‐wave velocity (PWV) indices and ankle‐brachial index (ABI) by an automatic device (VP2000, OMRON Health Care Co. Ltd., Kyota, Japan) in outpatients with ≥ 1 cardiovascular risk. PAD was defined as ABI ≤ 0.9. Among 2309 outpatients (mean age 62.4 years), worse renal function was associated with higher brachial‐ankle PWV, heart‐carotid PWV, heart‐femoral PWV (hf‐PWV), and lower ABI (all P < .001). Multivariate regression models showed independent associations between lower eGFR, lower ABI (Coef: 0.42 & 0.41 for right and left), higher hf‐PWV (Coef: −11.4 [95% CI: −15.4, −7.3]) and greater PAD risk (adjusted OR: 0.83 [95% CI: 0.76, 0.91], all P < .05). eGFR set at 77 mL/min/1.73m² was observed to be useful clinical cutoff (c‐statistics: 0.67) for identifying PAD (P for ΔAUROC: .009; likelihood X ²: 93.82 to 137.43, P < .001) when superimposed on clinical risks. This study suggested early renal insufficiency is tightly linked to region‐specific vascular stiffness and PAD.     

Sodium nitrate supplementation improves blood pressure reactivity in patients with peripheral artery disease

Background & aimsPeripheral artery disease (PAD) is characterized by elevated blood pressure (BP), low nitric oxide availability (NO), and exaggerated pressor responses to sympatho-excitatory stressors. Inorganic nitrate reduces peripheral BP in healthy and chronically diseased populations. The objective of this study was to investigate the effects of eight-weeks of sodium nitrate (NaNO₃) supplementation on indices of BP in PAD patients.Methods21 patients with PAD were recruited to participate in this study, undergoing 8-weeks of NaNO₃ (n = 13; 73 ± 9 years) or placebo (n = 8; 69 ± 10 years) supplementation. BP responsiveness to a cold pressor test (CPT) were examined prior to and following the supplementation period. The systolic BP response (change from rest) during the first (26 ± 10 vs. 19 ± 11 mmHg) and second minutes (32 ± 10 vs. 26 ± 12 mmHg) of CPT were reduced following NaNO₃ (P < 0.05 for both) but not after placebo (first minute: 22 ± 10 vs. 24 ± 10 mmHg, P = 0.30; second minute 26 ± 10 vs 27 ± 10 mmHg, P = 0.72) supplementation.ConclusionOur data suggest that eight-weeks of NaNO₃ supplementation reduces BP responsiveness to sympatho-excitatory stimuli.Clinical trials registration numberNCT01983826.     

Leg symptoms, the ankle-brachial index, and walking ability in patients with peripheral arterial disease

OBJECTIVE: To determine how functional status and walking ability are related to both severity of lower extremity peripheral arterial disease (PAD) and PAD-related leg symptoms. DESIGN: Cross-sectional study. SETTING: Academic medical center. PARTICIPANTS: Patients aged 55 years and older diagnosed with PAD in a blood flow laboratory or general medicine practice (n = 147). Randomly selected control patients without PAD were identified in a general medicine practice (n = 67). MEASUREMENTS: Severity of PAD was measured with the ankle-brachial index (ABI). All patients were categorized according to whether they had (1) no exertional leg symptoms; (2) classic intermittent claudication; (3) exertional leg symptoms that also begin at rest (pain at rest), or (4) exertional leg symptoms other than intermittent claudication or pain at rest (atypical exertional leg symptoms). Participants completed the 36-Item Short-Form Health Survey (SF-36) and the Walking Impairment Questionnaire (WIQ). The WIQ quantifies patient-reported walking speed, walking distance, and stair-climbing ability, respectively, on a scale of 0 to 100 (100 = best). MAIN RESULTS: In multivariate analyses patients with atypical exertional leg symptoms, intermittent claudication, and pain at rest, respectively, had progressively poorer scores for walking distance, walking speed, and stair climbing. The ABI was measurably and independently associated with walking distance (regression coefficient = 2.87/0.1 ABI unit, p =.002) and walking speed (regression coefficient = 2.09/0.1 ABI unit, p =.015) scores. Among PAD patients only, pain at rest was associated independently with all WIQ scores and six SF-36 domains, while ABI was an independent predictor of WIQ distance score. CONCLUSIONS: Both PAD-related leg symptoms and ABI predict patient-perceived walking ability in PAD.     

踝肱指数在糖尿病周围血管病变中的应用

踝肱指数是一种简单、有效的评估周围血管疾病的指标,可通过观察下肢血管的血流量,快捷、非侵入性的筛选早期动脉粥样硬化.近年来广泛用于糖尿病患者外周血管病变的诊断和预后分析,对糖尿病患者下肢动脉病变的筛查、随访以及预防坏疽有重要的临床价值.本文从踝肱指数测量、诊断标准、影响因素、临床运用等方面作一综述.     

Effects of simvastatin on walking performance and symptoms of intermittent claudication in hypercholesterolemic patients with peripheral vascular disease

PURPOSE: To analyze the effects of short-term therapy with simvastatin on walking performance in hypercholesterolemic patients with peripheral vascular disease. METHODS: Eighty-six patients with peripheral arterial disease (Fontaine stage II), intermittent claudication, and total cholesterol levels >220 mg/dL were enrolled in a randomized, placebo-controlled, double-blind study. Forty-three patients were assigned to simvastatin (40 mg/d); the remaining 43 patients were assigned to placebo treatment. All patients underwent an exercise test and clinical examination, and completed a self-assessment questionnaire at 0, 3, and 6 months. Pain-free and total walking distance, resting and postexercise ankle-brachial indexes, and questionnaire scores were determined at each follow-up. RESULTS: At 6 months, the mean pain-free walking distance had increased 90 meters (95% confidence interval [CI]: 64 to 116 meters; P <0.005) more in the simvastatin group than in the placebo group. Similar results were seen for the total walking distance (mean between-group difference in the change, 126 meters; 95% CI: 101 to 151 meters; P <0.001), and for the ankle-brachial index at rest (mean, 0.09; 95% CI: 0.06 to 0.12; P <0.01) and after exercise (mean, 0.19; 95% CI: 0.14 to 0.24; P <0.005). There was also a greater improvement in claudication symptoms among patients treated with simvastatin. The effects on walking performance, ankle-brachial indexes, and questionnaire scores had also been significant at 3 months. CONCLUSION: High-dose short-term therapy with simvastatin may improve walking performance, ankle-brachial pressure indexes, and symptoms of claudication in hypercholesterolemic patients with peripheral vascular disease.     

脉压指数联合动脉硬化指数对冠心病患者冠状动脉病变严重程度的预测价值

[目的]探讨脉压指数(PPI)联合动脉硬化指数(AI)对冠心病患者冠状动脉病变严重程度的预测价值。[方法]选取2019年1月—10月在佛山市中医院经冠状动脉造影(CAG)检查诊断为冠心病的150例患者,分为单支组(36例)、双支组(49例)、三支组(65例);同期行CAG后排除冠心病的患者50例纳入对照组。冠心病分型：稳定型心绞痛(SAP)患者37例、不稳定型心绞痛(UAP)患者42例、急性非ST段抬高型心肌梗死(NSTEMI)患者35例、急性ST段抬高型心肌梗死(STEMI)患者36例。比较各组PPI、AI水平差异,并分析冠心病患者冠状动脉病变严重程度的影响因素。Gensini评分与PPI、AI水平的相关性采用Pearson分析。PPI、AI预测冠状动脉病变严重程度的效能采用ROC曲线分析。[结果]单支组、双支组及三支组PPI、AI水平依次增加(P<0.05)。SAP组、UAP组、NSTEMI组及STEMI组PPI、AI水平相比差异无统计学意义(P>0.05)。PPI、AI均与Gensini评分存在正相关(r=0.561、r=0.629,均P=0.000)。多因素Logi...     

Arterial stiffness and subendocardial viability ratio in patients with peripheral arterial disease

Arterial stiffening is a hallmark of the aging process and atherosclerosis, including peripheral arterial disease (PAD). We investigated the associations between carotid‐femoral pulse wave velocity (c‐fPWV), augmentation index corrected for heart rate (Aix@HR75), ankle brachial index (ABI), and subendocardial viability ratio (SEVR), an indicator of cardiac perfusion. The c‐fPWV, Aix@HR75, and SEVR was estimated using applanation tonometry. The ankle systolic pressure measurements for the calculation of the ABI were obtained using an 8‐mHz Doppler probe. The study group included 555 subjects, mean age 63 ± 11 years (248 PAD (ABI < 1.0), and 307 non‐PAD (ABI ≥ 1.0 ≤ 1.3). After the stepwise selection process in both PAD and non‐PAD patients SEVR was not related to c‐fPWV and ABI (P = .154; P = .156) and (P = .101; P = .402), respectively. In PAD patients, SEVR was negatively related to Aix@HR75 (P < .0001) and aortic PP (P = .0005). In conclusion, arterial stiffness is associated with non‐invasive indices of myocardial perfusion in PAD patients, suggesting a potential pathophysiological link for increased cardiovascular events.     

踝肱指数在诊断2型糖尿病患者下肢动脉病变中的临床意义

目的:了解踝肱指数(ABI)在诊断2型糖尿病下肢动脉病变(LEAD)的临床意义和影响因素。方法:对231例2型糖尿病患者测定ABI,以ABI值0.9为异常分为LEAD组(46例)和非LEAD组(对照组,185例),所有患者均进行体重量指数,腰臀比,血糖、血脂、血压、尿微量白蛋白等检查,并对其结果进行分析。结果:在231例2型糖尿病患者中,46例ABI0.9的LEAD患者的病程[(9.1±6.3)年:(4.5±5.7)年]、糖化血红蛋白[10.9±3.3)%:7.8±1.2)%]、低密度脂蛋白-胆固醇[(3.1±0.9)mmol/L:(2.6±1.1)mmol/L]及脉压[(59±15)mmHg:(52±14)mmHg],均明显高于对照组(P均0.05)。结论:糖尿病合并下肢动脉病变者具有病程长、血糖高、脉压差大、血脂紊乱等特点,踝肱指数是一项花费小、简单无创的诊断下肢动脉病变的可靠指标。     

Prevention of serious vascular events by aspirin amongst patients with peripheral arterial disease: randomized, double-blind trial

OBJECTIVE: To assess the prophylactic efficacy of aspirin and a high-dose antioxidant vitamin combination in patients with peripheral arterial disease (PAD) in terms of reduction of the risk of a first vascular event (myocardial infarction, stroke, vascular death) and critical limb ischaemia. DESIGN: Randomized, placebo-controlled, double-blind clinical trial with 2 x 2 factorial design. SETTING: Thirty-seven European angiology/vascular medicine units. SUBJECTS: A total of 366 outpatients with stage I-II PAD documented by angiography or ultrasound, with ankle/brachial index <0.85 or toe index <0.6; 210 patients completed the follow-up. INTERVENTIONS: Four treatment groups: (i) oral aspirin (100 mg daily), (ii) oral antioxidant vitamins (600 mg vitamin E, 250 mg vitamin C and 20 mg beta-carotene daily), (iii) both or (iv) neither, given for 2 years. MAIN OUTCOME MEASURE: Major vascular events (cardiovascular death, myocardial infarction or stroke) and critical leg ischaemia. RESULTS: Seven of 185 patients allocated aspirin and 20 of 181 allocated placebo suffered a major vascular event (risk reduction 64%, P = 0.022); five and eight patients, respectively, suffered critical leg ischaemia (total 12 vs. 28, P = 0.014). There was no evidence that antioxidant vitamins were beneficial (16/185 vs. 11/181 vascular events). Neither treatment was associated with any significant increase in adverse events. Inclusion of this trial in a meta-analysis of other randomized trials of anti-platelet therapy in PAD makes the overall results highly significant (P < 0.001) and suggests that low-dose aspirin reduces the incidence of vascular events by 26%. CONCLUSIONS: For the first time direct evidence shows that low-dose aspirin should routinely be considered for PAD patients, including those with concomitant type 2 diabetes.     

Metabolic syndrome, peripheral vascular disease and coronary artery disease: A concise review

Metabolic syndrome has a very strong association with both forms of cardiovascular (CV) disease - coronary artery disease and peripheral vascular disease. There is also a marked interrelationship between the two forms of CV disease. When one form of CV disease is present, the other should be strongly suspected and the possible occurrence of associated vascular events should be clinically evaluated. When three of the five major components that define metabolic syndrome are present, the clinical evidence indicates that one or both forms of CV disease are present, at least in incipient form. To give maximum clinical benefit to the patient at risk, the clinician must be aware of these associations, look for them and institute the measures that can reduce the risk of progression.     

Radial augmentation index associated with increase in B-type natriuretic peptide in patients with hypertension

Brain natriuretic peptide (BNP) level has been used as a marker of left ventricular (LV) systolic dysfunction (LVSD), even though some patients with atherosclerosis have a high BNP level irrespective of LV function. In this study, we investigate whether augmentation index (AI), which is an index of wave reflection, is involved in increasing BNP level in hypertensive patients without LVSD. Sixty treated hypertensive patients were enrolled in this study. Radial AI (r-AI) was measured in all patients. The patients were classified into tertiles on the basis of r-AI to identify the characteristics of the patients with a high r-AI.BNP level was significantly higher in the patients classified into the highest tertile of r-AI. In echocardiography, e′, which is index of left ventricular (LV) diastolic function, decreased and LV mass index (LVMI) increased gradually with r-AI, whereas there was no difference in LV ejection fraction (LVEF). r-AI significantly correlated with LVMI (r = 0.35, p < 0.01) and e′ (r = − 0.30, p < 0.05). In univariate analysis, age, heart rate, r-AI, LVEF, e′ and LVMI were significantly correlated with BNP level, whereas multivariate analysis demonstrated that only r-AI and LVEF correlated with BNP level. In conclusion, an increase in r-AI was significantly associated with an increase in BNP level in hypertensive patients without LVSD. LV hypertrophy and diastolic dysfunction associated with increase in r-AI may be involved in increase in BNP level.     

Radiation‐induced peripheral artery disease

Radiation therapy is a cause of cardiovascular morbidity and mortality. This is due to the significant degree of atherosclerosis seen in the vessels in the vicinity of the area being irradiated. Radiation‐induced peripheral arterial disease is increasingly being recognized as large populations of cancer patients survive longer, yet it is a problem that is often under reported. Although it has most commonly been associated with carotid artery disease, all vascular beds are prone to this form of injury. The injury is accelerated by usual risk factors for atherosclerosis. Developing a healthy lifestyle, dietary prudence and the aggressive treatment of hypertension, diabetes mellitus, and dyslipidemia should all be encouraged in this patient population. When revascularization strategies are warranted, the percutaneous approach may be superior to open surgery as technical difficulties may arise in the fibrotic, scarred tissue. Stenting with distal embolic protection devices should be considered as the treatment of choice for patients with radiation‐induced carotid artery disease. Several reports also suggest good results with balloon angioplasty with or without stenting in the case of radiation‐induced renal, iliac, and femoral artery disease. Lifelong antiplatelet therapy may be appropriate. © 2008 Wiley‐Liss, Inc.     

Impact of geriatric nutritional risk index on prognosis in peripheral artery disease patients undergoing endovascular therapy

The prevalence of peripheral artery disease continues to rise, with major amputations and mortality remaining prominent. Frailty is a significant risk factor for adverse outcomes in the management of the vascular disease. The geriatric nutritional risk index has been used to predict adverse outcomes in lower extremity peripheral artery disease and is a nutrition-based surrogate for frailty. The authors recruited 126 patients with peripheral artery disease who underwent endovascular stent implantation. As in previous reports, malnutrition was diagnosed by the geriatric nutritional risk index. The authors used Kaplan-Meier and multivariate Cox proportional hazards regression analyses to analyze the risk of major adverse limb events, which included mortality, major amputation, and target limb revascularization. There were 67 major adverse limb events during a median follow-up of 480 days. Malnutrition on the basis of the geriatric nutritional risk index was present in 31% of patients. Cox regression analysis showed that malnutrition based on the geriatric nutritional risk index was an independent predictor of major adverse limb events. Kaplan-Meier analysis showed that major adverse limb events increased with worsening malnutrition. Our single-center, retrospective evaluation of geriatric nutritional risk index (as a synonym for body health) correlates with an increased risk of major adverse limb events. Future directions should focus not only on identifying these patients but also on modifying risk factors to optimize long-term outcomes.