Medical management of risk factors for vascular disease

Peripheral arterial disease (PAD) is a powerful marker of the risk of cardiovascular events such as stroke and myocardial infarction, even in asymptomatic patients. The development of PAD is underpinned by both modifiable risk factors, including smoking, diabetes, dyslipidaemia, hypertension and obesity and non-modifiable risk factors, including male gender and increased age. Optimizing medical management of risk factors, with tight control of diabetes, antiplatelet therapy and exercise, can significantly reduce risk of cardiovascular morbidity and mortality.     

Medical management of risk factors for vascular disease

Peripheral arterial disease (PAD) is a powerful marker of the risk of cardiovascular events such as stroke and myocardial infarction, even in asymptomatic patients. The development of PAD is underpinned by both modifiable risk factors (including smoking, diabetes, dyslipidaemia, hypertension and obesity) and non-modifiable risk factors (including male gender and increased age). Optimizing medical management of risk factors–with tight control of diabetes, antiplatelet therapy and exercise–can significantly reduce the risk of cardiovascular morbidity and mortality.     

Supporting a call to action for peripheral artery disease: insights from two prospective clinical registries

BACKGROUND: Patients affected by peripheral arterial disease (PAD) incur a heightened risk of adverse cardiovascular events, including stroke, myocardial infarction, and vascular mortality. We examined risk factors, medications, and prognosis of outpatients with PAD enrolled in two national, prospective, practice-based Canadian registries that encompassed 484 physician practices: the Vascular Protection and Guideline Oriented Approach in Lipid Lowering registries. METHODS: The 2 registries were combined to analyze 9810 patients with vascular disease, diabetes mellitus, or age 65 years or older plus at least 2 additional cardiovascular risk factors. Risk factors, medications, and major cardiovascular events were recorded at baseline and again at 6 months' follow-up. RESULTS: Compared with patients without PAD (n = 8303), those with PAD (n = 1507) had substantially worse risk factor profiles and were more likely to have coexisting coronary or cerebrovascular disease. Both groups received high rates of treatment with evidence-based therapies, including antiplatelet drugs, statins, and angiotensin-converting enzyme inhibitors. Despite this, patients with PAD had a nearly twofold higher risk of major cardiovascular events at 6 months than non-PAD patients (7.3% vs 4.1%; P < .0001). After adjustment for multiple confounding factors, the presence of PAD at baseline continued to predict a heightened risk of adverse vascular sequelae (odds ratio, 1.54; 95% confidence interval, 1.18-2.01; P < .0001). CONCLUSIONS: These data support a strong relationship between PAD and worsened vascular prognosis that is independent of both conventional vascular risk factors and concomitant cardiovascular disease. The presence of PAD should therefore provide a clear impetus for intensive risk factor modification and use of preventive medical therapy in affected patients.     

Peripheral arterial disease

To provide an overview of the epidemiology, links to cardiovascular disease, diagnosis, and management of patients suffering from peripheral arterial disease (PAD). The most common symptom of PAD is intermittent claudication, but non-invasive measures, such as the ankle–brachial index, show that asymptomatic PAD is several times more common in the population than intermittent claudication. PAD prevalence and incidence are both sharply age-related, rising to more than 10% among patients in their 60s and 70s. The major risk factors for PAD are those for coronary and cerebrovascular disease, with some differences in the relative importance of different factors. Smoking is a particularly strong risk factor for PAD, as is diabetes mellitus. PAD is strongly associated with concomitant coronary and cerebrovascular diseases. Diagnosis includes both clinical examination and objective imaging. The severity of PAD is broadly classified as asymptomatic, causing symptoms of intermittent claudication, or resulting in critical limb-threatening ischaemia (CLTI). Treatment may be conservative in the early stages with medical therapy to address cardiovascular risk factors and exercise therapy. People with CLTI have a threatened limb and will in addition require lower limb revascularization, by surgical, endovascular or combined (‘hybrid’) techniques. In some people primary amputation is the best option, either because they have no revascularization option or the limb is non-salvageable.     

Prevalence of and risk factors for peripheral arterial disease in the patients with hypertension among Han Chinese

OBJECTIVES: Peripheral arterial disease (PAD) is associated with morbidity and mortality of coronary heart disease and stroke. Hypertension is an independent risk factor for peripheral arterial disease. However, the prevalence and risk factors of PAD in hypertensive patients have not been studied in China. METHODS: In order to investigate the prevalence of PAD and its risk factors in China, a cross-sectional study was carried out. A total of 4716 patients with hypertension and 833 age-gender matched people without hypertension were recruited; age 40 to 75 years, from seven rural communities. PAD was defined as an ankle-brachial index (ABI) or=140 mm Hg, diastolic blood pressure >or=90 mm Hg, or history of antihypertensive drug use. RESULTS: The prevalence of PAD is 8.7% (n = 408) in patients with hypertension (n = 4716), higher than in people without hypertension (5.0%, n = 833, P = .004). Hypertensive patients with PAD were older, (61 +/- 8.6 vs 58 +/- 8.6, P < .01), had more conventional cardiovascular risk factors including systolic blood pressure (170 +/- 22.6 vs 167 +/- 22.7, P < .01), pulse pressure (72 +/- 19.7 vs 68 +/- 18.9, P < .01), blood glucose (5.8 +/- 2.2 vs 5.6 +/- 1.7, P < .05), total cholesterol (5.7 +/- 1.3 vs 5.5 +/- 1.1, P < .05), and serum uric acid (355 +/- 98.0 vs 293 +/- 86.2, P < .05) than the hypertensive patients without PAD. After adjusting for gender, age, and other cardiovascular risk factors by using multiple logistical regression analysis, PAD was still associated with current smoking (odds ratio [OR] = 1.65, 95% confidence interval [CI] 1.18-2.29), history of stroke (OR = 1.50, 95% CI 1.12-2.00), serum uric acid (OR = 1.21, 95% CI 1.10-1.59), and total cholesterol (OR = 1.12, 95% CI 1.10-1.59). CONCLUSION: This study reports, for the first time, the prevalence of PAD in Chinese patients with hypertension, which is quite different from that in westerners, and that PAD is independently associated with conventional cardiovascular risk factors.     

Novel and traditional cardiovascular risk factors for peripheral arterial disease in incident-dialysis patients

Peripheral arterial disease (PAD), which threatens limb viability and patient survival, is increasing in frequency in the dialysis population, but associated risk factors remain poorly defined. We conducted a cross-sectional analysis of the association of novel and traditional cardiovascular risk factors with PAD in incident-dialysis patients enrolled in the CHOICE study by application of multivariate logistic-regression models with adjustment for confounders. Risk factors were determined by interview, record review, and laboratory analysis of frozen specimens. Among 922 patients, 25% had a diagnosis of PAD. After adjustment, higher prevalence of PAD was associated with increasing age (odds ratio [OR], 95% CI = 1.28 [range: 1.12 to 1.48] per 10-year increase in age); presence of diabetes mellitus (OR, 95% CI = 2.76 [range: 1.72 to 4.42]); higher Index of Co-Existent Disease (ICED), ICED 2 and ICED 3 versus ICED 0-1, (OR, 95% CI = 2.04; [range: 1.24 to 3.35] and OR, 95% CI = 2.81 [range: 1.83 to 4.30], respectively). After adjustment, we found no statistically significant association between CRP and prevalence of PAD. The prevalence of PAD diagnosis was 34% higher per quartile increase in Lp(a) (OR, 95% CI = 1.34 [range: 1.13 to 1.59]). Similarly, the prevalence of PAD diagnosis was 19% higher per quartile increase in total homocysteine (OR, 95% CI = 1.19 [range: 1.05 to 1.35]). The prevalence of PAD is high in incident-dialysis patients and is associated with several novel and traditional cardiovascular risk factors. This study identifies several novel risk factors (eg, Lp(a) and total homocysteine) and underscores the need for further research to reduce the burden of PAD in this high-risk group of patients.     

Perceptions of Canadian vascular surgeons toward pharmacological risk reduction in patients with peripheral arterial disease

Patients with peripheral arterial disease (PAD) are at a markedly higher risk of cardiovascular morbidity and mortality, with evidence indicating that risk-reduction pharmacotherapy can serve to attenuate cardiovascular events in these patients. Given the central role of vascular surgeons in the treatment of patients with PAD, we sought to determine their perceptions and knowledge of risk-reduction pharmacotherapy in patients with PAD. We conducted a cross-sectional survey of 79 Canadian vascular surgeons who attended the 2004 annual meeting of the Canadian Society for Vascular Surgery, the largest and most representative meeting of its kind in Canada. The recommended targets of low-density lipoprotein cholesterol, blood glucose, and blood pressure were known to 53.8%, 40.4%, and 57.7% of vascular surgeons, respectively. The majority of vascular surgeons (65.4%) reported screening for risk factors in <50% of cases. Although 90.4% of vascular surgeons would recommend antiplatelet therapy for PAD, only 5.8% would recommend angiotensin converting enzyme (ACE) inhibitors and 19.2% would recommend lipid-lowering therapy with statins. Eighty-four percent of Canadian vascular surgeons indicated that their self-assessment of risk reduction in PAD was average to below average, yet 90.4% of them believed that risk-reduction therapy should be recommended or initiated by vascular surgeons. Canadian vascular surgeons’ perceptions toward risk reduction in PAD identify knowledge and action gaps, despite the recognition that recommending and instituting therapy is important to patient care. Given the heightened risk of cardiovascular disease in patients with PAD, these data have important implications. Presented at the Twenty-seventh Annual Meeting of the Canadian Society for Vascular Surgery, Toronto, Ontario, Canada, September 9-10, 2005.     

Peripheral arterial disease predicts overall and cardiovascular mortality in peritoneal dialysis patients

Background: Peripheral arterial disease (PAD) is an important manifestation of systemic atherosclerosis and is common among dialysis patients. Cardiovascular disease (CVD) accounts for the leading cause of mortality in dialysis patients, and PAD has been found as a predictor for cardiovascular as well as overall mortality in general population. However, the study on the role of PAD in the prognosis of peritoneal dialysis patients is rather limited. Methods: Prevalent continuous ambulatory peritoneal dialysis patients over 60 years old were recruited in this study and were followed-up regularly to death or the end of the study. The diagnosis of PAD was based on ankle-brachial pressure index (ABI) < 0.9 or intermittent claudication. Univariate and multivariate Cox proportional hazard models were used to identify the risk factors for cardiovascular and overall mortality. Survival curves were estimated by the Kaplan-Meier method followed by log-rank test to compare the mortality rate between PAD and non-PAD patients. Results: One hundred and seventy-one patients were included and 62 (36%) had PAD complication. In the follow-up of 24.4 (median 34.6) months, 36 deaths were recorded: 19 from PAD group and 17 from non-PAD group. Twenty-one patients died due to CVD: 13 from PAD group and 8 from non-PAD group. The presence of PAD and serum albumin was found independently associated with cardiovascular and overall mortality using Cox proportional hazards model. Conclusion: PAD is very common in aged peritoneal dialysis patients and independently associated with both cardiovascular and overall mortality.     

Peripheral Arterial Disease Predicts Overall and Cardiovascular Mortality in Peritoneal Dialysis Patients

Background: Peripheral arterial disease (PAD) is an important manifestation of systemic atherosclerosis and is common among dialysis patients. Cardiovascular disease (CVD) accounts for the leading cause of mortality in dialysis patients, and PAD has been found as a predictor for cardiovascular as well as overall mortality in general population. However, the study on the role of PAD in the prognosis of peritoneal dialysis patients is rather limited. Methods: Prevalent continuous ambulatory peritoneal dialysis patients over 60 years old were recruited in this study and were followed-up regularly to death or the end of the study. The diagnosis of PAD was based on ankle-brachial pressure index (ABI) < 0.9 or intermittent claudication. Univariate and multivariate Cox proportional hazard models were used to identify the risk factors for cardiovascular and overall mortality. Survival curves were estimated by the Kaplan–Meier method followed by log-rank test to compare the mortality rate between PAD and non-PAD patients. Results: One hundred and seventy-one patients were included and 62 (36%) had PAD complication. In the follow-up of 24.4 (median 34.6) months, 36 deaths were recorded: 19 from PAD group and 17 from non-PAD group. Twenty-one patients died due to CVD: 13 from PAD group and 8 from non-PAD group. The presence of PAD and serum albumin was found independently associated with cardiovascular and overall mortality using Cox proportional hazards model. Conclusion: PAD is very common in aged peritoneal dialysis patients and independently associated with both cardiovascular and overall mortality.     

Thrombophilic risk factors for symptomatic peripheral arterial disease

OBJECTIVE: Peripheral arterial disease (PAD) is a common manifestation of systemic atherosclerosis. Over the last years, several novel mediators relevant to the process of atherogenesis have been identified, but few and conflicting data are available on the possible association with PAD symptoms. The aim of this study was to determine an extended thrombophilic risk profile of patients with symptomatic PAD. METHODS: Two hundred eighty patients with symptomatic PAD admitted to the Department of Vascular Surgery of the University of Florence were compared with 280 control subjects without PAD, matched for age and gender. The following metabolic and genetic risk factors were evaluated: lipoprotein(a), homocysteine, antiphospholipid antibodies, plasminogen activator inhibitor-1, factor V Leiden mutation, prothrombin variant, and 5,10-methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism. RESULTS: Multivariate logistic regression analysis, adjusted for traditional cardiovascular risk factors, showed a significant association between PAD symptoms and prothrombin variant, altered levels of homocysteine, lipoprotein(a), plasminogen activator inhibitor-1, and antiphospholipid antibodies. Moreover, the presence of high levels of lipoprotein(a) and another metabolic risk factor raised the likelihood of PAD symptoms (dyslipidemia and elevated lipoprotein[a]: odds ratio [OR], 29; 95% confidence interval [CI], 6.2 to 136.2; P <.0001; hyperhomocysteinemia and elevated lipoprotein[a]: OR, 37.7; 95% CI, 3.7 to 381.5; P <.0001). A significant correlation between the number of altered thrombophilic parameters and the Fontaine stage was observed ( R = 0.16; P = .006). CONCLUSION: There is an independent association between altered levels of important thrombophilic risk factors and PAD symptoms. The clinical significance of this association needs to be tested in prospective population-based trials.     

Kidney function and risk of peripheral arterial disease: results from the Atherosclerosis Risk in Communities (ARIC) Study

Chronic kidney disease (CKD) is associated with an increased risk for cardiovascular disease, but its association with peripheral arterial disease (PAD) is unclear. With the use of data from the Atherosclerosis Risk in Communities (ARIC) Study, 14,280 middle-aged adults were categorized on the basis of estimated GFR >/=90, 60 to 89, and 15 to 59 ml/min per 1.73 m(2) for normal kidney function, mildly decreased kidney function, and stages 3 to 4 CKD, respectively. Incident PAD was defined as a new onset of ankle-brachial index <0.9 assessed at regular examinations, new intermittent claudication assessed by annual surveillance, or PAD-related hospital discharges. Incidence rates and relative risks (RR) for PAD were compared across these categories. During a mean follow-up time of 13.1 yr (186,616 person-years), 1016 participants developed PAD. The incidence rates per 1000 person-years were 4.7, 4.9, and 8.6 for the normal kidney function, mildly decreased kidney function, and CKD groups, respectively. Compared with participants with normal kidney function, the age-, gender-, race-, and ARIC field center-adjusted RR for PAD was 1.04 (95% confidence interval [CI] 0.91 to 1.18) for those with mildly decreased kidney function and 1.82 (95% CI 1.34 to 2.47) for those with CKD. After additional adjustment for cardiovascular disease risk factors, an increase in risk for incident PAD still was observed in participants with CKD, with a multivariable adjusted RR of 1.56 (95% CI 1.13 to 2.14). Patients with CKD are at increased risk for incident PAD. Development of strategies for screening and prevention of PAD in this high-risk population seems warranted.     

Characteristics and treatments of patients with peripheral arterial disease referred to UK vascular clinics: results of a prospective registry.

BACKGROUND: Peripheral arterial disease (PAD) is often associated with risk factors including cigarette smoking, hypertension and hypercholesterolaemia, and patients have a high risk of future vascular events. Good medical management results in improved outcomes and quality of life, but previous studies have documented sub-optimal treatment of risk factors. We assessed the management of cardiovascular risk factors in patients with PAD referred to specialist vascular clinics. METHODS: This was a prospective, protocol driven registry carried out in UK vascular clinics. Patients who were first-time referrals for evaluation of PAD were eligible if they had claudication plus ankle-brachial pressure index (ABPI) < or = 0.9. Statistical associations between key demographic and treatment variables were explored using a chi-squared test. RESULTS: We enrolled 473 patients from 23 sites. Mean age was 68 years (SD 10) and 66% were male. Mean estimated claudication distance was 100 m, and ABPI was 0.74. Mean systolic blood pressure (SBP) was 155 mmHg, and 42% had a SBP >160 mmHg. Forty percent were current smokers and half had tried to give up in the prior 6 months, but there was no evidence of a systematic method of smoking cessation. Mean total cholesterol was 5.4 (SD1.2) mmol/l and 30% had levels >6 mmol/l. Antiplatelet therapy had been given to 70% and statins to 44%. Prior CHD was present in 29% and these patients had significantly higher use of antiplatelet therapy, statins and ACE-inhibitors. CONCLUSIONS: In spite of attempts to raise awareness about PAD as an important marker of cardiovascular risk, patients are still poorly treated prior to referral to a vascular clinic. In particular, the use of evidence-based treatments is sub-optimal, while hypertension and cigarette smoking are poorly managed. More work needs to be done to educate health professionals about the detection and optimal medical management of PAD.     

Fibrinogen predicts mortality in high risk patients with peripheral artery disease.

OBJECTIVE: Fibrinogen plays a key role in the pathogenesis of atherosclerosis and complications of atherothrombotic disease. We investigated the prognostic impact of fibrinogen levels on mortality of high risk patients with peripheral artery disease (PAD). METHODS: We studied 486 patients with PAD and several cardiovascular comorbidities. Atherosclerotic risk factors and fibrinogen levels were determined at initial presentation and patients were followed for median 7 years (IQR 6-10) for all-cause and cardiovascular mortality. Multivariate Cox regression analysis was applied to assess the predictive value of fibrinogen levels (in quartiles) on patients' outcome. RESULTS: Cumulative survival rates at 1, 3, 5 and 10 years were 96, 91, 83 and 67%, respectively. Overall, 138 patients (28%) died, 70% of these patients died of cardiovascular complications (n=96). Patients with fibrinogen levels 10.2-12.2 micromol/l (third quartile) and patients with fibrinogen levels above 12.2 micromol/l (fourth quartile) had a significantly increased adjusted risk for all-cause mortality (hazard ratios [HR] 1.87 and 1.90, p=0.025 and p=0.020, respectively) compared to patients in the lowest quartile (fibrinogen below 8.6 micromol/l). A consistent effect was observed for cardiovascular causes of death. Diabetes mellitus and critical limb ischemia were the only other independent predictor variables (HR 2.08, p<0.001 and 1.88, p=0.001, respectively). CONCLUSION: Elevated fibrinogen levels in high risk patients with PAD indicate an increased risk for poor outcome, particularly for fatal cardiovascular complications.     

Family history is a major determinant of subclinical peripheral arterial disease in young adults

BACKGROUND: Cardiovascular disease is prevalent in first-degree relatives of young adults with premature-onset peripheral arterial occlusive disease (premature PAD), but it is not known whether the genetic influence is independent of other risk factors, the most prevalent of which is smoking. This study was performed to determine the relative contributions of family history and smoking to the development of occult PAD in siblings of patients with premature PAD. METHODS: The prevalence of occult PAD was determined with carotid, abdominal, and lower extremity duplex ultrasound scanning in 50 asymptomatic siblings (25 men, 25 women) of patients with premature PAD (onset 20 cigarettes/day) and 50 nonsmokers. RESULTS: Duplex ultrasound scans demonstrated raised arterial lesions in 20 asymptomatic siblings (40%), 20 heavy smokers (40%), and 2 nonsmoking control subjects (4%), resulting in 42 affected and 108 unaffected subjects. As expected, smokers were far more likely to have arterial lesions than were nonsmokers (odds ratio [OR], 11.19; 95% confidence interval [CI], 4.1-30.7; P <.0001). Individuals with a family history of premature PAD were almost three times more likely to have arterial lesions than those with no family history of cardiovascular disease (OR, 2.76; 95% CI, 1.3-5.8; P =.006). Stratified and multivariable logistic regression indicated no interaction between smoking and family history, indicating simple additive effects on PAD. CONCLUSIONS: Family history is a major determinant of occult PAD in young adults, and is at least as important as standard atherosclerotic risk factors. A high proportion of heavy smokers have clearly detectable lesions even though asymptomatic. Smoking and family history act additively to increase the risk for premature PAD.     

Atherothrombotic risk factor clustering in healthy male relatives of male patients with intermittent claudication

OBJECTIVE: Family history is an independent risk factor for premature acute myocardial infarction; in contrast, familial risk for peripheral arterial disease (PAD) has yet to be determined. Elevated levels of hemostatic proteins are consistently predictive for cardiovascular risk in "healthy" subjects, and may cluster with underlying insulin resistance. Atherothrombotic risk factor clustering occurs in first-degree relatives of subjects with coronary artery disease and type 2 diabetes. These may contribute to the enhanced cardiovascular risk in these subjects, and we hypothesised that familial clustering may occur in PAD. The objective of this study was to measure atherothrombotic risk factors in healthy male first-degree relatives of men with intermittent claudication, with emphasis on thrombotic risk. METHODS: One hundred sixty-five healthy male first-degree relatives were compared with control subjects matched for age, sex, and race (n = 165), free from a personal or family history of premature cardiovascular disease. Primary outcome measures were fibrinogen, von Willebrand factor, factor VII clotting activity (FVII:C), and factor XIII levels. Atherosclerotic risk factors were measured, and subjects were genotyped for common functional polymorphisms (factor VII r353q and fibrinogen B beta-455). RESULTS: Relatives had higher mean levels of fibrinogen (3.04 vs 2.89 g/L; P = .021), FVII:C (117% vs 104%; P = .000), factor XIII B subunit (1.11 vs 1.01 IU/mL; P = .000), and complex (A 2 B 2 ; 1.18 vs 1.11 IU/mL; P = .021). At multivariate analysis the association between relative status and fibrinogen, FVII:C, and factor XIII B subunit levels were independent of other variables. CONCLUSIONS: The healthy male relatives of men with PAD have elevated levels of fibrinogen, factor VII, and factor XIII. Our results support the existence of thrombotic risk factor clustering in this population at "high risk."     

Prognosis of Atrial Fibrillation in Patients with Symptomatic Peripheral Arterial Disease: Data from the REduction of Atherothrombosis for Continued Health (REACH) Registry

BackgroundAtrial fibrillation (AF) is a significant risk factor for cardiovascular (CV) mortality. This study aims to evaluate the prognostic implication of AF in patients with peripheral arterial disease (PAD).MethodsThe International Reduction of Atherothrombosis for Continued Health (REACH) Registry included 23,542 outpatients in Europe with established coronary artery disease, cerebrovascular disease (CVD), PAD and/or ≥3 risk factors. Of these, 3753 patients had symptomatic PAD. CV risk factors were determined at baseline. Study end point was a combination of cardiac death, non-fatal myocardial infarction (MI) and stroke (CV events) during 2 years of follow-up. Cox regression analysis adjusted for age, gender and other risk factors (i.e., congestive heart failure, coronary artery re-vascularisation, coronary artery bypass grafting (CABG), MI, hypertension, stroke, current smoking and diabetes) was used.ResultsOf 3753 PAD patients, 392 (10%) were known to have AF. Patients with AF were older and had a higher prevalence of CVD, diabetes and hypertension. Long-term CV mortality occurred in 5.6% of patients with AF and in 1.6% of those without AF (p < 0.001). Multivariable analyses showed that AF was an independent predictor of late CV events (hazard ratio (HR): 1.5; 95% confidence interval (CI): 1.09–2.0).ConclusionAF is common in European patients with symptomatic PAD and is independently associated with a worse 2-year CV outcome.     

Peripheral Artery Disease and CKD: A Focus on Peripheral Artery Disease as a Critical Component of CKD Care

The incidence of peripheral artery disease (PAD) is higher in patients with chronic kidney disease (CKD) than in the general population. PAD is a strong independent risk factor for increased cardiovascular disease mortality and morbidity, including limb amputation, in persons with CKD. Diagnosis of PAD in patients with CKD may be challenging in the absence of classic intermittent claudication or the presence of atypical leg symptoms. In addition, pedal artery incompressibility may decrease the accuracy of ankle-brachial index measurement, the most common PAD diagnostic tool. Alternative methods such as toe-brachial index should be used if clinical suspicion persists despite a normal ankle-brachial index value. Aggressive risk-factor modification, including treatment of diabetes, hyperlipidemia, and hypertension and smoking cessation, should be mandatory in all patients. Treatment of all individuals with PAD should include antiplatelet medications and prescribed supervised exercise programs and/or cilostazol for individuals with claudication symptoms. Preventive foot care measures and a multidisciplinary approach involving podiatrists and vascular and wound care specialists should be used to reduce amputations. Revascularization for critical limb ischemia is associated with poor outcomes in patients with CKD with PAD. Future investigation is recommended to evaluate the benefit of earlier treatment strategies in this high cardiovascular disease risk population with CKD.     

Association of increased levels of homocysteine and peripheral arterial disease in a Japanese-Brazilian population.

OBJECTIVES: Our aim was to evaluate the possible association between homocysteine levels and peripheral arterial disease (PAD) in a population-based study of Japanese-Brazilians. MATERIALS AND METHODS: This cross-sectional study was derived from a population-based survey on the prevalence of diabetes and associated diseases conducted in Japanese-Brazilians. A total of 1330 male and female subjects aged>or=30 years were submitted to clinical examination and laboratory procedures including homocysteine measurement. The ankle-brachial index (ABI) was calculated; subjects with ABI values <0.9 were diagnosed with PAD. The evaluable population included 1008 subjects. Logistic regression was used taking PAD as the dependent variable. RESULTS: Mean age of the population was 56.5 years and overall prevalence of PAD was 20%. A worse cardiovascular profile was found in male patients, including significantly higher homocysteine levels (11.9+/-1.8 vs. 9.1+/-1.1micromol/L, p<0.001). Men with PAD had higher prevalence rates of hyperhomocysteinemia compared to women (22.7% vs 7.6%). Univariate analysis showed an odds ratio of hyperhomocysteinemia for PAD of 1.51 [1.02-2.25] in men and 1.69 [1.06-2.68] in women. After adjustment for other cardiovascular risk factors, higher levels of homocysteine were only significantly related to PAD in men. CONCLUSION: In a Japanese-Brazilian population, elevated levels of homocysteine are associated with PAD in men. Prospective studies are necessary to confirm this finding.     

症状性下肢动脉疾病与肾动脉狭窄的相关性

目的探讨症状性下肢外周动脉疾病(PAD)患者合并肾动脉狭窄(RAS)的患病率及其相关因素。方法回顾性分析105例症状性PAD患者资料,记录动脉粥样硬化病变的常见高危因素;结合下肢动脉造影及肾动脉造影结果,分析各变量与症状性PAD合并RAS的关系。结果症状性PAD合并RAS的患病率为20.00%(21/105)。性别、年龄、吸烟史、糖尿病、高血压、心肌梗死、体质量、身高、体质量指数、白细胞计数、纤维蛋白原定量、血小板计数、平均血小板体积、血脂、钙离子、磷离子、钙磷比、尿酸、血肌酐、PAD临床分型、相似管径的下肢动脉血管病变与RAS无相关(P均>0.05);估测的肾小球滤过率(eGFR)与RAS相关(P<0.05),是RAS患病的独立预测因素。结论对于症状性PAD患者,应在下肢动脉造影的同时行双侧肾动脉造影,以早期发现肾动脉狭窄。