Functional decline in peripheral arterial disease: associations with the ankle brachial index and leg symptoms

Context  Among individuals with lower-extremity peripheral arterial disease (PAD), specific leg symptoms and the ankle brachial index (ABI) are cross-sectionally related to the degree of functional impairment. However, relations between these clinical characteristics and objectively measured functional decline are unknown. Objective  To define whether PAD, ABI, and specific leg symptoms predict functional decline at 2-year follow-up. Design, Setting, and Participants  Prospective cohort study among 676 consecutively identified individuals (aged 55 years) with and without PAD (n = 417 and n = 259, respectively), with baseline functional assessments occurring between October 1, 1998, and January 31, 2000, and follow-up assessments scheduled 1 and 2 years thereafter. PAD was defined as ABI less than 0.90, and participants with PAD were categorized at baseline into 1 of 5 mutually exclusive symptom groups. Main Outcome Measures  Mean annual changes in 6-minute walk performance and in usual-paced and fast-paced 4-m walking velocity, adjusted for age, sex, race, prior-year functioning, comorbid diseases, body mass index, pack-years of cigarette smoking, and patterns of missing data. Results  Lower baseline ABI values were associated with greater mean (95% confidence interval) annual decline in 6-minute walk performance (–73.0 –142 to –4.2] ft for ABI <0.50 vs –58.8 –83.5 to –34.0] ft for ABI 0.50 to <0.90 vs –12.6 –40.3 to 15.1] ft for ABI 0.90-1.50, P = .02). Compared with participants without PAD, PAD participants with leg pain on exertion and rest at baseline had greater mean annual decline in 6-minute walk performance (–111 –173 to –50.0] ft vs –8.67 –36.9 to 19.5] ft, P = .004), usual-pace 4-meter walking velocity (–0.06 –0.09 to –0.02] m/sec vs –0.01 (–0.03 to 0.003] m/sec, P = .02), and fastest-pace 4-meter walking velocity (–0.07 –0.11 to –0.03] m/sec vs –0.02 –0.04 to –0.006] m/sec, P = .046). Compared with participants without PAD, asymptomatic PAD was associated with greater mean annual decline in 6-minute walk performance (–76.8 (–135 to –18.6] ft vs –8.67 (–36.9 to 19.5] ft, P = .04) and an increased odds ratio for becoming unable to walk for 6 minutes continuously (3.63; 95% confidence interval, 1.58-8.36; P = .002). Conclusions  Baseline ABI and the nature of leg symptoms predict the degree of functional decline at 2-year follow-up. Previously reported lack of worsening in claudication symptoms over time in patients with PAD may be more related to declining functional performance to than lack of disease progression.