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

Olivier Stivalet,Loukman Omarjee,Dihia Belabbas,Estelle Le Pabic,Guillaume Mahé,Anita Paisant,Philippe Landreau,Alexis Le Faucheur

doi:10.3389/fcvm.2021.759666

Abstract

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.

Highlights

Lower Extremity Peripheral Artery Disease (LEPAD) affects more than 235 million people worldwide [1]
The ankle-brachial index at rest (Resting-ABI) is a clinical means recommended by the guidelines of the American Heart Association (AHA) to diagnose the presence and severity of LEPAD regardless of the symptoms reported by the patients [2]
Several studies have shown that exerciseTcPO2 using the Delta from Resting Oxygen Pressure (DROP) value is accurate to diagnose arterial stenoses of ≥50% assessed by computed tomography angiography (CTA) or angiography as a gold standard [3,4,5]

Summary

Introduction

Lower Extremity Peripheral Artery Disease (LEPAD) affects more than 235 million people worldwide [1]. The AHA statement proposed two different post-exercise criteria to diagnose LEPAD: either a post-exercise ABI decrease >20% or a post-exercise pressure decrease >30 mmHg. Exercise oximetry (exercise-TcPO2) has been proposed to diagnose lower limbs arterial stenoses [3,4,5]. Several studies have shown that exerciseTcPO2 using the Delta from Resting Oxygen Pressure (DROP) value is accurate to diagnose arterial stenoses of ≥50% assessed by computed tomography angiography (CTA) or angiography as a gold standard [3,4,5]. We have previously found that in patients with a normal resting-ABI, cut off values of post-exercise ABI decrease ≥18.5% or DROP ≤-15 mmHg have similar area under the curves (AUC) to detect LEPAD (i.e., arterial stenoses≥50%) [7].

Objectives

Methods

Results

Discussion

Conclusion