Peripheral arterial disease

Abstract

In a seminar on peripheral arterial disease (PAD) Kenneth Ouriel (Oct 13, p 1257)1Ouriel K Peripheral arterial disease.Lancet. 2001; 358: 1257-1264Summary Full Text Full Text PDF PubMed Scopus (572) Google Scholar states that atherosclerosis of the lower extremities is more common in elderly than in younger individuals.However, PAD also occurs in young adults (younger than 50 years). Young patients with PAD are of interest because early manifestation of disease is associated with severe symptoms, high comorbidity rate, and aggressive course producing early disability and death. Differences in presence of cardiovascular risk factors presumably distinguishes the manifestation of premature PAD from that seen in older adults.2Levy PJ Hornung CA Haynes JL Rush DS Lower extremity ischemia in adults younger than forty years of age: a community-wide survey of premature atherosclerotic arterial disease.J Vasc Surg. 1994; 19: 873-881Summary Full Text Full Text PDF PubMed Scopus (68) Google ScholarMost young patients with PAD are men. Hormonal protection of premenopausal women is generally cited as the major reason for delayed symptom presentation in women, although PAD does sometimes occur in young women. In the past few decades, several groups have studied this population and tried to identify specific determinants of disease.3Cronenwett JL Davis JT Gooch JB Garrett HE Aortoiliac occlusive disease in women.Surgery. 1980; 88: 775-784PubMed Google Scholar The reported case series conclude that young women with PAD seemed to be heavily loaded with atherosclerotic risk factors. A high prevalence of smoking, hypercholesterolaemia, hypertension, and oral contraceptive use was noted. However, the number of patients in these studies was limited and no controls were included.Large case-control studies have been done to investigate the risk factors for PAD. However, in these studies young women formed only a small part of the study population or were not included at all. Therefore, information on strength and distribution of risk factors in women younger than 50 years is still scarce.4Dormandy J Heeck L Vig S Predictors of early disease in the lower limbs.Semin Vasc Surg. 1999; 12: 109-117PubMed Google ScholarWe did a case-control study to identify risk factors for PAD in young women. All patients—220 patients and 629 controls—were women aged 18–49 years with no history of cardiovascular disease, who had been referred with first symptoms of intermittent claudication between 1990 and 1999. In all patients, PAD was confirmed by angiography. Risk factors for PAD were diabetes, smoking, hypertension, hypercholesterolaemia, hyperhomocysteinaemia, and obesity. 58% of women were exposed to three or more risk factors at time of diagnosis. We noted a strong synergy between risk factors studied.However, the risk factors studied could not explain the development of PAD in all young women. The reason why such severe PAD occurs decades earlier in hormonally protected patients is still not fully understood. Until now, the role of genetic factors in the development of PAD has not been defined. Only Valentine and colleagues5Valentine RJ Verstraete R Clagett P Cohen JC Premature cardiovasculair disease is common in relatives of patients with premature peripheral atheroslcerosis.Arch Intern Med. 2000; 160: 1343-1348Crossref PubMed Scopus (38) Google Scholar have investigated the prevalence of atherosclerotic occlusive disease among family members of young PAD patients. We noted a family history of atherosclerotic vessel disease in 63% of our patients and we suggest that manifestation of PAD in young women has a familial basis. Further research should focus on the role of genetic factors in relation to PAD in these patients. In a seminar on peripheral arterial disease (PAD) Kenneth Ouriel (Oct 13, p 1257)1Ouriel K Peripheral arterial disease.Lancet. 2001; 358: 1257-1264Summary Full Text Full Text PDF PubMed Scopus (572) Google Scholar states that atherosclerosis of the lower extremities is more common in elderly than in younger individuals. However, PAD also occurs in young adults (younger than 50 years). Young patients with PAD are of interest because early manifestation of disease is associated with severe symptoms, high comorbidity rate, and aggressive course producing early disability and death. Differences in presence of cardiovascular risk factors presumably distinguishes the manifestation of premature PAD from that seen in older adults.2Levy PJ Hornung CA Haynes JL Rush DS Lower extremity ischemia in adults younger than forty years of age: a community-wide survey of premature atherosclerotic arterial disease.J Vasc Surg. 1994; 19: 873-881Summary Full Text Full Text PDF PubMed Scopus (68) Google Scholar Most young patients with PAD are men. Hormonal protection of premenopausal women is generally cited as the major reason for delayed symptom presentation in women, although PAD does sometimes occur in young women. In the past few decades, several groups have studied this population and tried to identify specific determinants of disease.3Cronenwett JL Davis JT Gooch JB Garrett HE Aortoiliac occlusive disease in women.Surgery. 1980; 88: 775-784PubMed Google Scholar The reported case series conclude that young women with PAD seemed to be heavily loaded with atherosclerotic risk factors. A high prevalence of smoking, hypercholesterolaemia, hypertension, and oral contraceptive use was noted. However, the number of patients in these studies was limited and no controls were included. Large case-control studies have been done to investigate the risk factors for PAD. However, in these studies young women formed only a small part of the study population or were not included at all. Therefore, information on strength and distribution of risk factors in women younger than 50 years is still scarce.4Dormandy J Heeck L Vig S Predictors of early disease in the lower limbs.Semin Vasc Surg. 1999; 12: 109-117PubMed Google Scholar We did a case-control study to identify risk factors for PAD in young women. All patients—220 patients and 629 controls—were women aged 18–49 years with no history of cardiovascular disease, who had been referred with first symptoms of intermittent claudication between 1990 and 1999. In all patients, PAD was confirmed by angiography. Risk factors for PAD were diabetes, smoking, hypertension, hypercholesterolaemia, hyperhomocysteinaemia, and obesity. 58% of women were exposed to three or more risk factors at time of diagnosis. We noted a strong synergy between risk factors studied. However, the risk factors studied could not explain the development of PAD in all young women. The reason why such severe PAD occurs decades earlier in hormonally protected patients is still not fully understood. Until now, the role of genetic factors in the development of PAD has not been defined. Only Valentine and colleagues5Valentine RJ Verstraete R Clagett P Cohen JC Premature cardiovasculair disease is common in relatives of patients with premature peripheral atheroslcerosis.Arch Intern Med. 2000; 160: 1343-1348Crossref PubMed Scopus (38) Google Scholar have investigated the prevalence of atherosclerotic occlusive disease among family members of young PAD patients. We noted a family history of atherosclerotic vessel disease in 63% of our patients and we suggest that manifestation of PAD in young women has a familial basis. Further research should focus on the role of genetic factors in relation to PAD in these patients.