Ankle Blood Pressure Measurements Research Articles

ARM BASED ON LEG BLOOD PRESSURES (ABLE-BP): CAN SYSTOLIC LEG BLOOD PRESSURE MEASUREMENTS PREDICT BRACHIAL BLOOD PRESSURE? AN INDIVIDUAL PARTICIPANT DATA META-ANALYSIS

Objective: Hypertension is diagnosed and managed using brachial blood pressures; accurate measurement can be impeded by several temporary or permanent factors, including fractures, presence of vascular access devices, limb deformities and altered muscle tone after stroke. Leg (ankle) blood pressure measurement is a practical alternative, but limited data exist to guide clinicians’ interpretation of leg blood pressure values for hypertension diagnosis and treatment. Design and method: Individual participant data meta-analyses were undertaken, using data from 14 studies within the international inter-arm blood pressure difference individual participant data (INTERPRESS-IPD) Collaboration, to 1) determine the relationship between arm and leg systolic blood pressure, 2) develop and validate a multivariable model predicting arm from leg systolic blood pressure, and 3) investigate the prognostic association between leg systolic blood pressure and cardiovascular disease and mortality. Results: Arm and leg systolic blood pressure data existed for 33,710 individuals (mean age: 58 years, mean arm systolic/diastolic blood pressure at baseline: 138/80 mmHg, 45% female). Mean leg systolic blood pressure was 12.0 (95% CI, 8.8 to 15.2) mmHg higher than arm systolic blood pressure. The multivariable model derived to predict highest arm from highest leg systolic blood pressure demonstrated excellent performance (area under receiver operating characteristic curves, sensitivity and specificity remained above 0.89, 0.80 and 0.81, respectively, across blood pressure thresholds from 160 to 130 mmHg). Lowest leg systolic blood pressure was a predictor of all-cause mortality and cardiovascular events over a 10-year period. Cardiovascular risk scores were similar for observed arm systolic blood pressure and the highest arm systolic blood pressure predicted from lowest leg systolic blood pressure [Atherosclerotic Cardiovascular Disease Score: 16.73% (12.65) vs 17.17% (12.61), Framingham Score: 19.33% (15.05) vs 19.91% (15.06)]. Conclusions: These results provide a robust evidence-based method for describing the arm-leg systolic blood pressure relationship and estimating individual brachial systolic blood pressure and cardiovascular risk from leg blood pressure measurements using individual participant data. A freely available and easy-to-use web-based calculator has been created to support patients and clinicians in estimating equivalent arm blood pressure when only leg blood pressure measurements and patient characteristics are available.

Continuous Non-Invasive Arterial Pressure Monitoring (ClearSight System) and Ankle Blood Pressure Measurements as Alternatives to Conventional Arm Blood Pressure.

Measuring blood pressure (BP) via a pneumatic cuff placed around the arm has long been the standard method. However, in clinical situations where BP monitoring at the arm is difficult, the ankle is frequently used instead. We compared continuous non-invasive blood pressure (CNBP) measurements obtained at the finger, ankle BP and arm BP in patients undergoing breast cancer surgery. Arm BP, ankle BP (both obtained with a conventional pneumatic cuff) and CNBP measurements were obtained every 2.5 min during surgery. Correlation and Bland–Altman analyses were performed and differences among measurements were analyzed using a linear mixed model. A total of 245 sets of BP measurements were obtained from 10 patients. All systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean blood pressure (MBP) measurements of ankle BP and CNBP were positively correlated with the arm BP measurements (Spearman rho 0.688–0.836, p < 0.001 for each correlation). The difference between CNBP and arm SBP was significantly smaller (least squares mean (95% confidence interval): −6.03 (−11.40, −0.67)) compared to that between ankle and arm SBP (least squares mean (95% CI): −15.32 (−20.69, −9.96), p = 0.019). However, this significant difference was not observed in DBP and MBP (−1.23 vs. 1.75, p = 0.190 and −3.85 vs. −2.63, p = 0.604, respectively). Ankle SBP measurements showed larger differences from arm SBP measurements than did CNBP SBP measurements in patients undergoing breast cancer surgery. CNBP could serve as a useful alternative to ankle BP when standard arm BP measurements cannot be obtained.

Feasibility Study of Advanced Cardiovascular Screening in Middle-Aged Patients with Diabetes.

PurposeCardiovascular mortality remains high among patients with diabetes compared with the general population. The primary aim was to evaluate the interest in and demand for advanced cardiovascular screening in patients with diabetes; the secondary aim was to explore its efficiency in detecting unprotected subclinical cardiovascular disease (CVD).Patients and MethodsIn a cross-sectional design, randomly selected 40–60-year-old men and women with diabetes were invited to the screening trial. Screening encompassed (1) a comprehensive medical interview; (2) non-contrast computed tomography scanning to quantify coronary artery and aortic valve calcification, to measure left atrial size, to assess heart rhythm and to detect aortic and iliac dilatations; (3) ankle and brachial blood pressure measurements; and (4) blood and urine samples for measurements of HbA1c, lipid profile, renal function, NT-pro B-type natriuretic peptide (pro-BNP) and albuminuria. Primary outcome was participation rate; secondary outcome was rate of unprotected subclinical CVD.ResultsOf 465 invited patients, 191 (41.1%) attended screening. The participation rate was 40% (95% CI:33–47) for males and 42% (95% CI:36–48) for females. Twenty-four patients were excluded due to previous CVD. The remaining patients’ mean age was 52 years; 58% were males. Subclinical CVD was found in 64%, with a male preponderance (males 75% (95% CI:66–83; females 49% (95% CI:37–60)). Presence of severe coronary artery calcification (score ≥ 400) showed a male preponderance (males 19% (95% CI:12–27); females 7% (95% CI:3–16)). Aortic valve calcification, enlarged left atrial volume, atrial fibrillation, aortic dilatations, peripheral artery disease or increased pro-BNP were uncommon, and without any sex differences. Unprotected subclinical CVD was very common, and medical treatment was intensified in 60% (95% CI:53–68) of patients.ConclusionWe propose a feasible cardiovascular screening examination from which middle-aged patients with diabetes may benefit. However, the participation rate may be too low to warrant screening.

Biomass Fuel Use and Cardiac Function in Nepali Women.

Background:Exposure to household air pollution (HAP) from cooking with biomass fuel affects billions of people. We hypothesized that HAP from woodsmoke, compared to other household fuels, was associated with adverse cardiovascular outcomes, of which there have been few studies.Methods:A cross-sectional study was completed in 299 females aged 40–70 years in Kaski District, Nepal, during 2017–18. All participants underwent a standard 12-lead ECG, ankle and brachial systolic blood pressure measurement, and 2D color and Doppler echocardiography. Current stove type was confirmed by inspection. Blood pressure, height, and weight were measured using a standardized protocol. Hypertension was defined as ≥140/90 mmHg or prior diagnosis. Hemoglobin A1c (HbA1c) was obtained, with diabetes mellitus defined as a prior diagnosis or HbA1C ≥ 6.5%. We used adjusted linear and logistic multivariable regressions to examine the relationship of stove type with cardiac structure and function.Results:The majority of women primarily used liquified petroleum gas (LPG) stoves (65%), while 12% used biogas, and 23% used wood-burning cook-stoves. Prevalence of major cardiovascular risk factors was 35% with hypertension, 19% with diabetes mellitus, and 15% current smokers. After adjustment, compared to LPG, wood stove use was associated with increased indexed left atrial volume (β = 3.15, 95% CI 1.22 to 5.09) and increased indexed left ventricular end diastolic volume (β = 7.97, 95% CI 3.11 to 12.83). There was no association between stove type and systemic hypertension, left ventricular mass, systolic dysfunction, diastolic dysfunction, pulmonary hypertension, abnormal ankle-brachial index, or clinically significant ECG abnormalities.Conclusion:Biomass fuel use was associated with increased indexed left atrial volume and increased indexed left ventricular diastolic volume in Nepali women, suggesting subclinical adverse cardiac remodeling from HAP in this cross-sectional study. We did not find evidence of an association with hypertension or typical cardiac sequelae of hypertension. Future studies to confirm these results are needed.

Ankle and arm pressure recordings for the diagnosis of exercise-induced arterial endofibrosis

BACKGROUND: Measurement of ankle and brachial blood pressure after maximal exercise is largely used to diagnose exercise-induced arterial endofibrosis (EIAE). AIMS AND OBJECTIVES: We aimed to compare the different available methods and combination of these and propose a method based on graphical interpretation, for the diagnosis of EIAE. MATERIALS AND METHODS: Finally, we propose a discriminant analysis, allowing an easy graphical interpretation of data. We studied 52 patients with EIAE and 156 asymptomatic controls. RESULTS: Diagnosis accuracy for EIAE was at best 90.9% when using preexisting diagnostic thresholds alone. A combination of these thresholds increased the diagnostic accuracy up to 95.7%. A discriminant analysis equation with a 96.6% accuracy rate was inferred from a simplified algorithm. CONCLUSION: Our graphical representation is an accurate, simple, fast, and inexpensive manner for analyzing the results of exercise arterial pressures for detecting EIAE in athletes.

The ankle brachial index in people with and without diabetes: intra-tester reliability

BackgroundThe ankle-brachial index (ABI) is widely used for determining the presence and severity of peripheral arterial disease (PAD), and current guidelines suggest it should be used to monitor possible progression in affected individuals. It is therefore important that the technique demonstrates adequate reliability for repeated measurements. Existing studies suggest that the ABI is reliable in the general population however, there is a lack of evidence for the reliability of the ABI in people with diabetes. The aim of this study was to investigate the intra-tester reliability of the ABI in people with and without diabetes.MethodsEighty-five participants (40 with and 45 without diabetes) underwent ankle and brachial systolic blood pressure measurements by a single clinician during two testing sessions. Intraclass correlation coefficients (ICC), their 95% limits of agreement, standard error of measurement and minimal detectable change were determined.ResultsIntra-tester reliability of the ABI was found to be good (ICC: 0.80), however sub-group analysis of participants with and without diabetes found that ABI was slightly less reliable in people with diabetes (ICC: 0.78) than in those without (ICC: 0.82). The relatively large limits of agreement (− 0.16 to 0.16), standard error of measurement (0.03 overall, 0.04 for the diabetes group), and minimal detectable change (0.08 overall, 0.11 for the diabetes group) suggest that a large change in ABI is required for it to demonstrate a true change rather than the result of measurement variability. The minimal detectable change for the ABI was 0.08 overall, and 0.11 for the diabetes group.ConclusionsThe ABI demonstrated good reliability in all groups analysed. However, the wide limits of agreement and considerable standard error of measurement obtained support the use of multiple methods of vascular assessment for ongoing monitoring of lower limb vascular status.

The DanCavas Pilot Study of Multifaceted Screening for Subclinical Cardiovascular Disease in Men and Women Aged 65–74 Years

This pilot study of a large population based randomised screening trial investigated feasibility, acceptability, and relevance (prevalence of clinical and subclinical cardiovascular disease [CVD] and proportion receiving insufficient prevention) of a multifaceted screening for CVD. In total, 2060 randomly selected Danish men and women aged 65–74 years were offered (i) low dose non-contrast computed tomography to detect coronary artery calcification (CAC) and aortic/iliac aneurysms; (ii) detection of atrial fibrillation (AF); (iii) brachial and ankle blood pressure measurements; and (iv) blood levels of cholesterol and hemoglobin A1c. Web based self booking and data management was used to reduce the administrative burden. Attendance rates were 64.9% (n = 678) and 63.0% (n = 640) for men and women, respectively. In total, 39.7% received a recommendation for medical preventive actions. Prevalence of aneurysms was 12.4% (95% confidence interval [CI] 9.9–14.9) in men and 1.1% (95% CI 0.3–1.9) in women, respectively (p < .001). A CAC score > 400 was found in 37.8% of men and 11.3% of women (p < .001), along with a significant increase in median CAC score with age (p = .03). Peripheral arterial disease was more prevalent in men (18.8%, 95% CI 15.8–21.8) than in women (11.2%, 95% CI 8.7–13.6). No significant differences between the sexes were found with regard to newly discovered AF (men 1.3%, women 0.5%), potential hypertension (men 9.7%, women 11.5%), hypercholesterolemia (men 0.9%, women 1.1%) or diabetes mellitus (men 2.1%, women 1.3%). Owing to the higher prevalence of severe conditions, such as aneurysms and CAC ≥ 400, screening for CVD seemed more prudent in men than women. The attendance rates were acceptable compared with other screening programs and the logistical structure of the screening program proved successful.

The DanCavas Pilot Study of Multifaceted Screening for Subclinical Cardiovascular Disease in Men and Women Aged 65–74 Years

This pilot study of a large population based randomised screening trial investigated feasibility, acceptability, and relevance (prevalence of clinical and subclinical cardiovascular disease [CVD] and proportion receiving insufficient prevention) of a multifaceted screening for CVD. In total, 2060 randomly selected Danish men and women aged 65-74 years were offered (i) low dose non-contrast computed tomography to detect coronary artery calcification (CAC) and aortic/iliac aneurysms; (ii) detection of atrial fibrillation (AF); (iii) brachial and ankle blood pressure measurements; and (iv) blood levels of cholesterol and hemoglobin A1c. Web based self booking and data management was used to reduce the administrative burden. Attendance rates were 64.9% (n=678) and 63.0% (n=640) for men and women, respectively. In total, 39.7% received a recommendation for medical preventive actions. Prevalence of aneurysms was 12.4% (95% confidence interval [CI] 9.9-14.9) in men and 1.1% (95% CI 0.3-1.9) in women, respectively (p<.001). A CAC score > 400 was found in 37.8% of men and 11.3% of women (p<.001), along with a significant increase in median CAC score with age (p=.03). Peripheral arterial disease was more prevalent in men (18.8%, 95% CI 15.8-21.8) than in women (11.2%, 95% CI 8.7-13.6). No significant differences between the sexes were found with regard to newly discovered AF (men 1.3%, women 0.5%), potential hypertension (men 9.7%, women 11.5%), hypercholesterolemia (men 0.9%, women 1.1%) or diabetes mellitus (men 2.1%, women 1.3%). Owing to the higher prevalence of severe conditions, such as aneurysms and CAC≥400, screening for CVD seemed more prudent in men than women. The attendance rates were acceptable compared with other screening programs and the logistical structure of the screening program proved successful.

Experiences from the Pilot Study of the Danish Cardiovascular Screening (DANCAVAS) Study

Objective: To assess the feasibility, organization, and attendance experience of men and women, aged 65e74, who underwent a combination cardiovascular screening for aortic aneurysms, coronary calcium scores, atrial fibrillation, hypertension, peripheral arterial disease, hypercholesterolemia and diabetes mellitus. Methods: Attenders were booked via a web-based program with 10 minute sessions, covering four issues: 1) Informed consent and an interview, including family history, medication, history of smoking, prior cardiovascular disease and quality of life. 2) Bilateral brachial and ankle blood pressure measurements. 3) Electroocardiogram gated non-contrast computed tomography and, 4) Blood sampling. Data were then entered into a database, supplemented with a weekly running program to identify positive findings for recommended additional prevention. Results: Web-based solutions for booking and data-management worked remarkably well with no major issues. There were 1044 men and 1016 women invited, of which 678 (63%) men and 640 (63%) women attended screening. No exclusion criteria were applied. Compared to the American MESA group, a more rapid increase in CAC by age was registered in Danish males and women. Apart from these findings and isolated hypercholesterolaemia, men had an increased risk of all other positive findings, especially concerning ascending aortic-, abdominal aortic-, and iliac aneurysm. In all, men accounted for 90.9% of all detected aneurysms. In 7.8% of these aneurysms, criteria for surgery were fulfilled. Conclusion: The offer of this combination screening proved feasible, while acceptable attendance rates were observed, and it appears potentially most cost-effective for men. Consequently, the offer of this combination screening will be extended to other sites with randomization of 45.000 men aged 65e74 years.

Blood pressure measurements in the ankle are not equivalent to blood pressure measurements in the arm.

Blood pressure (BP) is often measured on the ankle in the emergency department (ED), but this has never been shown to be an acceptable alternative to measurements performed on the arm. To establish whether the differences between arm and ankle non-invasive BP measurements were clinically relevant (i.e. a difference of ≥10 mmHg). This was a prospective cross-sectional study in an urban ED making use of a convenience sample of 201 patients (18 - 50 years of age) who were not in need of emergency medical treatment. BP was measured in the supine position on both arms and ankles with the correct size cuff according to the manufacturer's guidelines. The arm and ankle BP measurements were compared. There was a clinically and statistically significant difference between arm and ankle systolic BP (SBP) and mean arterial pressure (MAP) (-13 mmHg, 95% confidence interval (CI) -28 - 1 mmHg and -5 mmHg, 95% CI -13 - 4 mmHg, respectively), with less difference in diastolic BP (DBP) (2 mmHg, 95% CI -7 - 10 mmHg). Only 37% of SBP measurements and 83% of MAP measurements were within an error range of 10 mmHg, while 95% of DBP measurements agreed within 10 mmHg. While the average differences (or the bias) were generally not large, large variations in individual patients (indicating poor precision) made the prediction of arm BP from ankle measurements unreliable. Ankle BP cannot be used as a substitute for arm BP in the ED.

Clinical Nurse Specialists Leading Research to Improve Practice in the Use of Ankle Blood Pressure Readings

The purpose of this article is to describe Clinical Nurse Specialist (CNS) practice as it relates to leadership in clinical research through the presentation of a study on ankle blood pressure (BP) measurements led by the CNS. Under the direction of the CNS, staff nurses engaged in the EBP process to explore the association between arm and ankle BP measurements. This EBP project led to a research study which was directed and led by the CNS. CNS practice requires leadership in the areas of evidence-based practice and research. CNS leadership was critical to the success of the research project. A descriptive study was undertaken which examined the agreement between upper extremity BP readings and ankle BP readings by comparing a series of three simultaneous ankle and arm BP readings on 174 subjects. Leading the research project elevated the CNS's visibility and influence within the organization by clearly demonstrating the value of the CNS in the research process and the impact nursing research has on nursing practice and patient outcomes.

Observational study comparing non‐invasive blood pressure measurement at the arm and ankle during caesarean section

Upper-arm non-invasive blood pressure measurement during caesarean section can be uncomfortable and unreliable because of movement artefact in the conscious parturient. We aimed to determine whether ankle blood pressure measurement could be used instead in this patient group by comparing concurrent arm and ankle blood pressure measured throughout elective caesarean section under regional anaesthesia in 64 term parturients. Bland-Altman analysis of mean difference (95% limits of agreement [range]) between the ankle and arm was 11.2 (-20.3 to +42.7 [-67 to +102]) mmHg for systolic arterial pressure, -0.5 (-21.0 to +19.9 [-44 to +91]) mmHg for mean arterial pressure and -3.8 (-25.3 to +17.8 [-41 to +94]) mmHg for diastolic arterial pressure. Although ankle blood pressure measurement is well tolerated and allows greater mobility of the arms than measurement from the arm, the degree of discrepancy between the two sites is unacceptable to allow routine use of ankle blood pressure measurement, especially for systolic arterial pressure. However, ankle blood pressure measurement may be a useful alternative in situations where arm blood pressure measurement is difficult or impossible.

Effect of pre‐test rest duration on toe and ankle systolic blood pressure measurements

Background Measurement of toe and ankle blood pressure is used to evaluate the peripheral arterial status of patients, yet the pre-test rest period is inconsistent in published studies and among practitioners, and could affect results. The aim of this systematic review was to evaluate all research that has investigated the effect of different periods of pre-test rest on toe and ankle systolic blood pressure. Methods MEDLINE (from 1946), EMBASE (from 1947), CINAHL (from 1937), and Cochrane Central Register of Controlled Trials (CENTRAL) (from 1800) were searched up to April 2012. No language or publication restrictions were applied. Eighty-eight content experts and researchers in the field were contacted by email to assist in the identification of published, unpublished, and ongoing studies. Studies evaluating the effect of two or more pretest rest durations on toe or ankle systolic blood pressure were eligible for inclusion. No restrictions were placed on participant characteristics or the method of blood pressure measurement. Outcomes included toe or ankle systolic blood pressure and adverse effects. Abstracts were independently assessed by two reviewers for potential inclusion. Results 1658 abstracts were identified by electronic searching. Thirty three of the 88 content experts and researchers in the field replied, identifying five potentially relevant studies. No studies were eligible for inclusion. Conclusion There is no evidence of the effect of different periods of pre-test rest duration on toe and ankle systolic blood pressure measurements. Rigorous trials evaluating the effect of different durations of pre-test rest are required to direct clinical practice and research.

Excellent tolerance to cilnidipine in hypertensives with amlodipine - induced edema

Background:Ankle edema is a common adverse effect of amlodipine, an L-type calcium channel blocker (CCB). Cilnidipine is a newer L/N-type CCB, approved for treatment of essential hypertension.Aim:This study was designed to determine whether cilnidipine can produce resolution of amlodipine-induced edema while maintaining adequate control of hypertension.Materials and Methods:A prospective study was performed on 27 patients with essential hypertension with amlodipine-induced edema. Concomitant nephropathy, cardiac failure, hepatic cirrhosis, or other causes of edema, and secondary hypertension were excluded by appropriate tests. Amlodipine therapy was substituted in all the cases with an efficacy-equivalent dose of cilnidipine. Clinical assessment of ankle edema and measurement of bilateral ankle circumference, body weight, blood pressure, and pulse rate were performed at onset of the study and after 4 weeks of cilnidipine therapy.Results:At completion of the study, edema had resolved in all the patients. There was a significant decrease in bilateral ankle circumference and body weight (P < 0.001). There was no significant change in mean arterial blood pressure and pulse rate.Conclusions:Therapy with cilnidipine resulted in complete resolution of amlodipine-induced edema in all the cases without significant worsening of hypertension or tachycardia. Cilnidipine is an acceptable alternative antihypertensive for patients with amlodipine-induced edema.

Hemoglobin A1c and Arterial and Ventricular Stiffness in Older Adults

ObjectiveArterial and ventricular stiffening are characteristics of diabetes and aging which confer significant morbidity and mortality; advanced glycation endproducts (AGE) are implicated in this stiffening pathophysiology. We examined the association between HbA1c, an AGE, with arterial and ventricular stiffness measures in older individuals without diabetes.Research Design & MethodsBaseline HbA1c was measured in 830 participants free of diabetes defined by fasting glucose or medication use in the Cardiovascular Health Study, a population-based cohort study of adults aged ≥65 years. We performed cross-sectional analyses using baseline exam data including echocardiography, ankle and brachial blood pressure measurement, and carotid ultrasonography. We examined the adjusted associations between HbA1c and multiple arterial and ventricular stiffness measures by linear regression models and compared these results to the association of fasting glucose (FG) with like measures.ResultsHbA1c was correlated with fasting and 2-hour postload glucose levels (r = 0.21; p<0.001 for both) and positively associated with greater body-mass index and black race. In adjusted models, HbA1c was not associated with any measure of arterial or ventricular stiffness, including pulse pressure (PP), carotid intima-media thickness, ankle-brachial index, end-arterial elastance, or left ventricular mass (LVM). FG levels were positively associated with systolic, diastolic and PP and LVM.ConclusionsIn this sample of older adults without diabetes, HbA1c was not associated with arterial or ventricular stiffness measures, whereas FG levels were. The role of AGE in arterial and ventricular stiffness in older adults may be better assessed using alternate AGE markers.

Importance of the Ankle-Brachial Pressure Index in the Diagnosis of Coronary Artery Disease in Women With Diabetes Without Anginal Pain

Clinical symptoms of coronary artery disease (CAD) are often atypical in women, particularly in those with diabetes mellitus. Therefore, a simple diagnostic test to identify a high-risk subset of women with diabetes who are likely to have CAD is important. A total of 407 consecutive patients (319 men and 88 women, age range 68 ± 11 years) with suspected CAD, who were not complaining of anginal pain, were evaluated. Among these patients, 170 had diabetes. Stress myocardial perfusion imaging and simultaneous brachial and ankle blood pressure measurements were performed to obtain the ischemic total perfusion deficit (TPD) and ankle-brachial pressure index (ABI), respectively. Ischemic TPD was not significantly different between men and women, whereas ischemic TPD was significantly greater in diabetic patients than in non-diabetic patients (6.9 ± 7.7% vs. 4.9 ± 6.1%; P = 0.005). In diabetic patients, ischemic TPD was not significantly different between men and women. However, women with ABI<0.9 showed significantly greater ischemic TPD than those with ABI≥0.9 (12.1 ± 10.8% vs. 5.1 ± 5.9%; P=0.04), whereas no difference in ABI was observed in men. ABI was useful in evaluating CAD in asymptomatic women with diabetes to detect a high-risk subset showing the ischemic TPD of >10%, which is regarded as a scintigraphic indicator for coronary revascularization.

Plasma osteoprotegerin is related to carotid and peripheral arterial disease, but not to myocardial ischemia in type 2 diabetes mellitus

BackgroundCardiovascular disease (CVD) is frequent in type 2 diabetes mellitus patients due to accelerated atherosclerosis. Plasma osteoprotegerin (OPG) has evolved as a biomarker for CVD. We examined the relationship between plasma OPG levels and different CVD manifestations in type 2 diabetes.MethodsType 2 diabetes patients without known CVD referred consecutively to a diabetes clinic for the first time (n = 305, aged: 58.6 ± 11.3 years, diabetes duration: 4.5 ± 5.3 years) were screened for carotid arterial disease, peripheral arterial disease, and myocardial ischemia by means of carotid artery ultrasonography, peripheral ankle and toe systolic blood pressure measurements, and myocardial perfusion scintigraphy (MPS). In addition, plasma OPG concentrations and other CVD-related markers were measured.ResultsThe prevalence of carotid arterial disease, peripheral arterial disease, and myocardial ischemia was 42%, 15%, and 30%, respectively. Plasma OPG was significantly increased in patients with carotid and peripheral arterial disease compared to patients without (p < 0.001, respectively), however, this was not the case for patients with myocardial ischemia versus those without (p = 0.71). When adjusted for age, HbA1c and U-albumin creatinine ratio in a multivariate logistic regression analysis, plasma OPG remained strongly associated with carotid arterial disease (adjusted OR: 2.12; 95% CI: 1.22-3.67; p = 0.008), but not with peripheral arterial disease or myocardial ischemia.ConclusionsIncreased plasma OPG concentration is associated with carotid and peripheral arterial disease in patients with type 2 diabetes, whereas no relation is observed with respect to myocardial ischemia on MPS. The reason for this discrepancy is unknown.Trial registration numberat http://www.clinicaltrial.gov: NCT00298844

Ankle and exercise blood pressures as predictors of coronary morbidity and mortality in a prospective follow-up study

Elevated ankle blood pressure (ABP) may be one of the earliest signs of subclinical atherosclerosis. However, its behavior in different degrees of atherosclerotic vascular damage has not been well characterized. We examined the association of ABP and brachial exercise blood pressure with the incidence of future coronary events. A cohort of 3808 consecutive ambulatory persons (mean age 50 years, 34% women), referred to a symptom-limited exercise test and free of cardiovascular events at baseline, was prospectively followed up for 15 years. Altogether, 383 (80 fatal and 303 non-fatal) incident coronary events occurred. Cox proportional hazards models, adjusting for several conventional risk factors, were used to analyse the independent association of ABP with the risk of an incident coronary heart disease (CHD) event. Persons with normal ankle, brachial resting and brachial exercise blood pressures were taken as the reference group. Other groups were formed on the basis of ankle and exercise blood pressures and compared with the reference group. Even in persons among whom the elevated ABP was the only abnormal finding, the multivariate adjusted hazard ratio (HR) of a future CHD event was significantly elevated (HR=1.60, 95% confidence interval 1.20-2.14, P<0.0001). In general, the HRs were higher for fatal events than for non-fatal events. The measurement of ABP could be an inexpensive and non-invasive tool to detect elevated risk of a CHD event.

Myocardial ischemia, carotid, and peripheral arterial disease and their interrelationship in type 2 diabetes patients

BackgroundCardiovascular disease (CVD) is the leading cause of death in type 2 diabetes mellitus (T2DM) patients. We examined the relationship between CVD in different vascular territories. MethodsT2DM patients without known or suspected CVD (n = 305) referred consecutively to a diabetes clinic for the first time and age-matched nondiabetic reference subjects (n = 40) were screened for myocardial ischemia, carotid, and peripheral arterial disease by means of myocardial perfusion scintigraphy, carotid artery ultrasonography, and peripheral ankle and toe systolic blood pressure measurements. ResultsIn the T2DM patients, the prevalence of myocardial ischemia, carotid, and peripheral arterial disease was 30%, 42%, and 15%, respectively, almost three times higher than in the reference subjects (P = 0.007, P = 0.001, and P = 0.09, respectively). T2DM patients with myocardial ischemia, carotid, or peripheral arterial disease had a significantly increased risk of CVD in other vascular territories as well (OR: 1.99, 2.09, and 3.09, respectively). However, 40%, 52%, and 22% of the T2DM patients with myocardial ischemia, carotid, or peripheral arterial disease demonstrated exclusively this particular type of CVD manifestation. ConclusionsIn T2DM patients, signs of CVD in one vascular territory carry a significantly increased risk of CVD in other territories, although many patients only presented one manifestation.

The association between diabetes mellitus and the prevalence of intermittent claudication: the HUNT study

The objective of this study was to investigate the association between diabetes mellitus (DM) and the prevalence of intermittent claudication (IC). Between 1995 and 1997, all residents aged 20 years or older in Nord-Trøndelag County, Norway were mailed an invitation to participate in a health survey (HUNT 2). A total of 19,712 participants aged 40-69 years old completed and returned the questionnaire included with the invitation. They also attended an examination where brachial blood pressure was measured and non-fasting venous blood was collected. The venous blood sample was subsequently analysed for concentrations of blood lipids. Responses to 12 questions on IC were previously tested against ankle blood pressure measurements (ABPI < 0.9) and the algorithm with the best test properties was used to identify individuals with IC. Participants reported a history of DM by simple questions in the questionnaire. Logistic regression analysis was then used to compute age-adjusted prevalence odds ratios for the association between exposure variables and the prevalence of IC. Potential confounding by smoking, blood lipids and brachial blood pressure was investigated in multivariate analyses. For both sexes IC was more common in individuals with DM (OR(women) = 3.8, CI, 1.9-7.6; OR(men) = 2.8, CI, 1.4-5.8) compared to participants without DM. Adjustment for smoking, blood lipids and brachial blood pressure did not substantially change these results. In conclusion, the prevalence of IC was more than three times higher in patients with DM compared to non-diabetic participants.