Change In Ankle-brachial Index Research Articles

Shorter Telomere Length is Associated With Greater Decrease in Ankle-Brachial Index in Elderly Chinese Women but not Men

Telomere shortening has been shown to contribute to the pathogenesis of atherosclerosis directly or through influencing cardiovascular risk factors. We examined telomere length (TL) and change in ankle-brachial index (ABI) over 5 years in a Chinese population aged 65 years and older living in the community. Telomere length was determined using the quantitative polymerase chain reaction (PCR) method in 976 men and 1030 women. Ankle-brachial index was measured using Doppler ultrasound. Analysis of covariance was used to examine the relationship between quartiles of TL and baseline ABI values as well as percentage change in ABI, adjusting for confounders. Women had longer TL and lower ABI values compared with men, and there was a significant trend for an inverse association between TL and percentage decline in ABI after adjustment for confounders. No significant association was observed in men. The findings support the association between TL and markers of atherosclerosis in older women but not men.

The Effects Of Resistance Training On Muscular Strength And Ankle-brachial-index In Those With Osteoarthritis

Knee osteoarthritis (OA) is a primary cause of disability in adults. The negative consequences associated with physical inactivity and OA necessitates the need for investigation into methods of prevention and treatment. PURPOSE: To investigate the effects of a resistance training program on muscular strength and ankle-brachial-index (ABI) in an osteoarthritic population. METHODS: Fifteen subjects, 14 females and one male, were randomly assigned to an intervention group (6 females, 1 male, age=67.50 ± 5.13yrs, height=164.69 ± 5.88cm, mass=89.47±19.29kg) or control group (6 females, age=72.10±9.31yrs, height=164.69±5.39cm, mass=81.55±23.42kg). Peak torque/body weight isometric lower extremity muscular strength (hip, knee and ankle) and ABI was measured in all subjects at the start of the study and again 4 weeks later. The intervention group participated in a resistance-training program for the lower extremity three days per week. The control group refrained from any strength training. Both groups participated in twenty minutes of cardiovascular activity during the four week study. RESULTS: No differences were observed between groups (intervention, control) or across time (pre, four weeks) for muscular strength variables, and ABI (p >.05). Trends towards significance was seen with changes in hip abductor strength (p= 0.6) and ABI, knee extensor strength and ABI (p= 0.08). CONCLUSION: The current study suggests that a four-week resistance training program for the lower-body may not be enough to demonstrate significant improvements in muscular strength and ABI. Although there were no significant improvements in lower extremity strength, there did appear to be relationship with strength increases and ABI. Therefore further research should continue to examine strength and potential improvement in vascular function in those with OA.

Abstract 4934: CLI-Bright: A Phase I Randomized Blinded Clinical Trial Comparing the Effect of Intramuscular Injection of Autologous Bone Marrow Derived Aldehyde Dehydrogenase Bright Cells and Mononuclear Stem Cells in Patients With Critical Limb Ischemia

Background: Critical limb ischemia (CLI) is an advanced stage of peripheral arterial disease (PAD) associated with high morbidity and mortality. Functional improvement and lower amputation rates have been reported in clinical studies using intramuscular (IM) injection of autologous bone marrow mononuclear cells (ABMMNC) into ischemic limbs. Aldehyde Dehydrogenase-Bright (ALDH br ) cells are a highly potent subpopulation of ABMMNC and preclinical studies suggest that ALDH br cells may contribute more effectively to angiogenesis. Therefore, we investigated the safety and efficacy of ALDH br compared to ABMMNC in CLI patients who were not candidate for revascularization. Methods: 21 patients (mean age 72, 13 men) with ankle-brachial index (ABI) < 0.5 and Rutherford category (RC) 4 – 5, were randomized to receive 10 IM injections of either ALDH br cells (n=11) or ABMMNCs (n=10) into the gastrocnemius muscle of the affected limb. Primary outcomes at 3 months were safety and efficacy based on ABI, transcutaneous partial pressure of oxygen (tcPO 2 ), RC, and ischemic ulcer grade. Paired t-test or Wilcoxon sign test was used for statistical analysis. Results: The mean number of ALDH br cells and ABMMNCs implanted were 1.33 × 10 6 and 1.207 × 10 6 . There were no significant clinical differences between the two groups at baseline. There was no adverse reaction to IM injections. One amputation occurred in each group. One death occurred in ALDH br patients, which was not related to the therapy. At 3 months in ALDH br group, ABI and RC improved 0.14 (p=0.025) and 0.64 (p=0.04), respectively. In the ABMMNC group, there were non significant changes in ABI and RC (0.08 and 0.67, respectively). No significant changes from baseline were noted in tcPO 2 and ischemic ulcer grade in either group. Conclusion: IM implantation of ALDHbr cells appears to be safe and our efficacy measures will be the first to compare selected from unselected cells in treatment of critical limb ischemia. Table: ABI, RC and tcPO2 in both groups

Invited commentary

Changes in the ankle-brachial index (ABI) and progression to peripheral arterial disease (PAD) may result in major detrimental effects on quality of life and functional status and, more importantly, are potent predictors of myocardial infarction, stroke, and death. Despite its frequent occurrence, little is known about the natural history of PAD among minority ethnic groups. The Multi-Ethnic Study of Atherosclerosis (MESA) was designed to determine ethnic differences in the progression of subclinical to clinical cardiovascular disease. In the current study, Allison et al assessed changes in ABI in the MESA cohort over a 3-year time period. The authors conclude that besides traditional risk factors, African Americans had a significantly higher risk of progression to a low ABI (<0.9) and a reduced trend towards progression to a high ABI (>1.4). Conversely, Hispanics and Chinese did not reveal significant changes in ABI over time. These findings should not come as a surprise as African Americans have repeatedly been shown to have a higher prevalence of PAD, which appears independent of both traditional and novel vascular risk factors. There are, however, several uncertainties and ambiguities that deserve further investigation. Although PAD has traditionally been defined as resting ABI of less than 0.90, the ABI may underestimate the severity of disease in individuals with calcified, noncompressible arteries, which are more frequent in individuals with diabetes, chronic renal failure, or advanced age. Although the literature quoted by most epidemiologic studies, including this one, regarding the accuracy of the ABI to detect PAD is primarily based in small clinical observational studies that assessed individuals with established PAD prior to treatment, the ABI has been accepted without adequate scrutiny in all populations, including those with high prevalence of diabetes. In the MESA cohort, Hispanics did not have an increased risk of significant ABI changes despite similar age and sex-adjusted prevalence of baseline diabetes and dyslipidemia compared with African Americans. Allison et al claim that the stability of ABI among Hispanics may be related to either no actual changes or similar progression in atherosclerosis and arterial rigidity. If one assumes that, as suggested by the authors, progression is the rule, the lack of changes in ABI may be more likely related to progression of both atherosclerosis and arterial rigidity. It may also mean that among Hispanics, there may be individuals with either baseline or subsequent stenosis of 50% or more in a major leg artery, ie, PAD, that may not result in lower ABI because of the “compensatory” increased arterial rigidity. The ABI may, therefore, be inaccurate to detect PAD in Hispanics given their high prevalence of diabetes and vascular calcification that render the ABI unreliable. Other noninvasive tests, such as pulse volume recordings and toe-brachial index, in addition to the ABI, should be assessed for accurate detection and screening of PAD in this defined population. Ethnicity and risk factors for change in the ankle-brachial index: The Multi-Ethnic Study of AtherosclerosisJournal of Vascular SurgeryVol. 50Issue 5PreviewThe aim of this study was to determine the risk factors for conversion from a normal to either a low or high ankle-brachial index (ABI). Full-Text PDF Open Archive

Effect of Double Filtration Plasmapheresis (DFPP) in Male Patients with Borderline Hyper-LDL-cholesterolemia : Lipid Removal and Inflammation Suppression

Objective: Double filtration plasmapheresis (DFPP) removal of LDL cholesterol (LDL-C) and other pathogenic substances in the blood has attracted attention as an effective treatment of arteriosclerotic lesions. We conducted a controlled open-label study to understand the physical and mental effects of DFPP.Methods: Seven (7) male patients with borderline hyper-LDL-C (134.0±41.1 mg/dL) were assigned to a DFPP group (age 43.0±5.3 years, BMI 26.0±4.5) and 7 others were assigned to a control group (age 39.1±11.4 years, BMI 28.9±8.1). The observation period was 8 weeks. Patients in the DFPP group received DFPP twice. The evaluation included the Anti-Aging QOL Common Questionnaire (AAQol) and the blood vessel tests of Pulse wave velocity (PWV) and ankle-brachial index (ABI).Results: Among physical symptoms in AAQol, “tired eyes,” “blurry eyes,” “stiff shoulders,” and “feeling of ill-health” significantly decreased after 8 weeks in the DFPP group. Hematology revealed that hemoglobin (+3.6%, p=0.047), total protein (+4.1%, p=0.019), and albumin (+4.9%, p=0.018) were maintained at higher levels after 8 weeks in the DFPP group than the control group. Despite LDL-C removal, the hepatic steatosis index ALT (+5.7%, p=0.008) and lipid metabolism index LDL-C (+11.6%, p=0.012) were apparently higher in the DFPP group. Endocrinology showed a decreasing trend of DHEA-s (−13.7%, p=0.003), increasing trend of cortisol (+27.5%, p=0.005), and increasing trend of progesterone (+50%, p=0.030) in the DFPP group compared with the control group. High-sensitivity CRP tended to decrease in the DFPP group compared with the control group (−26.5%, p=0.030). There was no significant change in PWV or ABI in the DFPP group. No serious adverse events were caused by DFPP.Conclusion: LDL-C removal by DFPP might suppress inflammation and improve tissue environment in visceral adipose and liver tissues with fatty deposits.

Alcohol Consumption and Lower Extremity Arterial Disease among Older Adults: The Cardiovascular Health Study

Few studies of the relation of alcohol intake to lower-extremity arterial disease (LEAD) have included clinical events and objective measurements repeated longitudinally. As part of the Cardiovascular Health Study, a study of older adults from four US communities, 5,635 participants reported their use of beer, wine, and spirits yearly. Incident LEAD was identified by hospitalization surveillance. Technicians measured ankle-brachial index 6 years apart in 2,298 participants. A total of 172 cases of LEAD were documented during a mean of 7.5 years of follow-up between 1989 and 1999. Compared with abstention, the multivariable-adjusted hazard ratios were 1.10 (95% confidence interval (CI): 0.71, 1.71) for <1 alcoholic drink per week, 0.56 (95% CI: 0.33, 0.95) for 1-13 drinks per week, and 1.02 (95% CI: 0.53, 1.97) for > or =14 drinks per week (p for quadratic trend = 0.04). These relations were consistent within strata of sex, age, and apolipoprotein E genotype, and neither lipids nor inflammatory markers appeared to be important intermediates. Change in ankle-brachial index showed a similar relation (p for quadratic trend = 0.01). Alcohol consumption of 1-13 drinks per week in older adults may be associated with lower risk of LEAD, but heavier drinking is not associated with lower risk.

Results from a phase II multicenter, double-blind placebo-controlled study of Del-1 (VLTS-589) for intermittent claudication in subjects with peripheral arterial disease

This study compared VLTS-589 (plasmid encoding the angiomatrix protein Del-1 in conjunction with poloxamer 188) with poloxamer 188 control, for the treatment of intermittent claudication in patients with moderate to severe peripheral arterial disease. Subjects with bilateral intermittent claudication and peak walking time (PWT) between 1 and 10 minutes on 2 qualifying (reproducible; within 25% of each other) treadmill tests were enrolled. Patients received VLTS-589 or poloxamer 188 control, administered as 21 intramuscular injections to each lower extremity (42 mL in each extremity). In addition to safety and tolerability, efficacy evaluations compared to baseline included the following: change in PWT at 90 days (primary end point), change in claudication onset time, change in ankle brachial index (ABI), and change in quality of life measures. A total of 105 patients were randomized and treated. During the 30, 90, and 180 days follow-up, mean PWT, claudication onset time, and ABI were significantly increased compared to baseline values in both treatment groups with no significant difference between groups in the primary or secondary end points. In addition, both groups demonstrated significantly improved quality of life at follow-up vs baseline, with no significant differences between groups. Serious adverse events were similar in both groups--none were definitely treatment-related. Intramuscular delivery of both Del-1 expressing plasmid and the control resulted in significant improvement in exercise capacity compared to baseline at 30, 90, and 180 days. There was no difference in outcome measures associated with the Del-1 plasmid.

Value of Electrocardiographic and Ankle–Brachial Index Abnormalities for Prediction of Coronary Atherosclerosis in Asymptomatic Subjects With Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (DM) is associated with increased cardiovascular risk, in part due to accelerated subclinical atherosclerosis. Electrocardiographic (ECG) and ankle-brachial index (ABI) abnormalities are used to screen for cardiovascular risk in the clinic. However, their capacity to identify patients with type 2 DM with nonobstructive subclinical atherosclerosis is unknown. Associations of ECG and ABI abnormalities with coronary artery calcium (CAC), a measure of coronary atherosclerosis, were examined using multivariable ordinal regression modeling in 589 asymptomatic patients with type 2 DM. Sensitivity, specificity, and positive and negative predictive values were determined. CAC was prevalent (44% CAC>00; 32% CAC>5th percentile score) despite normal electrocardiograms (64%) and ABIs (97%) in most subjects. Neither ECG nor ABI changes predicted CAC after adjusting for age, gender, and race. ECG abnormalities were neither sensitive nor specific for detection of CAC>100, >400, or>75th percentile (sensitivities 0.43, 0.45, and 0.34; specificities 0.69, 0.66, and 0.63, respectively). ABI abnormalities were not sensitive (0.03, 0.04, and 0.03) but had high specificity (0.98, 0.98, and 0.98). In subjects with normal electrocardiograms and ABIs, extensive CAC was remarkably prevalent (CAC>00 in 24%). In conclusion, ECG and ABI abnormalities failed to detect patients with subclinical coronary atherosclerosis and therefore may be of limited value in identifying many asymptomatic patients with type 2 DM at increased risk of cardiovascular disease.

Outcome After Endovascular Treatment of Deep Femoral Artery Stenosis:Results in a Consecutive Patient Series and Systematic Review of the Literature

To evaluate immediate and midterm clinical outcomes after percutaneous transluminal angioplasty (PTA) of deep femoral artery stenosis in patients with chronically occluded superficial femoral arteries (SFA) and to report the results of a systematic review of the literature in this field. A retrospective analysis was conducted of 55 consecutive patients (42 men; median age 72 years, interquartile range [IQR] 63-79) with severe intermittent claudication (n = 38) or critical limb ischemia (n = 17) who underwent balloon angioplasty of deep femoral artery stenosis. Patients were followed with ankle-brachial index (ABI) measurement, estimation of maximum walking capacity, clinical staging of peripheral artery disease (PAD), and duplex ultrasound imaging for restenosis. A systematic review of the literature using MEDLINE, EMBASE, and a hand search was done. Technical success (residual stenosis < 30%) was achieved in 85% (47/55), with 1 (2%) minor complication. The median ABI marginally increased from 0.48 at baseline to 0.53 post intervention without significant difference in the change of ABI between patients with supra- or infragenicular reconstitution of the femoropopliteal runoff. During a median 13-month (IQR 3-42) follow-up, no significant improvement in ABI or walking distance was maintained, and only 16 (29%) patients reported a sustained clinical improvement by 1 PAD stage. Cumulative patency and reintervention-free survival rates were, respectively, 71% and 61% at 1 year and 49% and 48% at 3 years. In the literature, only case series were found, but no randomized trial evaluating the efficacy of deep femoral artery PTA. PTA of the deep femoral artery can be performed with high technical success rates at a low interventional risk. However, in the majority of patients, this technique yields no sustained hemodynamic or clinical benefit. Due to a high rate of late failures, it should be reserved for limb salvage in patients without a surgical alternative.

Statin Use and Functional Decline in Patients With and Without Peripheral Arterial Disease

We determined whether statin use (vs. non-use) is associated with less annual decline in lower-extremity functioning in patients with and without lower-extremity peripheral arterial disease (PAD) over three-year follow-up. It is unclear whether statin use is associated with less functional decline in patients with PAD. Participants included 332 men and women with an ankle brachial index (ABI) <0.90 and 212 with ABI 0.90 to 1.50. Functional outcomes included 6-min walk distance and usual and rapid-pace 4-m walking velocity. A summary performance score combined performance in walking speed, standing balance, and time for five repeated chair rises into an ordinal score ranging from 0 to 12 (12 = best). Adjusting for age, race, gender, comorbidities, education, health insurance, total cholesterol/high-density lipoprotein level, body mass index, pack-years of smoking, leg symptoms, immediately previous year functioning, statin use/non-use, ABI, and change in ABI, the PAD participants using statins had less annual decline in usual-pace walking velocity (0.002 vs. -0.024 m/s/year, p = 0.013), rapid-pace walking velocity (-0.006 vs. -0.042 m/s/year, p = 0.006), 6-min walk performance (-34.5 vs. -57.9 feet/year, p = 0.088), and the summary performance score (-0.152 vs. -0.376, p = 0.067) compared with non-users. These associations were attenuated slightly by additional adjustment for high-sensitivity C-reactive protein levels. Among non-PAD participants, there were no significant associations between statin use and functional decline. The PAD patients on statins have less annual decline in lower-extremity performance than PAD patients who are not taking statins.

Hemostatic Factors, Inflammatory Markers, and Progressive Peripheral Atherosclerosis

The interplay between inflammatory and hemostatic mechanisms may play a crucial role in the development and progression of atherosclerosis. The authors evaluated the separate and joint associations of hemostatic and inflammatory variables on peripheral atherosclerotic progression in the Edinburgh Artery Study, a population cohort study of 1,592 men and women aged 55-74 years that started in 1987. Levels of fibrinogen, fibrin D-dimer, von Willebrand factor, tissue plasminogen activator antigen, factor VII, prothrombin fragment 1 + 2, urinary fibrinopeptide A, C-reactive protein, and interleukin-6 were measured at baseline. Arm and ankle blood pressures were measured, and atherosclerotic progression was assessed by computing ankle brachial index (ABI) at baseline (1,582 participants) and after 12 years of follow-up (813 participants). Fibrinogen (p = 0.05) and D-dimer (p < or = 0.05) were significantly associated with ABI change independently of baseline ABI and cardiovascular disease risk factors. However, these associations were no longer significant when analyses were adjusted for either C-reactive protein or interleukin-6. Moreover, subjects with higher levels of both D-dimer and interleukin-6 at baseline had the greatest ABI decline. In conclusion, fibrinogen and D-dimer, but not other hemostatic factors, were associated with progressive peripheral atherosclerosis. Since D-dimer and fibrinogen are acute phase reactants, these data support the hypothesis that inflammation is more related to atherosclerosis than is hypercoagulation.

Peripheral arterial disease in diabetic patients selected from a primary care setting: Implications for nursing practice

Although the care of patients with diabetes is increasingly provided in primary care, there is relatively little information on the prevalence and long-term progression of asymptomatic peripheral arterial disease (PAD) in diabetic populations selected from primary care settings. The aims of this study were to investigate prevalence and progression of PAD in 146 diabetic patients, and to compare mortality with 113 nondiabetic controls over a 7-year period. The prevalence of PAD in individual pedal arteries varied between 28.6% in the right posterior tibial artery to 48.8% in the left peroneal artery. During the 7-year period, 34.25% of the diabetic subjects died, and 17.5% moved to other locations. Of the remaining 70 patients, 35 (50%) showed no change in ankle-brachial index and 35 (50%) did show change. Comparison of risk factors between those who did and did not show evidence of progression revealed (1) a strong, significant, independent association between hyperglycemia (measured by plasma HbA1c) and progression of PAD among the diabetic population; and (2) a strong association between progression of the disease and family history of diabetes and ischemic vascular disease. There was a high death rate (34.25%) among the diabetic group, which was greater than for the age- and sex-matched nondiabetic controls (13.2%) drawn from the same practice. This high mortality was significantly related (P < .001) to the presence of PAD identified during first-year assessment. Once PAD develops in association with diabetes the long-term prognosis is poor and carries a high mortality rate mainly because of cardiovascular and cerebrovascular diseases. Both progression and mortality were significantly related to poor diabetic control. The role of the primary care nurse in assessing such patients by using Doppler-assisted measurements is one that should be expanded with the massive increase in the number of diabetic patients in the coming years.

Risk Factors for Declining Ankle-Brachial Index in Men and Women 65 Years or Older

An ankle-brachial index (ABI) of less than 0.9 is a noninvasive measure of lower extremity arterial disease and a predictor of cardiovascular events. Little information is available on longitudinal change in ABI or on risk factors for declining ABI in a community-based population. To assess risk factors for ABI decline, we studied 5888 participants in the Cardiovascular Health Study cohort (men and women 65 years or older). We measured ABI in 1992-1993 and again in 1998-1999. At baseline, we excluded individuals with an ABI less than 0.9, ABI greater than 1.4, or confirmed symptomatic lower extremity arterial disease (n = 823). The group with ABI decline included 218 participants with decline greater than 0.15 and to 0.9 or less. The comparison group comprised the remaining 2071 participants with follow-up ABI. The percentage of participants with ABI decline was 9.5% over 6 years of follow-up. The mean +/- SD decline was 0.33 +/- 0.12 in cases of ABI decline and 0.02 +/- 0.13 in non-cases. Independent predictors of ABI decline, reported as odds ratios, were age, 1.96 (95% confidence interval [CI], 1.42-2.71) for 75 to 84 years and 3.79 (95% CI, 1.36-10.5) for those older than 85 years compared with those younger than 75 years; current cigarette use, 1.74 (95% CI, 1.02-2.96); hypertension, 1.64 (95% CI, 1.18-2.28); diabetes, 1.77 (95% CI, 1.14-2.76); higher low-density lipoprotein cholesterol level, 1.60 (95% CI, 1.03-2.51), and lipid-lowering drug use 1.74 (95% CI, 1.05-2.89). Worsening lower extremity arterial disease, assessed as ABI decline, occurred in 9.5% of this elderly cohort over 6 years and was associated with modifiable vascular disease risk factors.

START Trial

Granulocyte-macrophage colony-stimulating factor (GM-CSF) was recently shown to increase collateral flow index in patients with coronary artery disease. Experimental models showed beneficial effects of GM-CSF on collateral artery growth in the peripheral circulation. Thus, in the present study, we evaluated the effects of GM-CSF in patients with peripheral artery disease. A double-blinded, randomized, placebo-controlled study was performed in 40 patients with moderate or severe intermittent claudication. Patients were treated with placebo or subcutaneously applied GM-CSF (10 microg/kg) for a period of 14 days (total of 7 injections). GM-CSF treatment led to a strong increase in total white blood cell count and C-reactive protein. Monocyte fraction initially increased but thereafter decreased significantly as compared with baseline. Both the placebo group and the treatment group showed a significant increase in walking distance at day 14 (placebo: 127+/-67 versus 184+/-87 meters, P=0.03, GM-CSF: 126+/-66 versus 189+/-141 meters, P=0.04) and at day 90. Change in walking time, the primary end point of the study, was not different between groups. No change in ankle-brachial index was found on GM-CSF treatment at day 14 or at day 90. Laser Doppler flowmetry measurements showed a significant decrease in microcirculatory flow reserve in the control group (P=0.03) and no change in the GM-CSF group. The present study does not support the use of GM-CSF for treatment of patients with moderate or severe intermittent claudication. Issues that need to be addressed are dosing, the selection of patients, and potential differences between GM-CSF effects in the coronary and the peripheral circulation.

C-Reactive Protein, Interleukin-6, and Soluble Adhesion Molecules as Predictors of Progressive Peripheral Atherosclerosis in the General Population

The relationship between levels of circulating inflammatory markers and risk of progressive atherosclerosis is relatively undetermined. We therefore studied inflammatory markers as predictors of peripheral atherosclerotic progression, measured by the ankle-brachial index (ABI) at 3 consecutive time points over 12 years. The Edinburgh Artery Study is a population cohort study of 1592 men and women aged 55 to 74 years. C-reactive protein (CRP), interleukin-6 (IL-6), intercellular adhesion molecule-1 (ICAM-1), vascular adhesion molecule-1 (VCAM-1), and E-selectin were measured at baseline. Valid ABI measurements were obtained on 1582, 1081, and 813 participants at baseline and 5-year and 12-year follow-up examinations, respectively. At baseline, a significant trend was found between higher plasma levels of CRP (P< or =0.05) and increasing severity of peripheral arterial disease (PAD), after adjustment for baseline cardiovascular risk factors. IL-6 at baseline (P< or =0.001) was associated with progressive atherosclerosis at 5 years (ABI change from baseline), and CRP (P< or =0.01), IL-6 (P< or =0.001), and ICAM-1 (P< or =0.01) were associated with changes at 12 years, independently of baseline ABI, cardiovascular risk factors, and baseline cardiovascular disease. Only IL-6 independently predicted ABI change at 5 years (P< or =0.01) and 12 years (P< or =0.05) in analyses of all inflammatory markers simultaneously and adjusted for baseline ABI, cardiovascular risk factors, and cardiovascular disease at baseline. These findings suggest that CRP, IL-6, and ICAM-1 are molecular markers associated with atherosclerosis and its progression. IL-6 showed more consistent results and stronger independent predictive value than other inflammatory markers.

Intermittent Claudication: Functional Capacity and Quality of Life after Exercise Training or Percutaneous Transluminal Angioplasty—Systematic Review

To systematically review published data about the short- and long-term effects of exercise training and angioplasty on functional capacity and quality of life of patients with intermittent claudication. Articles published between January 1980 and February 2003 were included if patients had intermittent claudication treated with exercise training or angioplasty and if both functional capacity and quality-of-life scores from Medical Outcomes Study 36-Item Short Form health survey were reported for at least 3 months of follow-up. Data were pooled by using a random effects model and weighted means. Pooled results were compared between the treatment groups by using the chi2 test and the Student t test (alpha = .05, two sided). In the analyses, five studies (202 patients) were included in the exercise group, and three studies (470 patients), in the angioplasty group. At 3 months of follow-up, the ankle-brachial index was significantly improved in the angioplasty group (mean change, 0.18; P < .01) but not in the exercise group (mean change, 0.01; P = .29). At 3 months, quality of life was significantly improved with regard to ratings of physical functioning and bodily pain in the exercise group (mean change, 18 and 10, respectively; P < .01) and physical role functioning in the angioplasty group (mean change, 30; P = .03). Mean change in ankle-brachial index significantly differed between the two treatment groups at 3 and 6 months (P < .01); mean change in quality-of-life scores did not. Improvement in quality of life was demonstrated after both exercise training and angioplasty, whereas functional capacity showed significant improvement after angioplasty. The ankle-brachial index significantly differed between the two treatment groups at 3 and 6 months, whereas the quality-of-life scores did not.

Natural history of physical function in older men with intermittent claudication

Purpose This study was undertaken to determine the natural history of physical function in older men limited by intermittent claudication. Methods Forty-three men limited by intermittent claudication (mean age, 69 ± 7 years) were recruited and followed up for 18 months. At baseline the patients reported a history of intermittent claudication for 6.1 ± 6.1 years, and were able to walk for 1.9 ± 1.6 blocks before experiencing claudication pain. Measurements during the 18-month study included ankle-brachial index (ABI), calf blood flow, 6-minute walk performance, monitored and self-reported physical activity, self-reported stability while walking, and summary performance score of physical function determined from a 4-m walk test, a chair stand test, and a tandem stand test. Results Pain-free walking distance during the 6-minute walk test decreased by 22% ( P < .05) from baseline (185 ± 96 m) to follow-up (144 ± 93 m), and the total 6-minute walk distance decreased by 9% ( P < .05), from 368 ± 106 m to 334 ± 90 m. Furthermore, monitored physical activity decreased by 31% ( P < .05), from 159 ± 151 kcal/d to 110 ± 137 kcal/d; self-reported physical activity declined by 27% ( P < .05), from 1.5 ± 1.0 units to 1.1 ± 0.8 units; tandem stance time declined by 14% ( P < .05), from 9.46 ± 1.83 seconds to 8.12 ± 2.10 seconds; summary performance score of physical function decreased by 12% ( P < .05), from 6.8 ± 2.4 units to 6.0 ± 2.4 units; and the percentage of patients reporting ambulatory unsteadiness and stumbling increased from 28% to 43% ( P < .05). Calf blood flow measured at rest declined by 18% ( P < .05), from 3.72 ± 1.81 (mL/100 mL −1/min −1) to 3.04 ± 1.43 mL/100 mL −1/min −1, whereas ABI did not change ( P > .05). Conclusion Older men limited by intermittent claudication experienced decline in ambulatory function, physical activity, physical function, stability, and calf blood flow over 18 months of follow-up, despite no change in ABI.

Outcome of Conservative Therapy of Patients with Severe Intermittent Claudication

Background. Intermittent claudication due to peripheral artery disease (PAD) can be treated conservatively, or by revascularization.Objectives. To assess the short-term outcome of conservatively-treated claudicants, and determine predictors for clinical improvement.Design. A retrospective cohort study.Methods. We evaluated Fontaine stage, walking distance and ankle brachial index (ABI) at baseline and after median 9 months (interquartile range (IQR) 6–24) in 181 patients with severe claudication.Results. We found clinical improvement by at least one Fontaine stage in 38 patients (21%) with an increased walking distance from baseline median 100 m (IQR 50–150) to follow-up median 650 m (IQR 300 to unlimited; p<0.001), but without changes in ABI (median 0.57, IQR 0.48–0.73 vs. median 0.54, IQR 0.45–0.81; p=0.10). One hundred and thirty-eight patients (76%) remained clinically and hemodynamically stable. A worsening of the clinical stage but without amputation was recorded in five patients (3%). Female gender (hazard ratio (HR) 0.51, p=0.052), diabetes (HR 0.35, p=0.020), and baseline ABI below 0.44 (HR 0.31, p=0.019) were associated with a reduced probability of clinical improvement.Conclusion. Certain patients with intermittent claudication show substantial clinical improvement with conservative medical therapy, despite any lack of hemodynamic improvement. Given the low number of patients with clinical deterioration in the short term, primarily conservative therapy should be the preferred initial option for most claudicants.

Changes in ankle brachial index in symptomatic and asymptomatic subjects in the general population.

To determine changes over time in the ankle brachial index (ABI) among subjects with and without intermittent claudication in the general population. Population cohort study. General population in Edinburgh, Scotland. A total of 1592 men and women aged 55 to 74 years selected at random from age-sex registers of 11 general practices and followed up over 12 years. Main outcome measures Changes in ABI for each leg recorded at baseline in 1988 and at subsequent 5-year and 12-year clinical examinations. Overall, 695 subjects (348 men and 347 women) had valid ABI measurements on both legs at all three examinations. At baseline, the ABI was on average.03 higher in the right leg than the left (P < or =.001). Men had a mean ABI that was.07 higher than women (P < or =.001). Mean ABI in the worse leg showed little change over 12 years in both men and women. However, in the whole population, the ABI in the better leg showed a significant drop, 1.15 to 1.08 (P < or =.001). A total of 179 cases of intermittent claudication were identified during the 12-year follow-up. At baseline, ABI in the worse leg of the claudicants was significantly lower than in healthy subjects (.99 vs 1.08; P < or =.01). In claudicants, mean ABI in the worse leg fell by.04 over 5 years (P < or =.05) and in the better leg showed a highly significant drop of.09 (P < or =.001) to levels similar to those of the worse leg. The mean ABI in the worse leg of study subjects showed little progression over 12 years. Individuals with intermittent claudication experienced a greater decline in both legs compared with those without claudication. Deterioration occurred more rapidly in the limb with a higher ABI at baseline, which possibly indicates a systemic tendency to atherosclerosis.

Incidence, time-of-onset, and anatomical distribution of recurrent stenoses after remote endarterectomy in superficial femoral artery occlusive disease

Purpose: The incidence, time-of-onset, and anatomical distribution of recurrent stenoses after remote endarterectomy in superficial femoral artery (SFA) occlusive disease were studied. Methods: Patients undergoing SFA remote endarterectomy procedures were examined with duplex surveillance. Patients were examined at 6 weeks, 3, 6, 9, and 12 months, and then annually. Recurrent stenosis was defined as a peak systolic velocity ratio of 2.5 or higher. Duplex results were also compared with clinical and hemodynamic changes. Results: Restenoses were identified in 46 of 101 (46%) limbs treated after a mean interval of 5.8 months (range, 1 to 18 months). These 46 limbs formed the base of this study. The median follow-up period was 25 months. Thirty-eight (83%) of all restenoses were detected within 1 year. The lesions were located within the entire SFA and were not specifically related to the adductor canal or distal stented region only. Multiple stenoses were found in 21 limbs. Only 10 (22%) restenoses were correlated with worsening of clinical symptoms, change of ankle-brachial index, or both. Ten of 23 cases (43%) of nonrevised restenoses progressed to occlusion. These 10 occlusions occurred in all patients with restenosis that developed within the first year. Nonrevised late restenoses (more than 1 year) were not associated with any reocclusion. Conclusion: Recurrent stenoses after SFA remote endarterectomy were noticed in 46 of 101 (46%) limbs. Most restenoses (83%) developed within the first year. In the nonrevised group, time-of-onset restenosis (less than 1 year) was correlated with a higher risk for occlusion ( P = .02). The location of restenoses were found without any anatomical site of preference along the entire endarterectomized SFA segment. (J Vasc Surg 1999;30:106-13.)