Coexistence Of Peripheral Arterial Disease Research Articles

Diabetes mellitus in peripheral artery disease: Beyond a risk factor.

Peripheral artery disease (PAD) is one of the major cardiovascular diseases that afflicts a large population worldwide. PAD results from occlusion of the peripheral arteries of the lower extremities. Although diabetes is a major risk factor for developing PAD, coexistence of PAD and diabetes poses significantly greater risk of developing critical limb threatening ischemia (CLTI) with poor prognosis for limb amputation and high mortality. Despite the prevalence of PAD, there are no effective therapeutic interventions as the molecular mechanism of how diabetes worsens PAD is not understood. With increasing cases of diabetes worldwide, the risk of complications in PAD have greatly increased. PAD and diabetes affect a complex web of multiple cellular, biochemical and molecular pathways. Therefore, it is important to understand the molecular components that can be targeted for therapeutic purposes. In this review, we describe some major developments in enhancing the understanding of the interactions of PAD and diabetes. We also provide results from our laboratory in this context.

Prevalence and outcomes of peripheral artery disease in a real-world cohort of patients with acute coronary syndrome: insights from the prospective SPUM registry

Abstract Background Despite substantial improvement in secondary preventive therapy, the burden of recurrent cardiovascular (CV) events remains high. Peripheral artery disease (PAD), is a potential marker of increased residual ischemic risk in acute coronary syndrome (ACS) patients suggesting greater net clinical benefit from intensified individualized therapy. Purpose We aimed to assess the prevalence and cardiovascular (CV) outcomes of peripheral arterial disease (PAD) in 4'787 patients with acute coronary syndromes (ACS) in the Swiss prospective multicenter SPUM study. Methods PAD was defined according to international guidelines. The composite primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), i.e., stroke, myocardial infarction (MI) and death at 1 year. Adjusted Cox proportional hazards regression models were used to estimate the risk associated with PAD and outcomes. Results Out of 4'787 ACS patients, 285 patients (6.0%) had PAD. These patients were older (70.1±10.6 vs 63.3±12.4, p<0.001), presented all traditional CV risk factors (all p<0.001) and were more likely to have a complex history of CV disease, such as previous MI (24.3% vs 11.4%, p<0.001), prior percutaneous (32.3% vs 13.8%, p<0.001) or surgical (12.6% vs 3.5%, p<0.001) coronary revascularization. PAD-patients presented also higher levels of inflammatory biomarkers, such as hs-CRP, and GRACE 2.0 score (all p<0.001). At 1 year, patients with PAD had a higher rate of MACCE compared to those presenting without PAD. Rates of the individual components of the primary endpoint and CV-death were all significantly higher in patients with PAD (all p<0.001), except for a numerical increase in MI (5.3% vs 3.3%, p=0.060). This enhanced risk persisted after adjustment for differences in baseline characteristics, with a 53% (Adj. HR 1.53, CI95% 1.14–2.08, p=0.005) increase in MACCE. In spite of high-intensity anti-thrombotic therapy, PAD patients presented the same rate (Adj. HR 1.03, CI95% 0.68–1.54, p=0.901) of major bleeding events at 1 year. Conclusions Among a real-world cohort of ACS patients, the coexistence of PAD, a very-high CV risk phenotype, is associated with significantly increased rates of MACCE, but no difference in major bleeding events. These observations might help clinicians to further stratify this very-high risk population and to identify patients who may derive the greatest benefit from more intense secondary prevention therapies. Funding Acknowledgement Type of funding sources: None.

Ankle Brachial Index vs Transcutaneous Partial Pressure of Oxygen for Predicting Healing of Diabetic Foot Ulcers with Peripheral Arterial Disease: a Comparative Study

Foot ulcer is a common complication of diabetes mellitus. The co-existence of peripheral arterial disease (PAD) increases the risk of non-healing of the ulcer. Ankle brachial index (ABI) and transcutaneous partial pressure of oxygen (TcPO2) are two tests used to assess the vascularity of the foot, using two different parameters. This study was done to compare the sensitivity, specificity and diagnostic accuracy of ABI and TcPO2 and to find out which of these is a better predictor of healing in diabetic foot ulcers in patients without palpable foot pulses. The hospital-based longitudinal study was done from March 2016 to March 2018 among 121 adult patients diagnosed with diabetic foot ulcer without palpable peripheral pulses who fit the inclusion and exclusion criteria. Vascularity of the foot in these patients was assessed using ABI and TcPO2. The participants were followed up for 3 months, and the healing status was recorded. The mean (SD) age of patients was 64.99 (10.03) years. Out of 121 patients, 89 were men and 32 were women. The mean ABI in healed and non-healed group were significantly different (P value < 0.001). TcPO2 also showed significant difference in healed and non-healed groups (P value < 0.001). The values of 0.65 in receiver operating characteristic (ROC) curve showed optimal sensitivity (86.1%) and specificity (75.5%) for ABI. ROC curve with a TcPO2 cut-off value of 27.5 mmHg had optimal sensitivity (84.7%) and specificity (81.6%). Although sensitivity of TcPO2 and ABI is comparable (84.7% v 86.1%), specificity and diagnostic accuracy are better for TcPO2.

Peripheral Artery Disease and Risk of Fibrosis Deterioration in Nonalcoholic Fatty Liver Disease: A Prospective Investigation

ObjectiveLiver fibrosis is an important predictor of mortality in nonalcoholic fatty liver disease (NAFLD). Peripheral artery disease (PAD) and liver fibrosis share many common metabolic dysfunctions. We aimed to explore the association between PAD and risk of fibrosis deterioration in NAFLD patients. MethodsThe study recruited 1,610 NAFLD patients aged ≥ 40 years from a well-defined community at baseline in 2010 and followed up between August 2014 and May 2015. Fibrosis deterioration was defined as the NAFLD fibrosis score (NFS) status increased to a higher category at the follow-up visit. PAD was defined as an ankle-brachial index of < 0.90 or > 1.40. ResultsDuring an average of 4.3 years' follow-up, 618 patients progressed to a higher NFS category. PAD was associated with 92% increased risk of fibrosis deterioration [multivariable-adjusted odds ratio (OR): 1.92, 95% confidence interval (CI): 1.24, 2.98]. When stratified by baseline NFS status, the OR for progression from low to intermediate or high NFS was 1.74 (95% CI: 1.02, 3.00), and progression from intermediate to high NFS was 2.24 (95% CI: 1.05, 4.80). There was a significant interaction between PAD and insulin resistance (IR) on fibrosis deterioration (P for interaction = 0.03). As compared with non-PAD and non-IR, the coexistence of PAD and IR was associated with a 3.85-fold (95% CI: 2.06, 7.18) increased risk of fibrosis deterioration. ConclusionPAD is associated with an increased risk of fibrosis deterioration in NAFLD patients, especially in those with IR. The coexistence of PAD and IR may impose an interactive effect on the risk of fibrosis deterioration.

CORRELATION OF ABNORMAL ANKLE-BRACHIAL INDEX WITH SEVERITY OF CORONARY ARTERY DISEASE IN PATIENTS HOSPITALIZED FOR ACUTE MYOCARDIAL INFARCTION

Objective: The coexistence of peripheral artery disease in patients with coronary artery disease (CAD) has been associated with a poor cardiovascular outcome. The aim of this study was to assess the usefulness of ankle-brachial index (ABI) assessment in predicting the severity of coronary artery disease in patients with acute myocardial infraction (AMI). Design and method: We studied 101 patients [77.2% male; mean age 60.9 years; 63.4% hypertensives; 24.8% with diabetes mellitus (DM)] who were hospitalized because of ST-elevation MI (STEMI, 51.5%) and Non-ST–elevation MI (NSTEMI). All patients underwent baseline estimation of clinical and laboratory parameters during their hospitalization. The ABI was measured according to established methodology using a certified automated device and abnormal ABI was defined as a value <0.9. Severity of CAD was estimated by the number of affected main vessels. Results: In the entire population, mean ABI was 1.11 ± 0.19, while 15.8% of patients had abnormal ABI. NSTEMI patients compared to those with STEMI demonstrated relatively lower ABI (1.07 ± 0.18 vs 1.12 ± 0.16; p = 0.144) and had more often abnormal ABI (22.4% vs 9.6%; p = 0.103). Using univariate analysis in the entire population, severity of CAD was correlated with age (r = 0.133; p = 0.053), history of DM (r = 0.225; p = 0.01), abnormal ABI (r = 0.242; p = 0.015) and ABI value (r = 0.214; p = 0.029). In multivariate regression models, both ABI value (b = 0.212; p = 0.037) and abnormal ABI (b = 0.224; p = 0.036) remained significant predictors of CAD severity independently of gender, age, DM, smoking, low density lipoprotein (LDL-C), 24-h systolic BP and the type of MI. Conclusions: Estimation of ABI managed to predict multivessel CAD in patients with AMI. These findings in patients with ACS scheduled to undergo a cardiac catheterization may raise the suspicion of advanced disease, alerting the need for more aggressive diagnostic and therapeutic strategies.

Long-Term Clinical and Angiographic Outcomes After Implantation of New-Generation Drug-Eluting Stents for Patients on Maintenance Hemodialysis.

Prior research has revealed poorer clinical outcomes after drug-eluting stent (DES) implantation for hemodialysis patients. This study aims to investigate the long-term clinical and angiographic outcomes after new-generation DES implantation for hemodialysis patients.We retrospectively enrolled 91 consecutive patients (118 lesions) who underwent successful new-generation DES (everolimus-, zotarolimus-, and biolimus-eluting stents) implantation for the first time. We measured the serum calcium and phosphorus levels in the blood samples obtained just before hemodialysis. The follow-up period of clinical events was, at least, 1.5 years. In this study, major adverse cardiac and cerebrovascular events (MACCE) and clinically driven target lesion revascularization were reported in 36 (39.6%) and 11 (12.1%) patients, respectively. The prevalence of peripheral artery disease was significantly higher in the MACCE group (41.7% versus 14.5%, P = 0.006). The serum calcium level was significantly higher in the MACCE group (9.34 ± 0.92 mg/dL versus 8.77 ± 0.88 mg/dL; P = 0.004). The multivariate Cox proportional hazards model revealed that the serum calcium level (hazard ratio, 1.86; 95% confidence interval [CI]: 1.26-2.77; P = 0.002), suboptimal (over 55 mg2/dL2) calcium-phosphorus product (hazard ratio, 3.27; 95% CI: 1.41-7.61; P = 0.006) and the coexistence of peripheral artery disease (hazard ratio, 3.15; 95% CI: 1.49-6.65; P = 0.003) were independent predictors of MACCE.For hemodialysis patients, MACCE remains a frequent occurrence after new-generation DES implantation and is associated with calcium-phosphate metabolism and peripheral artery disease.

Associations and interactions between variants in selenoprotein genes, selenoprotein levels and the development of abdominal aortic aneurysm, peripheral arterial disease, and heart failure.

BackgroundLittle is known on the role of selenoprotein genes in cardiovascular disease. This study examines the associations of the SEPP1, SELENOS, TXNRD1, TXNRD2, GPX4, and SOD2 polymorphisms and selenoprotein P (SeP) and thioredoxin concentrations with the development of abdominal aortic aneurysm (AAA) and aortoiliac occlusive disease (AOID), as well as their influence on cardiac phenotype.Methods564 patients with AAA, 400 patients with AIOD, and 543 controls were enrolled and characterized for coronary artery disease, myocardial infarction, and systolic heart failure (HF) occurrence. In AAA, the coexistence of peripheral arterial disease (PAD) was examined. Genotypes were determined using TaqMan-based assays. Selenoprotein concentration was assessed using the ELISA method.ResultsThe SELENOS rs34713741T, SEPP1 rs3877899A, and GPX4 rs713041T alleles were related to a 30–60% increase in the AIOD/PAD risk in the recessive or dominant model (all associations at P < .05). The SEPP1 rs3877899A allele was a protective factor for the development of AAA without concomitant PAD (OR = 0.68 for the dominant model, P = .014), but not AAA with concomitant PAD. The cumulative two-locus effects of selenoprotein genes on the AAA/AIOD risk were observed, including the multiplicative interaction between the SELENOS rs34713741T and GPX4 rs713041T alleles (both in the recessive model) affecting the AIOD risk (OR = 5.27, P = .001) and its clinical phenotype. Coexistence of HF in aortic diseases was related to both the SEPP1 rs7579A allele (OR = 1.83 for carriers, P = .013) and increased SeP concentrations; SeP level ≥8.5 mg/mL caused a 3.5-fold increase in the risk of HF. In AAA, SeP levels were correlated with BMI (r = -0.575, P < .0001).ConclusionsOur results provide evidence that selenoprotein polymorphisms constitute a risk factor for HF and peripheral atherosclerosis, but prevent the development of AAA. Excessive weight might result in reduced antioxidant reserve efficiency in AAA. Validation studies are required to establish whether SeP concentration may be a marker for HF.

Effect of Body Mass Index on Mortality and Morbidity in Patients Undergoing Coronary Artery Bypass Grafting Surgery.

This study aims to investigate the effect of body mass index (BMI) on mortality and morbidity in patients undergoing coronary artery bypass grafting (CABG) surgery. We retrospectively evaluated the medical records of 403 patients undergoing coronary artery bypass surgery in our center. The patients were divided into 5 groups according to their BMI values. Preoperative demographic characteristics, operative data, and postoperative complications during the six-month follow-up period were compared between the groups. There were no statistically significant differences between the groups except the coexistence of peripheral artery disease (P = .009), ejection fraction (P = .021) and chronic obstructive pulmonary disease (P = .044). There were no statistically significant differences between the groups in terms of postoperative complications. No relationship was found between postoperative complications and the implemented surgical procedures. An overall 30-day mortality rate of 1.48% was observed, and the six-month mortality rate was 1.7%. According to this study, obesity does not lead to an increased risk of mortality and other adverse outcomes after CABG surgery. However, obesity may prolong hospital stay and increase the cost of CABG operation.

SEPP1 gene variants and abdominal aortic aneurysm: gene association in relation to metabolic risk factors and peripheral arterial disease coexistence.

An inadequate selenium level is supposed to be a risk factor for cardiovascular diseases. However little is known about variation of the genes encoding selenium-containing proteins that would confirm the causality in these diseases. The aim of this study was to analyze the relationships between two functional variants of selenoprotein P gene (SEPP1 rs3877899G>A, rs7579G>A) and the occurrence of abdominal aortic aneurysm (AAA) and aortoiliac occlusive disease (AIOD), as well as their metabolic risk factors. In AAA, the rs3877899A allele was associated with higher systolic blood (P < .003) and pulse pressure (P < .003) values (recessive model), and with coexistence of peripheral arterial disease (PAD; carriers: P = .033). The other SEPP1 variants were associated with BMI values and influenced the risk of aortic diseases, depending on body weight. The strongest associations in the case-control analysis was found between the presence of the rs3877899G-rs7579G haplotype and development of AAA in overweight and obese subjects (OR = 1.80, 95%CI = 1.16–2.79, P = .008). The higher BMI values were correlated with lower age of AAA patients and larger size of aneurysm. Our results suggests the potential role of the selenoprotein P in pathogenesis of AAA. Future studies should consider the role of the rs3877899G-rs7579G haplotype as a risk factor for aggressive-growing AAAs.

Mortality in Patients with Pad with Respect to Glycaemic Status: A Review

Peripheral arterial disease (PAD) is a manifestation of atherosclerosis. Atherosclerosis is a chronic inflammatory process and nonenzymatic glycation is a process of major interest in relation to how risk factors promote atherogenesis. A strong association between diabetes mellitus (DM) and PAD has been established, and the association is related to the duration of DM. Previous studies have revealed a higher prevalence of DM in patients with PAD compared to general populations and populations at risk of developing DM. The typical dyslipidaemia found in patients with PAD is similar to that found in patients with insulin resistance, and an association of HbA1c with atherogenic dyslipidaemia is described. HbA1c has been described as a predictor for DM and of micro and macrovascular disease. 5-year all-cause mortality in PAD is 19–37% and 10-year all-cause mortality is 42-54%. The mortality in PAD increases with age, with the severity of the peripheral vascular disease, and with the coexistence of PAD with coronary artery disease and DM. Patients with DM, defined by glucose criteria, and PAD have an increased mortality compared with patients with PAD alone. Recent studies have shown an association of HbA1c levels with vascular complications and death in patients with DM. No studies could be found that aimed to validate HbA1c against glucose criteria as a predictor for mortality in patients with PAD. Further studies on patients with PAD and DM are needed to identify which is the best diagnostic method to predict mortality in PAD with respect to glycaemic status: the glucose parameters or the HbA1c.

Abstract 9570: Advanced Endothelial Dysfunction in Patients with Coexistence of Coronary Artery Disease and Peripheral Artery Disease -Effect of Cilostazol on the Advanced Endothelial Dysfunction-

Backgrounds In patients with coronary artery disease (CAD), coexistence of peripheral arterial disease (PAD) indicates poor cardiovascular prognosis. Endothelial dysfunction plays a crucial role in cardiovascular diseases and reactive hyperemia peripheral arterial tonometry (RH-PAT) can noninvasively examine endothelial function. We hypothesized that advanced endothelial dysfunction might associate with the coexistence of CAD and PAD and we investigated effects of cilostazol on the endothelial dysfunction in diabetic patients with PAD. Methods and Results We measured RH-PAT index (RHI) and ankle-brachial index (ABI) in consecutive stable patients with coronary risk factors (n=511). CAD was defined by coronary angiography (stenosis≥50%, n=358) and PAD was diagnosed by ABI&lt;0.9, ABI&gt;1.4 with vascular imaging evidence of PAD, previous history of peripheral revascularization, or Fontaine classification≥II (n=73). CAD group (n=358) demonstrated significant lower RHI than non-CAD group (n=153) (RHI: 0.52±0.20 vs. 0.60±0.20, p&lt;0.001). RHI were significantly attenuated in patients with coexistence of CAD and PAD (n=63) compared to CAD patients without PAD (n=295) (RHI: 0.40±0.17 vs. 0.54±0.19, p&lt;0.001). In patients with CAD, univariate logistic regression analysis revealed that age (odd ratio (OR)=1.09, p=0.006), smoking (OR=9.94, p&lt;0.001), body mass index (OR=0.76, p=0.001), high density lipoprotein-cholesterol (OR=0.96, p=0.038), estimated glomerular filtration ratio (OR=0.96, p=0.001), and RHI (per 0.1) (OR=0.57, p&lt;0.001) correlated with the presence of PAD. Multivariate logistic regression analysis demonstrated independent correlation of RHI with the coexistence of PAD in CAD-patients (OR: 0.60, 95% confidence interval 0.451 to 0.798, p&lt;0.001). 12 weeks cilostazol treatment (200mg/day) significantly improved the endothelial dysfunction in diabetic patients with PAD (n=21, age 67±7) (RHI; 0.48±0.11 to 0.68±0.25, p&lt;0.001). Conclusions: Advanced endothelial dysfunction is associated with coexistence of PAD in CAD patients and cilostazol ameliorated the endothelial dysfunction in diabetic patients with PAD. Severe impairment of endothelial function might be a key component in the concomitant CAD and PAD.

Lumbar spinal stenosis associated with peripheral arterial disease: a prospective multicenter observational study

BackgroundIntermittent claudication is a common symptom of both lumbar spinal stenosis (LSS) and peripheral arterial disease (PAD) in middle-aged and elderly people. However, the prevalence and clinical characteristics of LSS with PAD (LSSPAD) have not been investigated in a multicenter study. The aim of this study was to investigate the prevalence and clinical characteristics of LSS associated with PAD. Methods570 patients diagnosed with LSS using a clinical diagnostic support tool and MRI at 64 facilities were enrolled. We evaluated each patient’s medical history, physical findings, ankle brachial index, Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) score, and the Short Form 36 (SF-36) score. Statistical analyses were performed to compare LSSPAD patients and LSS patients without PAD using the t test, Mann–Whitney’s U test, and multivariate recurrence analysis. p values of <0.05 were considered statistically significant. ResultsThe LSSPAD group comprised 38 patients (6.7 %); 20 (3.5 %) had pre-diagnosised PAD while 18 (3.2 %) had undetected PAD. The clinical characteristics of these patients were advanced age, diabetes, and a history of ischemic heart disease and cerebrovascular disorder. 570 patients enrolled, and 448 (78.6 %) of those patients were followed up at three - months after enrollment. Pain in buttocks and legs improved less in the LSSPAD group than in the LSS group (p < 0.05). Improvements in the “general health” score in SF-36 were lower in the LSSPAD group than in the LSS group (p < 0.05). ConclusionsAdvanced age, diabetes, and a history of cerebrovascular disorder and ischemic heart disease were associated with LSSPAD. Because LSSPAD patients show less improvement in QOL than patients with LSS but without PAD do, clinicians should consider the coexistence of PAD in LSS patients.

Digital Amputation in Systemic Sclerosis: Prevalence and Clinical Associations. A Retrospective Longitudinal Study

To evaluate the prevalence of digital necrosis requiring surgical amputation in a single-center group of patients with systemic sclerosis (SSc) and to compare the characteristics of patients with and those without this severe complication. We reviewed the medical records of 188 patients with SSc [162 women, 26 men, mean age 59.2 yrs, mean disease duration 8.0 yrs, mean time from onset of Raynaud's phenomenon (RP) 11.7 yrs, median followup duration 92 mo] enrolled in the Rheumatology Unit since 2004. Demographic and clinical features were collected, as well as the presence of the typical risk factors for atherosclerosis. Nine patients (4.8%) underwent partial or total surgical digital amputation because of necrotic process; all these patients except 1 had a long history of multiple and persisting digital ulcers. All 9 patients had concomitant large-vessel involvement. Comparison of cases with and without digital amputation showed that this complication was associated with older age, long history of RP, long disease duration, presence of anticentromere antibody, and coexistence of peripheral artery disease and hypercholesterolemia. Discussion. We noted that 4.8% of patients with SSc underwent digital amputation. Our retrospective analysis suggests that peripheral artery disease is strongly associated with digital amputation. The preventive strategy for digital ulcers and amputation associated with SSc should include an extensive diagnostic and preventive investigation for peripheral atherosclerosis.

Concomitant coronary and peripheral arterial disease: Relationship between the inflammatory status of the affected limb and the severity of coronary artery disease

In coronary artery disease (CAD), concomitant peripheral arterial disease (PAD) entails increased systemic inflammatory profile and more severe coronary atherosclerosis. We investigated the relationship between the inflammatory status in the affected limb and CAD severity. In 46 CAD+PAD and 31 CAD-alone patients, the inflammatory status of the leg circulation was measured by the transfemoral gradients of neutrophil myeloperoxidase (MPOx) content and interleukin-6 (IL-6). CAD severity was defined by evaluating coronary artery endothelial function, number of significant coronary stenoses, and prevalence of three-vessel CAD and myocardial infarction (MI). In the affected limb of CAD+PAD patients, the transfemoral gradients of neutrophil MPOx content and IL-6 were higher (P < .01, for both) than in the healthy leg of CAD-only patients. At multivariate analysis, CAD+PAD patients with transfemoral gradients of MPOx and IL-6 > median had a more compromised coronary artery endothelial function (P < .05, for both). Furthermore, CAD+PAD patients with transfemoral gradients of neutrophil MPOx content > median showed an independent association with a greater number of significant coronary stenoses, and a greater prevalence of three-vessel CAD and previous MI (P < .01, for all). A more severe coronary atherosclerosis was observed also in CAD+PAD patients with transfemoral gradients of IL-6 > median vs those with IL-6 < median, although differences were not statistically significant. In CAD patients, the coexistence of PAD does not necessarily entail a more severe coronary atherosclerosis. Only those with an inflammatory status of the affected limb presents more severe CAD. Future studies will clarify whether the presence of peripheral inflammation plays a mechanistic role in CAD evolution.

Recanalization of peripheral arteries by interventional cardiologists: Rationale and results

The coexistence of peripheral artery disease (PAD) and multilevel atherosclerosis increases death and stroke rates in patients with coronary artery disease (CAD). These patients are often treated conservatively without revascularisation of inferior limbs. We included 66 consecutive patients with complex CAD diagnosed by coronary angiography. All patients underwent percutaneous coronary intervention (PCI) for non-ST elevation acute coronary syndrome (NSTEACS) before or simultaneously with peripheral angioplasty (PTA). Major adverse cardiac and cerebrovascular events (MACCE) during long-term follow-up were assessed. There were 3 deaths, one myocardial infarction, two urgent PCIs, two ischaemic strokes and two TIAs, 8 repeated PTAs in previously treated peripheral lesions, 7 elective PTAs of other vessels after the index procedure in different hospitalisations and no amputation. Patients with concomitant CAD and PAD could safely undergo percutaneous cardiovascular interventions with promising long-term follow-up.

Coronary artery disease and intermittent claudication: how to manage the patient

Coexistence of peripheral arterial disease (PAD) and coronary artery disease (CAD) is common. PAD worsens the prognosis of patients with and without CAD. Thus, patients with PAD should be treated for secondary prevention, regardless of the diagnosis of CAD. PAD should be sought in smokers or diabetics aged between 59 and 69 years, in those older than 70 years, in those with known atherosclerotic disease, and in those with suspicion of PAD. As a screening tool, Doppler measurement of the ratio between ankle and arm pressures offers the best approach. Conversely, pharmacological stress imaging should be employed to rule out CAD in PAD patients. Treatment of PAD implies risk factor modification, especially smoking cessation and lipid profile. Pharmacological treatments include preventive drugs and drugs that affect claudication. Unfortunately, few drugs have been proven effective for the latter. These include cilostazol and propionyll-camitine, which ameliorates symptoms and quality of life. It remains unresolved whether different treatment strategies for coexistent CAD impact favourably on prognosis in these problematic patients.