Concomitant Peripheral Arterial Disease Research Articles

In concomitant coronary and peripheral arterial disease, inflammation of the affected limbs predicts coronary artery endothelial dysfunction

Background In coronary artery disease (CAD), concomitant peripheral arterial disease (PAD) entails more severe coronary atherosclerosis. We investigated whether the inflammatory status of affected limbs impairs coronary artery endothelial function (CAEF). Methods We measured the neutrophil myeloperoxidase content (NMPOxC) and plasma levels of interleukin-6 and C-reactive protein in the aorta, femoral vein, and coronary sinus of 22 CAD + PAD and 18 CAD-alone patients. CAEF was assessed by the cold pressure test. Human coronary artery endothelial cells (HCAECs) were incubated with serum from the femoral vein and aorta of CAD + PAD patients to determine whether blood leaving the affected limb activates HCAECs. Results In CAD + PAD patients, NMPOxC was higher across the femoral circulation than across the coronary circulation ( p < 0.01); it was also higher than across healthy femoral circulation of CAD patients ( p < 0.01). These findings apply also to interleukin-6, but not to C-reactive protein. The transfemoral gradient of NMPOxC and interleukin-6 significantly correlated with CAEF. The NMPOxC/CAEF relationship was much greater after exercise ( R = 0.79, p < 0.001), which increased neutrophil activation across the affected circulation. The post-exercise association remained significant after adjustment for potential confounders ( p < 0.01). Serum from the affected limb of CAD + PAD patients induced, in vitro, a significant release of MCP-1 from HCAECs versus serum from the aorta of the same patients (630 [550–740] vs. 547 [490–620]; p < 0.05). Conclusions In CAD + PAD, triggers from the affected circulation may activate the endothelium at distant sites. Thus, PAD, besides being a marker of cardiovascular risk, could exert a mechanistic function in CAD progression.

Lower extremity peripheral arterial disease in individuals with coronary artery disease: Prognostic importance, care gaps, and impact of therapy

Our objective was to examine the effect of concomitant lower extremity peripheral arterial disease (PAD) on long-term prognosis and pharmacotherapy in patients with coronary artery disease (CAD). Prospective cohort study enrolling all patients with angiographically proven CAD between April 1, 2000, and December 31, 2004, in Alberta, Canada. Of 28,649 patients (mean age 64 years) with CAD, 2509 (9%) had a physician-assigned diagnosis of lower extremity PAD. Mortality was higher in the patients with CAD and PAD over a mean follow-up of 3.1 years, even after adjusting for the fact that patients with PAD had more severe CAD and more comorbidities (adjusted hazard ratio [HR] 1.41, 95% CI 1.28-1.55). Fewer patients with CAD and PAD received antiplatelet agents (83% vs 86%, odds ratio 0.86, 95% CI 0.77-0.97) or beta-blockers (63% vs 67%, odds ratio 0.89, 95% CI 0.82-0.98), but users of these agents exhibited lower mortality (adjusted HR 0.68, 95% CI 0.60-0.77, for antiplatelet agents and adjusted HR 0.72, 95% CI 0.64-0.80, for beta-blockers). Approximately half of these patients were prescribed statins or angiotensin-converting enzyme inhibitors, and 27% were using all 3 evidence-based anti-atherosclerotic therapies (antiplatelets, statin, and angiotensin-converting enzyme inhibitor). In patients with CAD, lower extremity PAD is independently associated with poorer outcomes. Although all evidence-based therapies are underused in patients with CAD, patients with concomitant PAD are less likely to be prescribed antiplatelet agents or beta-blockers--both agents are associated with improved survival in patients with CAD and PAD.

Aortoiliac and femoropopliteal lesions in patients with concomitant peripheral arterial disease and medial arterial calcification

Objective: To characterize stenosis and/or occlusion in patients with concomitant peripheral arterial disease (PAD) and medial arterial calcifi cation (MAC). Patients and methods: We performed continuous-wave Doppler technique (to measure the ankle-brachial index - ABI) and duplex ultrasonography in 75 consecutive patients at risk for PAD (57 males, age 72.6±6.3 years) admitted to a Medical Clinic between January and March 2006. Group A was composed of 15 subjects with plaques and ABI higher than 1.3 (MAC - 20%). Normal ABI was found in 43 patients (group B - 57.33%). Group C included 17 patients with ABI lower than 0.9 (ischemia - 22.67%). Results: Nonsignifi cant aortoiliac stenosis (less than 50%) was found in 70 subjects (15 in group A, 39 in group B, and 16 in group C - nonsignifi cant). Signifi cant femoropopliteal stenosis (greater than 50%) was detected in eight patients (fi ve in group A, one in group B, and two in group C – p<0.001). Nonsignifi cant femoropopliteal stenosis was identifi ed in 54 subjects (seven in group A, 42 in group B, and fi ve in group C - p<0.001). Conclusion: Signifi cant femoropopliteal stenosis signifi cantly correlated with presence of MAC. Nonsignifi cant femoropopliteal stenosis was identifi ed in patients with normal ABI.

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.

Metabolisches Syndrom und periphere arterielle Verschlusskrankeit als Indikatoren für erhöhtes kardiovaskuläres Risiko

The usefulness of the metabolic syndrome (MetS) or a low ankle brachial index (ABI), respectively, to identify patients with high risk for cardiovascular events has repeatedly been postulated. However, robust data on the prevalence and prognosis of such patients are missing in the primary care setting. In the prospective, non-interventional "German epidemiological trial on Ankle Brachial Index (getABI) at total of 6880 unselected patients > or = 65 years were observed by their General Practitioners over 3 years. Death and cardiovascular events were recorded. The definition of MetS was similar to the one of NCEP ATP III (National Cholesterol Education Program--Adult Treatment Panel III). ABI (ratio of the systolic blood pressures measured at the distal part of the calf and at the upper arm) was measured with Doppler sonography. Peripheral arterial disease (PAD) was defined as ABI <0.9 or peripheral revascularization/amputation owing to PAD. Survival analyses were conducted with a Cox proportional hazard model. Hazard rate ratios (HRR, 95 % confidence intervals, CI) were multvariate adjusted. The observation time for the total cohort was more than 20,000 patient years (PY). Cardiovascular mortality in patients with MetS (n = 3040, 44 %) compared to patients without MetS (n = 3795; 55 %) was doubled (8.5 vs. 4.0 per 1,000 PY; HRR: 2.0; CI 1.3 - 2.9). Concomitant presence of MetS and PAD (n = 651; 9.5 %) increased the mortality risk compared to patients without both conditions (n = 3194; 46.4 %) drastically (21.1 vs. 3.0 per 1000 PY; HRR: 5.7; CI: 3.5 - 9.4). Similar significant risk increases also were noted for all-cause mortality or a combined endpoint of mortality and vascular morbidity. Further, in lower ABI categories cardiovascular event rates increased. Patients with MetS carry a substantially increased risk of premature death, especially cardiovascular death, and therefore require intensive treatment of their risk factors. This holds especially true if concomitant PAD is present.

Revisiting the frequency of peripheral arterial disease in patients with coronary artery disease: is there a difference between diabetic and non-diabetic patients?

The aim of this study was to investigate whether frequency of concomitant peripheral arterial disease (PAD) is associated with angiographic severity of coronary artery disease (CAD), as well as to ascertain if diabetic patients differ from those without diabetes in the association between these two manifestations of atherosclerosis. This study included 302 patients (229 men, mean age 62.2 +/- 11.5 years) with documented CAD, divided into groups I-III, according to the angiographic severity of coronary atherosclerosis. Group I comprised 140 patients (104 men) with severe CAD, group II comprised 63 patients (48 men) with moderate CAD and group III comprised 99 patients (77 men) with mild CAD. Each of the groups I-III was further divided into the subgroups of diabetic and non-diabetic patients. Included were also 88 patients (42 men, mean age 61.7 +/- 9.5 years) without CAD and a control group of 60 healthy volunteers (30 men), aged 18-40 years. PAD was diagnosed by means of a Doppler apparatus. Frequency of PAD was associated with angiographic severity of CAD (p = 0.0001). This association was shown both in diabetic (p = 0.012) and in non-diabetic patients (p = 0.0041). Significantly (p < or = 0.01) higher frequency of PAD among diabetic patients was found in each of the groups I-III. Among patients with CAD, frequency of concomitant PAD is associated with angiographic severity of coronary atherosclerosis. This association is demonstrated both in diabetic and in non-diabetic patients. Finally, PAD is significantly more frequent in diabetic patients, irrespective of the angiographic severity of CAD.

Full Length Article

The Influence of Peripheral Arterial Disease on Outcomes: A Pooled Analysis of Mortality in Eight Large Randomized Percutaneous Coronary Intervention Trials Jacqueline Saw, Deepak L. Bhatt, David J. Moliterno, Sorin J. Brener, Steven R. Steinhubl, A. Michael Lincoff, James E. Tcheng, Robert A. Harrington, Maarten Simoons, TingFei Hu, Mobeen A. Sheikh, Dean J. Kereiakes, Eric J. Topol Patients undergoing percutaneous coronary intervention (PCI) frequently have concomitant peripheral arterial disease (PAD). We performed a pooled analysis of 8 randomized PCI trials (EPIC, EPILOG, EPISTENT, RAPPORT, CAPTURE, IMPACT-II, TARGET, and CREDO), evaluating short- and long-term clinical outcomes of PAD patients undergoing PCI. Patients with PAD had higher 7-day, 30-day, and 6-month death or myocardial infarction rates and 1-year mortality. With multivariable analyses, PAD remained an independent predictor of mortality at 30 days, 6 months, and 1 year. We aimed to evaluate clinical outcomes among peripheral arterial disease (PAD) patients following percutaneous coronary intervention (PCI). A significant proportion of patients with coronary artery disease undergoing PCI have concomitant PAD, which may be associated with worse outcomes. We performed a pooled analysis of 8 randomized PCI trials. We included multicenter PCI trials that compared antiplatelet therapies (EPIC, EPILOG, EPISTENT, RAPPORT, CAPTURE, IMPACT-II, TARGET, and CREDO) and had baseline PAD status recorded. Multivariable analyses were performed with stepwise logistic regression for 7- and 30-day outcomes and Cox regression for 6-month and 1-year events. In our pooled analysis of 19,867 patients undergoing PCI, 1,602 (8.1%) were previously diagnosed with PAD. Patients with PAD had higher incidences of 7-day death (1.0% vs. 0.4%; p < 0.001) or myocardial infarction (MI) (6.8% vs. 5.6%; p = 0.047), 30-day death (1.7% vs. 0.7%; p < 0.001) or MI (7.4% vs. 6.1%; p = 0.05), 6-month death (4.2% vs. 1.5%; p < 0.001) or MI (9.1%, vs. 7.7%; p = 0.048), and 1-year death (5.0% vs. 2.1%; p < 0.001). There was a trend toward higher major bleeding risk with PAD (4.8% vs. 3.9%; p = 0.06). With multivariable analyses, PAD remains a significant predictor of mortality at 30 days (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.03 to 2.70; p = 0.039), 6 months (HR 1.76, 95% CI 1.31 to 2.37; p < 0.001), and 1 year (HR 1.46, 95% CI 1.08 to 1.96; p = 0.013). The presence of PAD is associated with higher rates of post-PCI death and MI, and is an independent predictor of short- and long-term mortality.

The Influence of Peripheral Arterial Disease on Outcomes: A Pooled Analysis of Mortality in Eight Large Randomized Percutaneous Coronary Intervention Trials

We aimed to evaluate clinical outcomes among peripheral arterial disease (PAD) patients following percutaneous coronary intervention (PCI). A significant proportion of patients with coronary artery disease undergoing PCI have concomitant PAD, which may be associated with worse outcomes. We performed a pooled analysis of 8 randomized PCI trials. We included multicenter PCI trials that compared antiplatelet therapies (EPIC, EPILOG, EPISTENT, RAPPORT, CAPTURE, IMPACT-II, TARGET, and CREDO) and had baseline PAD status recorded. Multivariable analyses were performed with stepwise logistic regression for 7- and 30-day outcomes and Cox regression for 6-month and 1-year events. In our pooled analysis of 19,867 patients undergoing PCI, 1,602 (8.1%) were previously diagnosed with PAD. Patients with PAD had higher incidences of 7-day death (1.0% vs. 0.4%; p < 0.001) or myocardial infarction (MI) (6.8% vs. 5.6%; p = 0.047), 30-day death (1.7% vs. 0.7%; p < 0.001) or MI (7.4% vs. 6.1%; p = 0.05), 6-month death (4.2% vs. 1.5%; p < 0.001) or MI (9.1%, vs. 7.7%; p = 0.048), and 1-year death (5.0% vs. 2.1%; p < 0.001). There was a trend toward higher major bleeding risk with PAD (4.8% vs. 3.9%; p = 0.06). With multivariable analyses, PAD remains a significant predictor of mortality at 30 days (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.03 to 2.70; p = 0.039), 6 months (HR 1.76, 95% CI 1.31 to 2.37; p < 0.001), and 1 year (HR 1.46, 95% CI 1.08 to 1.96; p = 0.013). The presence of PAD is associated with higher rates of post-PCI death and MI, and is an independent predictor of short- and long-term mortality.

IMPACT OF DIABETES MELLITUS ON SEVERITY OF CONCOMITANT PERIPHERAL ARTERIAL OCCLUSIVE DISEASE IN PATIENTS WITH CORONARY ARTERY DISEASE

Aim of the study: The aim of the study was to evaluate the impact of Diabetes Mellitus (DM) on severity of concomitant Peripheral Arterial Occlusive Disease (PAOD) in patients with Coronary Artery Disease (CAD).Patients and methods: This study included 302 patients (229 men) with a mean age of 62.2±11.5 years who had angiographically documented CAD. Patients were divided into Group I (severe CAD), Group II (moderate CAD) and Group III (mild CAD). Each of the groups I-III was divided into subgroups comprising diabetic patients (subgroups Ia, IIa, IIIa) and non-diabetic patients (subgroups Ib, IIb, IIIb). PAOD was evaluated by measurement of Toe-Brachial Index (TBI).Results: PAOD was diagnosed in 69 patients (22.8%). Symptoms of PAOD (intermittent claudication or rest pain) were present in 38 patients (55%), while 31 patients (45%) were asymptomatic. Frequency of symptoms attributable to PAOD did not differ (p=0.43) between diabetic patients (25 out of 49 patients, 51%) and non-diabetic patients (13 out of 20 patients, 65%). TBI was significant (p=0.04) lower in diabetic (0.41±0.03) than in non-diabetic patients with PAOD (0.51±0.03). This significant difference was found in each of the Groups I-III. Severity of PAOD was significant associated with angiographic gravity of CAD, both in diabetic (p=0.046) and in non-diabetic patients (p=0.047).Conclusions: DM has an adverse impact on severity of concomitant PAOD in patients with CAD. This impact does not depend on angiographic gravity of CAD. However, the association between severity of PAOD and angiographic gravity of CAD is demonstrated both in diabetic and in non-diabetic patients.

RISK FACTORS FOR CONCOMITANT PERIPHERAL ARTERIAL OCCLUSIVE DISEASE IN PATIENTS WITH CORONARY ARTERY DISEASE: IS THERE A DIFFERENCE BETWEEN DIABETIC AND NON-DIABETIC PATIENTS?

Aim of the study: The aim of the present study was investigation of cardiovascular risk factors for concomitant Peripheral Arterial Occlusive Disease (PAOD) in diabetic vs. non-diabetic patients with coronary artery disease (CAD).Patients and methods: This study included 302 patients (229 men) with a mean age of 62.2±11.5 years and angiographically documented CAD. These were divided into Group A comprising 116 diabetic patients (79 men) and Group B comprising 186 non-diabetic patients (150 men). Peripheral Arterial Occlusive Disease (PAOD) was diagnosed using a Doppler apparatus. Cardiovascular risk factors that were investigated included age, history of myocardial infarction, smoking, Body-Mass Index, Waist-Hip-Ratio, hypertension and serum lipids.Results: PAOD was diagnosed in 49 patients of Group A (42.4%) and 20 patients of Group B (10.8%). In Group A concomitant PAOD was associated with significantly (p=0.0001) longer diabetes duration and significantly (p=0.0001) higher frequency of insulin treatment, as well as significantly (p=0.02) higher triglycerides and significantly (p=0.039) lower HDL-Cholesterol. In Group B patients with PAOD had significantly (p=0.0001) higher age and significantly higher (p=0.041) LDL-Cholesterol levels than those without PAOD. No association was found between PAOD and presence of remaining risk factors in either group. In multiple regression analysis, concomitant PAOD was associated with diabetes duration (p=0.0026) and insulin treatment (p=0.0004) in Group A, while it was associated with age (p=0.01) in Group B. The associations with serum lipids were no longer significant.Conclusions: Among non-diabetic patients with CAD, those who have concomitant PAOD are significantly older. Among diabetic patients with CAD, those who have concomitant PAOD show significantly longer diabetes duration and significantly higher frequency of insulin treatment.

Peripheral arterial disease, acute coronary syndromes, and early invasive management: The TACTICS TIMI 18 trial

Patients with peripheral arterial disease (PAD) represent a high-risk patient subset in the setting of non-ST-segment elevation acute coronary syndromes (NSTE ACS). The efficacy and safety of early invasive management for such patients remains unclear. Early invasive management would be well tolerated and effective among patients with NSTE ACS and PAD. Patients from the Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction (TACTICS-TIMI) 18 trial were stratified by the presence or absence of PAD and assessed with respect to baseline clinical factors. The outcomes of patients with PAD and NSTE ACS were examined with respect to treatment assignment to either early invasive therapy or conservative treatment of NSTE ACS. Finally, the bleeding and stroke rates of patients with PAD managed invasively were compared with patients with PAD managed conservatively. Of 2219 patients with NSTE ACS overall, 166 (7.5%) had concomitant PAD. Compared with those patients without PAD, those with PAD were older (75 vs. 62 years, p < 0.001) and were more likely to have high-risk clinical features, including prior histories of bypass surgery (39 vs. 20%, p < 0.001) or diabetes mellitus (38 vs. 27%, p = 0.002), and more ST-segment depression on their 12-lead electrocardiogram (43 vs. 29%, p < 0.001). Among such patients, early invasive management was associated with significant reductions in the risk of myocardial infarction (MI) at 30 days (11.4 vs. 2.3%, p = 0.03). At 180 days, compared with early conservative management, early invasive treatment for patients with PAD and NSTE ACS was associated with similar reductions in MI (12.7 vs. 3.5%, p = 0.04), and was also accompanied by significant reductions in risk of death (10.1 vs. 2.3%, p = 0.05). No excess in bleeding or stroke rates was noted among patients with PAD managed invasively. Among patients with NSTE ACS and a history of PAD, early invasive management is well tolerated and accompanied by significant reductions in morbidity and mortality when compared with a more conservative, ischemia-driven approach.

Relationship Between Intermittent Claudication, Inflammation, Thrombosis, and Recurrent Cardiac Events Among Survivors of Myocardial Infarction

Among coronary disease patients, concomitant peripheral arterial disease is a potent risk factor for future cardiac events and mortality. We sought to determine clinical and biochemical markers that might better elucidate the relationship between coronary and peripheral arterial disease. Two months after an index myocardial infarction, 1045 patients provided detailed medical histories and underwent blood testing for selected hemostatic, lipid, and inflammatory markers. Patients were then followed up prospectively for a mean of 26 months. Compared with individuals without intermittent claudication (n = 966), those with claudication (n = 78) (information was unavailable for 1 individual) were significantly older and demonstrated an increased frequency of diabetes mellitus, tobacco use, prior cardiac and cerebrovascular events, and depressed left ventricular function. Individuals with claudication were less likely to receive beta-blocker therapy after the index infarction. Individuals with claudication had evidence of enhanced procoagulant and proinflammatory states manifested by relative elevations in plasma fibrinogen, D-dimer, C-reactive protein, and serum amyloid A concentrations. During follow-up, the presence of claudication was associated with an independent 2-fold increase in the combined end point of death or nonfatal cardiac event (38.5% vs 17.8%, P =.001) and a 5-fold increase in cardiac mortality (19.2% vs 3.6%, P =.001). Patients with intermittent claudication who were not treated with beta-blockers had a significant 3-fold mortality excess relative to those receiving beta-blockers. Following myocardial infarction, the added presence of intermittent claudication is associated with heightened procoagulant and proinflammatory states and an underuse of beta-blocker therapy and is a strong independent predictor of recurrent cardiovascular events.

Lower extremity peripheral arterial disease in hospitalized patients with coronary artery disease.

The prevalence of coronary artery disease (CAD) in patients with peripheral arterial disease (PAD) has been well defined. However, the prevalence of PAD in hospitalized patients with CAD has not been defined. The ankle-brachial index (ABI) is a useful non-invasive tool to screen for PAD. The aim of our study was to assess the prevalence of PAD in hospitalized patients with CAD by measuring the ABI. The study was conducted at the University of Wisconsin Hospital and Clinics inpatient Cardiovascular Medicine Service. Medically stable patients with CAD were invited to participate prior to hospital discharge. Data regarding cardiovascular risk factors, history of previous PAD, physical examination, and ABI were collected. An ABI less than or equal to 0.9 or a history of previous lower extremity vascular invention was considered to be indicative of significant PAD. A total of 100 patients (66 men and 34 women) were recruited. Forty patients were found to have PAD (mean ABI in non-revascularized patients with PAD = 0.67). By measuring the ABI, 37 (25 men) were positive for PAD and three had an ABI corrected with previous revascularization. Of these patients, 21 (52.5%) had previously documented PAD. Patients with PAD were older (p = 0.003), had a greater smoking history (p = 0.002), were more likely to have diabetes (p = 0.012), hypertension (p = 0.013) and a trend towards more dyslipidemia (p = 0.055). In conclusion, hospitalized patients with CAD are likely to have concomitant PAD. Risk factors for PAD in this patient population include advanced age, history of smoking, diabetes, hypertension, dyslipidemia and abnormal pulse examination. Identification of patients with PAD by measuring the ankle-brachial index is easily done.

Increased inflammatory status and higher prevalence of three-vessel coronary artery disease in patients with concomitant coronary and peripheral atherosclerosis

The aim of this study was to determine whether patients with coronary artery disease (CAD) and concomitant peripheral arterial disease (PAD) have a greater inflammatory status than those with CAD alone. To this aim, we evaluated PAD (ankle/brachial pressure index <0.9), and measured plasma levels of C-reactive protein (CRP), interleukin-6 (IL-6) and the soluble forms of intercellular adhesion molecule-1 (sICAM-1) and vascular cell adhesion molecule-1 (sVCAM-1) in 234 patients who underwent coronary angiography. Median levels of CRP, IL-6 and sICAM-1 were higher in the CAD without PAD (n=134) and CAD+PAD (n=40) groups than in 60 patients without either disease ("controls"). Median CRP values were higher in patients with CAD+PAD than in patients with CAD alone (4.7 mg/L [1.5; 7.6] vs 2.4 mg/L [0.9; 3.8], p < 0.01).Three-vessel CAD was diagnosed in 60% of CAD+PAD patients and in 21% (p< 0.01) of CAD only patients. After adjustment for confounding factors, only PAD was independently associated with three-vessel CAD (p<0.001). This association was maintained after adjustment for IL-6, the only inflammatory parameter significantly associated with three-vessel CAD at univariate analysis (p<0.01). In conclusion, in CAD the coexistence of PAD is associated with a greater inflammatory status and more widespread coronary atherosclerosis. These results could help to explain the high cardiovascular risk of patients with concomitant CAD and PAD and suggest that PAD be included among the variables used to identify CAD patients for further diagnostic evaluation.

Atherothrombosis--the neurologist's point of view.

Patients with peripheral arterial disease (PAD) have an increased risk of cerebral ischaemia, but many transient ischaemic attacks are not recognized by patients, or by physicians who are not neurologists. Similarly, PAD is common in stroke patients, but often remains unrecognized by neurologists. Major long-term risks in patients with cerebral ischaemia due to atherosclerosis are myocardial infarction and recurrence of stroke. Neurologists should consider concomitant PAD when choosing a treatment strategy. Patients with PAD need to be educated about their risk for cerebral ischaemic events, and physicians caring for PAD patients need to identify those individuals who may require carotid surgery. The appropriate strategy for prevention of stroke in PAD patients consists of optimal management of risk factors for stroke (smoking, arterial hypertension, hypercholesterolaemia), antiplatelet therapy with clopidogrel as first-choice treatment, and carotid surgery in patients with high-grade stenosis of the internal carotid artery who are at low risk for surgery.

Peripheral atherosclerosis in familial hypercholesterolaemia

Unlike coronary artery disease, peripheral atherosclerosis is considered to be infrequent in heterozygous familial hypercholesterolaemia. The authors studied 20 consecutive asymptomatic familial hypercholesterolaemic patients and an age- and sex-matched control group of consecutive normolipidaemic and asymptomatic patients admitted to the hospital for elective non-vascular surgery. The patients and the controls were studied non-invasively by measuring the ankle-arm systolic blood pressure ratio at rest. Peripheral atherosclerosis was common in this study population in contrast to the control group: an abnormal (less than 0.97) pressure ratio was found in 13 patients (65%) in the study group but in only one person in the control group. Eight out of 20 patients had coronary artery disease, and seven of them had an asymptomatic concomitant peripheral artery disease. Neither the classical risk factors, i.e. age, smoking, obesity, hypertension and glucose intolerance, nor serum lipid or lipoprotein status or the parameters of cholesterol metabolism correlated with peripheral atherosclerosis. It is concluded that atherosclerosis in familial hypercholesterolaemia is a multilevel disease that frequently affects also the peripheral arteries.