Frequency Of Peripheral Arterial Disease Research Articles

Frequency of Peripheral Arterial Disease in Type-II Diabetic Patients presenting with Diabetic Retinopathy

Background: Type-II Diabetes Mellitus (T2DM) often leads to Diabetic Retinopathy (DR), but the prevalence of coexisting Peripheral Arterial Disease (PAD) in these patients is unclear, creating controversy in existing literature. This study aims to fill this gap by investigating the frequency of PAD in T2DM patients with DR, enhancing our understanding of diabetes-related complications. Objective: To determine frequency of peripheral arterial disease in T2DM patients presenting with diabetic retinopathy. Study Design: It was a cross sectional study. Settings: This study was conducted at the Department of Medicine, DHQ Teaching Hospital, KMU Institute of Medical Sciences, Kohat Pakistan. Duration: Six months from 05-01-2022 to 04-07-2022. Methods: A total 165 T2DM patients presenting with diabetic retinopathy and meeting inclusion criteria were enrolled in this study after taking informed written consent. Ankle brachial pressure index was measured. Two blood pressure readings were taken 5 minutes apart and average was calculated for analysis. Peripheral arterial disease was labeled. SPSS version 26.0 was used for data analysis. Results: The mean age of the participants was 51.1±14.69. There were 63 (38.2%) females and 102 (61.8%) males. Mean BMI was 26.87±3.73 kg/m2. The mean duration of diabetes in the participants was 6.43±2.36 years. As regards type of retinopathy, 62 (37.6%) had Proliferative Diabetic Retinopathy (PDR), and 103 (62.4%) had Non-Proliferative Diabetic Retinopathy (NPDR). Mean Ankle Brachial Pressure Index (ABPI) among the participants was 1.01±0.25. Peripheral arterial disease was noticed in 28.5% of the T2DM patients presenting with diabetic retinopathy. Stratification of frequency of PAD for various sub groups of age, gender, BMI, duration of disease and type of retinopathy produced insignificant difference between sub groups (p-value>0.05). Conclusion: In conclusion, our investigation of Type 2 diabetic patients with diabetic retinopathy uncovers a significant 28.5% prevalence of peripheral arterial disease (PAD). Stratification across age, gender, BMI, disease duration, and retinopathy type reveals no substantial differences. These results underscore the systemic nature of vascular complications, emphasizing the importance of comprehensive care strategies.

Frequency of Peripheral Arterial Disease among Diabetic Patients

Background: Peripheral artery disease, or PAD, is among the significant macro-vascular problems of diabetes mellitus and is connected with the cardio death rate and a higher rate of impairment after extremity amputation in people with diabetes. For that reason, the present research is targeted at figuring out the frequency as well as corresponding elements of Peripheral artery disease among diabetic patients at Hayatabad Medical Complex MTI, Peshawar. Place and Duration of study: Hayatabad Medical Complex MTI, Peshawar, Pakistan. The duration of the study was 6 months from 5th September 2021 to 5th March 2022. Methods: An institution based cross sectional research had been carried out among diabetes mellitus patients. A pre-tested interviewer administered a survey had been utilized to gather the information. The existence of stenosis, as well as its grading, had been influenced by color Doppler ultra-sonography. Adjusted odds ratios, along with their confidence interval (CI), were calculated for possible predictors within the ultimate model. P = 0.05 had been utilized to declare mathematical significance. Results: The mean chronological age of the research respondents was 60.5 ± 8.4 years. Two hundred fifty (55.5 %) sufferers were men, and two hundred (44.4%) were women. Sixty-seven (63.4%) sufferers were symptomatic. Age (adjusted odds ratio = 2.11 (2.45-3.11), high Glycated Hemoglobin (adjusted odds ratio = 3.87 (3.53-6.98)), as an ex-smoker (adjusted odds ratio = 5.78 (3.73-22.12), and present cigarette smoker (adjusted odds ratio = 10.12 (3.90-38.34)) were considerably connected with peripheral artery disease. Conclusion: The frequency of peripheral artery disease between people with diabetes was higher. Growing age, higher Glycated Hemoglobin, and smokers boost the probability of developing peripheral artery disease. Physicians must protect against peripheral artery disease, screen diabetic sufferers aged with higher Glycated Hemoglobin and people who smoke and treat them on time.

The Importance of Arterial Stenosis in Diabetic Patients Case Presentation

Abstract For the adult population the frequency of peripheral arterial disease is 3% - 4%. Cardiovascular and cerebrovascular event rates, both fatal and non-fatal, are increased in patients with PAD and DM relative to nondiabetic patients with PAD. It is the clinical case of a 62-year-old patient, diagnosed with type 2 diabetes with chronic obliterative arteriopathy stage IV of the lower limbs. Postoperative evolution was favorable, as there was no need for amputation of the left hallux or debridement of necrotic tissues, due to the decision to perform the timely iliofemoral bypass that restored arterial flow to the femoral and iliac arteries through the prosthetic graft. Continued treatment to normalize lipid metabolism, hypertension, repeated vasodilator therapy, diet and exercise are absolutely necessary and must be included in the long-term therapeutic plan of patients who have undergone restorative surgery, with timely referral to specialist medical services.

Prevalence and Predictors of Lower Limb Amputation in the Spinal Cord Injury Population.

Despite limited data demonstrating altered hemodynamics in the lower extremities (LEs) among the population with spinal cord injury (SCI) and increased frequency of peripheral arterial disease (PAD), epidemiologic data are limited for amputations, a potential consequence. This study investigates the association of amputation due to vascular complications as a secondary outcome measure within the SCI population. A retrospective cohort study was performed within a veteran population with SCI at a US Department of Veteran Affairs hospital to determine the prevalence of limb loss. We hypothesized that premorbid SCI increased the likelihood of LE amputation. Of 1055 charts reviewed, 91 (8.7%) patients had an amputation, 70 (76.1%) had a dysvascular etiology. Transfemoral amputations were the most common level (n = 53) of amputation. Our results showed a positive correlation between the completeness of injury and the prevalence of amputation. There is an increased frequency of amputation among the veteran population with SCI compared with that of the general US population. Amputations frequently occur at more proximal levels with motor complete injuries. Studies using a larger population and multiple centers are needed to confirm this alarming trend.

Descriptive Study: Frequency and risk factors of peripheral arterial disease in patients with type II Diabetes Mellitus of Hospital José Carrasco Arteaga, Cuenca.

BACKGROUND: Peripheral arterial disease (PAD) is more common in patients with type 2 Diabetes Mellitus (DM2) than in the general population, making them a high-risk group for morbidity and mortality. The aim of this study was to determine the frequency of peripheral arterial disease, by measuring ankle-brachial index, and the frequency of its risks factors in patients with type 2 Diabetes Mellitus at Hospital José Carrasco Arteaga. METHODOS: descriptive, cross-sectional study, with a simply randomized sample of patients diagnosed with Type 2 Diabetes Mellitus, who attended the outpatient clinic of Hospital José Carrasco Arteaga, Cuenca - Ecuador, in 2017 ( 315 patients). An interview was applied to the patients, to collect data on sociodemographic characteristics and certain important medical history; ankle-brachial index was determined; complementary laboratory tests made six months prior to the study were evaluated. Finally, frequencies and percentages of each variable were described; we used IMB SPSS version 22 software. RESULTS: Of the total number of patients, the average age was 62.9 years, with a predominance of the female sex. The frequency of PAD in patients with DM2 was 35.30%. PAD was more frequent in: age group over 50 years (38.8%), male sex (43.9%), disease evolution time ≥ 5 years (35.5%), in smoking patients(38.4%), in patients with elevated glycosylated hemoglobin levels (HbA1c ≥7%)(40.6%),in patients with hypertriglyceridemia, in patients with elevated LDL and in men with low HDL values. CONCLUSION: we can conclude that the peripheral arterial disease frequency in patients with type 2 Diabetes Mellitus, at Hospital José Carrasco Arteaga, using the ankle-brachial index as a diagnostic method was 35.50%.

Évaluation des lésions artérielles périphériques chez le coronarien avéré à l’Institut de cardiologie d’Abidjan en Côte d’Ivoire

BackgroundCoronary artery disease is mainly due to atherosclerosis. The aim of this study was to evaluate the frequency of peripheral arterial disease in proven coronary artery disease and to determine the associated factors in our context. Material and methodsWe included in a cross-sectional descriptive and analytical study 224 patients with proven coronary artery disease confirmed on coronary angiography from March 1 to October 30, 2019. It took place in the external exploration department of the Abidjan Heart Institute. An ultrasonographic exploration of the supra-aortic trunks and arteries of the lower extremity with measurement of the ankle brachial index (ABI) was carried out. ResultsThe mean age was 57.4±10.9 years (27–81years). There was a clear male predominance with a sex-ratio of 5. The prevalence of carotid artery disease was 56.4% of patients. The main factors associated with elevated Intima Media Thickness (IMT) and the presence of carotid plaques were male sex (OR=8.8; P=0.038), smoking (OR=2.5; P=0.049) and multi-truncular involvement (OR=3.2; P=0.014). In the lower extremities, there was a prevalence of peripheral arterial disease of 48.5%. The main factors associated with the decrease of ABI were age ≥50 years (OR=2.6; P=0.043), diabetes (OR=2.8; P=0.02), dyslipidemia (OR=3.8; P=0.001) and pluri-truncular involvement (OR=4.5; P<0.0001). ConclusionThe presence of significant coronary artery disease in our context is associated with a high prevalence of peripheral carotid artery and lower extremity artery disease. This is all the more so as we are male, over 50 years old, pluri-truncular with many cardiovascular risk factors.

Foot Osteomyelitis in Patients Without Diabetes—Editorial Comment

Relatively few articles have been written on the subject of foot osteomyelitis in patients without diabetes. Even a PubMed search using the terms “osteomyelitis, foot” yields a majority of articles on diabetic foot osteomyelitis. But is there a difference between the two? In this article, Mitbander et al1 conclude that foot osteomyelitis is not clinically distinct in patients with diabetes versus those without, and the approach to management need not differ. We commend the authors for their important and interesting article. It is the first study to our knowledge that seeks to directly compare the two. There are pitfalls for any investigator trying to study osteomyelitis, whether in patients with or without diabetes. The answers to the most basic questions such as definition of the condition, appropriate diagnosis, length and course of treatment, surgical versus medical therapies, and even the definition of a “cure” remain elusive. Various clinical practice guidelines have attempted to answer some of these questions, but most recommendations are based on relatively low levels of evidence and tend to comprise mostly consensus opinion. For the case definitions used to include patients into this study, the authors reference the International Working Group on the Diabetic Foot 2008 consensus statement. That this work was specifically looking at diabetic foot osteomyelitis is, in and of itself, demonstrative of the central premise of this work. Are criteria used to define osteomyelitis in the diabetic foot different from those in patients without diabetes? Should clear diagnostic criteria (was osteomyelitis diagnosed via positive bone culture, histopathology, changes on plain x-ray or magnetic resonance imaging, elevated erythrocyte sedimentation rate?) be required to define a case? The authors state that the frequency of peripheral arterial disease (PAD) was similar in both groups, yet the nondiabetes cohort was more frequently found to be smokers. The authors reference the relatively recent Society for Vascular Surgery “WIFI” consensus document to define PAD. These guidelines utilize not only ankle-brachial index but also ankle systolic pressure, toe pressures, and transcutaneous oximetry to stratify patients into 1 of 4 risk grades. Were any, or all, of these techniques used to diagnose PAD in this population? Is it possible that the cigarette smoking in the nondiabetic group led to microvascular disease of the toes that may not have been appreciated if only ankle-brachial index or ankle pressures were utilized? How is a cure defined other than “no further surgery being necessary”? This singular point is one of the reasons there are so few outcome studies on the treatment of osteomyelitis. No one can agree upon an end point! Is there a better definition of treatment failure, which the authors define as “unanticipated resection of additional bone from the initial area of infection or an above-ankle amputation because of ongoing infection”? It's not at all uncommon for patients with osteomyelitis, either with or without diabetes, to have to undergo serial bone debridements. This does not mean that the treatment is a “failure” but rather is part of the standard treatment. Likewise, it would be important to mention the length of treatment for each group. Do patients without diabetes require a longer or shorter course of therapy? The question of “how long to treat” is an important one and is usually based on radiographic studies, biomarkers, and clinical signs. Finally, given that the patient population was skewed toward older males because the study took place on the vascular service at a Veterans Administration Hospital (all but 2 patients were male, and only 20 subjects did not have diabetes), are these results generalizable across a broader population? It would be interesting to see if there were similar outcomes in future studies that included a more diverse demographics and a larger patient base. It was heartening to see the authors use oral antibiotics as their primary treatment regimen. Over the years, intravenous antibiotics have remained for many the perceived criterion standard for treating osteomyelitis. Many clinicians still doggedly cling to the notion that intravenous is superior to oral despite mounting evidence to the contrary. It is nice to see this timeworn dogma give way to an evidence-based approach. We look forward to more studies of this type and applaud the authors for taking the first step in answering the question: Are diabetic and nondiabetic foot osteomyelitis clinically distinct entities?

A study to assess frequency of peripheral arterial disease in patients presenting with acute coronary syndrome

Background: To determine the frequency of peripheral arterial disease (PAD) in patients presenting with acute coronary syndrome (ACS) and association of PAD with different risk factors of coronary artery disease (CAD) and to look for in hospital outcome of ACS patients with or without PAD.Methods: This cross-sectional observation study was undertaken in the department of cardiology, IPGME&amp;R Hospital, Kolkata from June 2015 to August 2016 to recruit 199 consecutive patients admitted with ACS and were evaluated with detailed clinical history, physical examination, ABI (Ankle Brachial Index) measurement, echocardiography and appropriate blood investigations.Results: Among 199 total ACS patients, STEMI was the predominant mode of presentation (71.86%) and majorities were male. PAD was seen in 26 patients and mean age was 56.68±8.84 years. Factors independently related with PAD in acute coronary syndromes are hypertension (OR- 1.49; 95% CI: 0.615-3.232), diabetes (OR- 2.55;95% CI : 0.9762-6.6665), smoking (OR-2.55; 95% CI: 1.055-6.19), past history of CVA (OR-11.15;95% CI: 1.77-70.32), LV systolic dysfunction (OR-1.388; 95% CI:0.607-3.1742). 2 and 13 patients died within 7 days of admission among 26 ACS-PAD group (7.69%) and 173 ACS-non-PAD group (7.5%) respectively and most of them had STEMI.Conclusions: Significant numbers of ACS patients are having PAD and older age, male sex, diabetes, hypertension, smoking and LV systolic dysfunction were found to be independent predictors for PAD in ACS patients. Early in hospital mortality was seem to be dependent on clinical presentation, not on presence or absence of PAD.

Peripheral Artery Disease and Osteoporosis

The frequency of peripheral arterial disease (PAD) increases with advancing age similar to that of osteoporosis [1],..

Frequency of Peripheral Arterial Disease in Patients With Chronic Venous Insufficiency.

Background:It is estimated that about 15% (10% - 30% in most of the studies) of the total adult population has some aspects of the Chronic Venous Insufficiency (CVI). Frequency of the Peripheral Arterial Disease (PAD) in the adult population is 3% - 4%. Studies dealing with etiopathogenesis of leg ulcers show that between 10% and 18% of all ulcers are of mixed, arterial-venous origin.Objectives:The purpose of this study was to find out if there is a higher frequency of PAD among CVI patients in comparison with the control group, as well as to discover some common risk factors for CVI and PAD.Patients and Methods:This cross-sectional descriptive study was conducted at the dermatovenereological clinic, clinical center of Vojvodina, Serbia. A total of 162 examinees were included. All patients were examined for the existence of CVI and staged according to CEAP (Clinical, etiology, anatomy and patophysiology) classification. In this way, 3 groups were formed: Patients with the mild forms of CVI (stage 1 - 4 by CEAP classification), 57 patients; patients with the severe forms of CVI (stage 5 and 6 by CEAP classification), 55 patients; control group (no CVI), 50 patients. Also, the Ankle Brachial Pressure Index (ABPI) was assessed in all subjects, and its value of ≤ 0.9 was set as criteria for diagnosis of PAD. The same sample was divided according to the presence of PAD into two groups. The most important risk factors for CVI and PAD were identified for each patient through complete examination, medical record and appropriate questionnaire.Results:Our results showed that the risk factors for CVI were high Body Mass Index (BMI), hypertension, predominantly standing position during work and positive family history for CVI. In the same sample it was found that 28 (17.28%) patients had PAD. Relevant risk factors for PAD in the present study were: high BMI, hypertension, diabetes and a positive family history for PAD. Comparison of frequency of PAD among patients with severe forms of CVI and control group showed that this difference was statistically significant (P = 0.0275; OR 3.375; 95% CI 1.125 - 10.12). After multivariate analyses, adjusted odds ratio OR was still statistically significant.Conclusions:The peripheral arterial disease is more frequent in patients with the severe form of CVI, than in patients without CVI. Concomitant risk factors for CVI and PAD were high BMI and hypertension. In each patient with severe CVI it is necessary to determine the ABPI, in order to exclude the presence of PAD.

Peripheral Arterial Disease among Diabetic Patients in Dr. Hasan Sadikin General Hospital Bandung 2012

Background : As one of the most devastating complication in diabetes mellitus, peripheral arterial disease is still under detected in health care services. This study aimed to reveal the frequency of peripheral arterial disease in diabetic patients in Endocrine and Metabolism Clinic in Dr. Hasan Sadikin General Hospital Bandung. Methods : A cross sectional descriptive study was conducted during the period of October to November 2012 in Endocrine and Metabolism Clinic in Dr. Hasan Sadikin General Hospital Bandung. As many as 54 patients who met the inclusion criteria and agreed to participate in this study signed the informed consent form then underwent history taking, simple physical examination of lower extremities, and Ankle-Brachial Index (ABI) measurement. Normality of the data distribution was calculated by Kolmogorov-Smirnov test. Results : From a total 54 diabetic patients enrolled, it was found 18 cases of peripheral arterial disease, consisted of 10 patients with Ankle-Brachial Index measurement ≤0.9 and 8 patients with Ankle-Brachial Index measurement >1.4. Most of the cases occurred in the elderly group (>60 years old) and had been diagnosed diabetes less than 10 years. Conclusions : The frequency of peripheral arterial disease in diabetic patients attended Dr. Hasan Sadikin General Hospital Bandung is 33.3% and more prevalent in elderly patients. It occurred mostly in patients diagnosed with diabetes less than 10 years. [AMJ.2015;2(1):287–90]

Association of height with peripheral arterial disease in type 2 diabetes.

ObjectiveTo investigate whether height is associated with peripheral arterial disease (PAD) in patients with type 2 diabetes.Research design and methodsThis was an observational study performed in 4,528 Chinese patients with type 2 diabetes. Anthropometric measures and the ankle-brachial index (ABI) were performed on each subject. PAD was defined as those patients with a history of revascularization or amputation due to ischemia, or an ABI <0.9.ResultsA total of 23.3 % of T2DM patients had PAD (men 22.9 % and women 23.7 %). The mean age and height were 57.8 ± 12.5 years and 170.5 cm for men, and 60.0 ± 11.7 years and 158.9 cm for women, respectively. The ABI and frequency of PAD were higher with decreasing height quartiles. An inverse association was observed between height- and gender-adjusted risk of PAD. This relationship remained unchanged following further adjustment for potential confounders. Subjects in the shortest stature group had of 1.174 times higher risk of PAD for men and 1.143 times for women, compared with those in the tallest stature group. The multivariate adjusted hazard ratios (95 % CI) of PAD for a 10-cm height increase were 0.85 (95 % CI 0.78–0.94).ConclusionA short stature seems to be associated with higher risk of PAD in Chinese diabetic patients. However, the cross-sectional nature of the study limits conclusions regarding the direction or causality. Further longitudinal study is warranted in this and other ethnic groups.

Frequency of Peripheral Arterial Disease Diagnosed by Measurement of the Ankle Brachial Index Among Diabetics with No Symptoms of Intermittent Claudication

Objective. The ankle brachial index (ABI) was measured at rest and after the six-minute walk test (6MWT) to determine the frequency of peripheral arterial disease among diabetics with no symptoms of intermittent claudication. Methodology. A total of 70 participants were enrolled in the study taken from at the outpatient department of Manila Doctors Hospital and Our Lady of Remedies Health Center, Malate from September to October 2011. Based from the blood pressure resting and after the 6MWT, ABI was computed such that a result of < 0.90 is diagnostic of PAD. Results. Mean age of participants was 60 years (SD + 12.2). Among the participants 74% were females, 63% were hypertensive, and 14% were smokers. Systolic and diastolic blood pressure was 140+18.32, 82+12.3 respectively. Participants who were hypertensive and who smoke was above 30%. ABI classified as non-compressible and borderline was 1.42 % and above 10% respectively. The frequency of PAD using ABI was 33% at rest and 37% after the 6MWT. No severe PAD was seen both resting and after 6MWT. Conclusion. The frequency of PAD among diabetics with no symptoms of intermittent claudication using ABI seen at the outpatient department of Manila Doctors Hospital and Our Lady of Remedies Health Center was relatively higher after the 6 MWT.

Peripheral artery disease in type II diabetes.

To determine the frequency of peripheral arterial disease (PAD) in type 2 diabetic patients. Cross-sectional observational study. Diabetes Clinic, Medical Unit III, Jinnah Postgraduate Medical Centre, Karachi, from January to June 2010. Three hundred and eighty seven (387) type II diabetic patients of either gender and any age were included in the study. Patients with a previous history of trauma to the arterial vasculature, pregnancy and those who underwent arterial graft procedures were excluded. Non-purposive convenient sampling technique was used to enroll patients in the study. PAD was diagnosed when ankle-brachial index (ABI) was less than 0.9. A p-value of less than 0.05 was considered statistically significant. Out of 387 studied patients, 128 were males (33.1%) and 259 were females (66.9%). Mean age was 52.22 ± 9.671 (22 - 76) years in the entire cohort. Mean duration of diabetes was 9.38 ± 6.39 years. PAD was detected in 152 (39.28%) of the total study subjects. Thirty-one of 128 male patients (24.22%) had PAD disease while 121 out of 259 female patients (46.71%) had evidence of PAD (p = 0.001). Hypertension was a significantly associated factor (p = 0.002). A high frequency of PAD was observed in the diabetic population particularly with hypertension and more prevalent in females.

Frequency of peripheral arterial disease and venous insufficiency in toenail onychomycosis

Onychomycosis in toenails is a common fungal infection and vascular abnormalities of lower extremities have been thought as one of the predisposing conditions. The aim of this study was to evaluate predisposition effect of venous insufficiency and peripheral arterial disease on toenail onychomycosis. Thirty-three patients with bilateral onychomycosis in toenails and 37 control subjects, who had healthy nails, were enrolled in the study. Veins and arteries of lower extremities were examined with Doppler ultrasound in terms of venous insufficiency or peripheral arterial disease. Patients with onychomycosis presented more frequent venous insufficiency than the control group (42.4% and 10.8%, respectively; P=0.003). Although all patients had bilateral onychomycosis, reflux was bilateral in six out of 14 patients with onychomycosis (42.8%). No significant difference in frequency of peripheral arterial disease was found in patients, compared to healthy controls. Our study demonstrated a significant relationship between onychomycosis and venous insufficiency, but not with peripheral arterial disease. Also, we point out discordance with bilateral onychomycosis and unilateral venous insufficiency.

Ankle-brachial Index, Peripheral Arterial Disease, and Diabetic Retinopathy

Dear Editor We read with interest the article by Yun et al. [1], who reported that the frequency of diabetic retinopathy was associated with the presence of arterial stiffness as measured by the brachial ankle pulse wave velocity, but not with common carotid artery intima-media thickness, carotid plaque, or peripheral arterial disease (PAD), in a Korean sample of type 2 diabetic patients. They suggested that the association between macroangiopathy and microangiopathy may be due to a functional rather than structural process within the vascular system, although arterial stiffness is widely accepted as a structural phenomenon characterized by medial calcium accumulation in the vessel wall. Yun et al. [1] found no relation of PAD as diagnosed by ankle brachial index (ABI) measurement to the presence of retinopathy in their diabetic participants. They successfully discussed this finding in light of the previous studies that had displayed conflicting data with respect to an association with microangiopathy and clinical or subclinical atherosclerotic diseases. They also linked their negative condition findings to several factors such as selective survival, discordant sample sizes in the tested groups, population characteristics, image magnification limitations, or the age distributions in their study population. At this point, we needed to make some more contribution by going through the diagnosis of PAD by ABI measurement in people with diabetes mellitus. Use of ABI measurement in the diagnosis of PAD in subjects with diabetes, especially in those with long-standing disease, requires caution with regard to recent findings in large trials and recommendations inserted into the guidelines. Diabetes has been linked not only to accelerated atherosclerosis and plaque formation but also to earlier initiation of arterial stiffness [2], as was also shown in the study by Yun et al. [1]. However, it is well known that arterial stiffness often causes inversely increased ABI values due to incompressible vessels [3], masking the presence of occlusive disease in the lower extremities that could be identified by ABI testing. Consistent with this, diabetes was clearly found to be a risk factor for a high ABI [4]. Moreover, diabetic individuals with ABI 1.40 were demonstrated to display similar patterns of abnormalities in different diagnostic tests for lower extremity ischemia, and a high ABI was suggested to be PAD-equivalent [4]. Therefore, it is possible that the true prevalence of PAD might have been underestimated by determining a low ABI in the study by Yun et al. [1], resulting in insufficient statistical power as well. Indeed, Table 1 of the study shows that the frequency of PAD was detected to be 20.45% lower in those subjects with retinopathy compared to those without, which is not consistent with the knowledge that the duration of diabetes is positively associated with the prevalence of cardiovascular diseases. In order to improve the understanding of our readers, it would be helpful if the authors could re-evaluate their data for high ABI (>1.4) or collectively with ABI ≤0.9 because, Papanas et al. [5] reported a significantly higher prevalence of a low ABI in diabetics with microvascular complications when the subjects with medial arterial calcification were specifically excluded.

Very Low Frequency of PAD in People with CHD in Six Middle Eastern Countries

We read with interest the article by Al-Thani et al. [1] reporting a very low frequency (2.6%) of peripheral arterial disease (PAD) in people with acute coronary syndrome in a multicenter study conducted in six Middle Eastern countries. A recent multicenter study in Turkey showed 20% prevalence of PAD in people with established cardiovascular disease or who were at risk for atherosclerotic diseases [2]. Diabetes that was present in 70% of the participants in their study is actually a major cause of arterial stiffness or calcification, which frequently results in misclassification of diabetics in ankle brachial index (ABI) testing by causing paradoxically high values [3]. In this context, it would be utmost helpful if the authors could provide some data related to the prevalence of a high ABI (>1.4) in their study population, so that the readers could recognize whether a high ABI potentially influenced the frequency of a low ABI. Another point that should be noted is the method of assessment of PAD by ABI testing. In recent years, many societies published detailed consensus guidelines on the definition and management of PAD [4–6]. Collectively, the ABI cut-off value for the diagnosis of PAD is currently accepted as ≤0.9. Although ABI of <0.8 can be found in several surveys as the diagnostic threshold, adherence to guidelines and their updates would be a superior evidence-based approach. In such case, it could be speculated that the prevalence of PAD would be recorded some higher in the study by Al-Thani et al. A final concern is the need for a correct calculation of ABI. As explained clearly in the TASC II guidelines, [4] higher readings of dorsalis pedis or tibialis posterior arteries should be used as the numerator in the index formula. However, Al-Thani et al. used the average (i.e., mean of dorsalis pedis plus tibialis posterior records) systolic blood pressure readings in each ankle as the numerator in order to calculate the ABI ratio. Compared to guideline recommendations, this method obviously results in use of lower values for any ankle especially when one of the readings is lower than the other, causing an increase in the frequency of a low ABI. Opposite to our concern regarding the ABI cut-off in the previous section, such a calculation could further reduce the reported prevalence of PAD in this multicenter large scale survey. However, through a scientific view, this does not eliminate the potential limitations. We guess that the readers would appreciate if the authors could comment on these issues.

Do cardiovascular disease risk prediction tools need to be updated in Europe?

Dr. Cimminiello and colleagues in their well-designed trial, examined the frequency of peripheral arterial disease (PAD) in patients with nonhigh cardiovascular risk in six countries of Europe [1]. The PANDORA study may not be the first of its kind, but the results presented by the authors deserves attention concerning the higher frequency of PAD in two Mediterranean countries Italy (22.9%) and Greece (28%) when compared to France (12.2%), Switzerland (12.2%), The Netherlands (8.1%) and Belgium (8.1%). It is noteworthy that the four countries with the highest prevalence of PAD in people with nonhigh risk profile for cardiovascular disease in the study are accepted as low risk countries in European guidelines on cardiovascular disease prevention published in 2007 [2]. Moreover, The Netherlands, which is indicated as a high risk country in the same guidelines displays a relatively lower frequency of the disease, not more than Belgium which is also a low risk country. The results are quite different, and, unless supported by scientific evidence, cannot easily be explained by methodological discrepancies in the recorded countries. Such big changes in the magnitude of the disease is also not likely in a couple of years. As we know, 2007 European guidelines and score charts were designed to estimate the probability of all types of cardiovascular diseases including PAD [2]. While trying to establish the benefits of a Mediterranean lifestyle, the PANDORA study suggests that we should also focus on whether we need to upgrade the current risk stratification models for some countries. Indeed, we recently published the results of a nationwide survey in Turkey, the CAREFUL study, which finds that the prevalence of a low ABI in a target population is 20% [3]. The major difference between the two studies is inclusion of diabetics and people with established cardiovascular diseases other than PAD in the CAREFUL study. While the frequency of PAD in Turkey initially seemed higher than expected, we now recognize that the burden of the disease in countries labeled with low cardiovascular risk is higher than that estimated, and is sufficient enough to update our understanding.

Assessment of Peripheral Arterial Disease of Lower Limbs with Ultrasonography and Ankle Brachial Index at the Initiation of Hemodialysis

Aim. Peripheral arterial disease (PAD) of the lower limbs carries high risks of leg amputation, quality of life deterioration, and death in hemodialysis (HD) patients. However, the frequency of PAD at the initiation of HD has not been adequately documented. In addition, the applicability of ultrasonography to diagnosing PAD is not yet clear in HD patients. Methods. Twenty-seven patients within three months after HD initiation were enrolled. Ultrasonography was performed regardless of ischemic symptoms. Significant stenosis or obstruction of lower limb arteries on ultrasonography was diagnosed as PAD. Results. Sixteen of the 27 (59.3%) showed PAD on echography. On the other hand, only six of the 27 (22.2%) had an ABI < 0.9. Sixteen patients had a total of 37 lesions revealed by ultrasonography, and the average number of PAD lesions was 2.3 per patient. The numbers of PAD lesions on ultrasonography were as follows: iliac artery, 7; femoral-popliteal artery, 15; and infra-popliteal artery, 15. The ABI was 0.95 ± 0.29 in PAD and 1.23 ± 0.13 in non-PAD patients (p = 0.005). Conclusions. A high prevalence of PAD at HD initiation was demonstrated. PAD may be missed using only the ABI (ankle brachial index). Ultrasonography is a reliable and non-invasive examination for detecting PAD.

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.