Non-invasively detected carotid stenosis and ischaemic heart disease in men with leg arteriosclerosis

doi:10.1016/0140-6736(93)92123-B

The Lancet

Volume 342, Issue 8880, 6 November 1993, Pages 1138-1141

https://doi.org/10.1016/0140-6736(93)92123-B Get rights and content

Abstract

Since the excess mortality rate associated with an ankle-brachial blood-pressure index (ABPI) less than 0 9 was only partly explained by an excess cardiovascular mortality, we believe that leg artery disease should not only be regarded as a marker of generalised arteriosclerosis but also as a sign associated with an increased risk of premature death. 439 men who were part of a prospective population study in Malmö, Sweden, were, at 68 years of age, invited to a health examination including, ABPI, carotid-artery ultrasonography, and 24 h ambulatory electrocardiographic monitoring. Cause- specific mortality and incidence of myocardial infarction (MI) during 8 years of follow-up was compared in men with and without signs of arteriosclerotic disease. Of 60 men with an ABPI <0·9, 20 (33%) had angina pectoris or previous Ml. Another 11 (18%) had silent ST-segment depression (≽1 mm); 3 (5%) had a history of stroke; and 17 (28%) had symptom-free carotid stenosis (>30% reduction of the cross-sectional diameter). Total mortality rate in men with no signs of arteriosclerotic disease was 19·6 per 1000 person-years and cardiac event rate (fatal and non-fatal Ml and death from chronic ischaemic heart disease was 8·6 per 1000 person-years). Leg artery disease, carotid stenosis, and ischaemic heart disease were in a univariate analysis all associated with an increased cardiac event rate and an increased total mortality rate. In a multivariate analysis an ABPI less than 0·9 was associated with a 2·4 times higher total mortality (95% Cl 1·5-3·9) and a 2·0 times higher cardiac event rate (1·1-3·9). Carotid stenosis and ischaemic heart disease contributed to the risk for Ml (RR 2 1; 95% Cl 1·2-3·8; and 2·1; 1 2-3·9, respectively), whereas no independent association with total mortality was found.

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Cited by (115)

Prognostic importance of diagnosticated peripheral arterial disease through the ankle brachial index in spanish general population
2020, Atencion Primaria
Determinar el valor pronóstico de tener un índice tobillo-brazo (ITB) bajo para padecer distintas enfermedades cardiovasculares y si mejora la capacidad predictiva de las principales funciones de riesgo cardiovascular.
Estudio de cohorte poblacional.
Área sanitaria Don Benito-Villanueva de la Serena (Badajoz). España.
Se seleccionaron 2.833 sujetos representativos de los residentes, entre 25 y 79 años.
Se midió el ITB en la inclusión y se registró el primer episodio de cardiopatía isquémica o ictus, la mortalidad cardiovascular y total en siete años de seguimiento. Se calcularon los hazard ratio (HR), ajustados por factores de riesgo cardiovascular, para el ITB bajo (< 0,9). Se determinaron los índices de reclasificación neta por categorías, clínica y continua para las funciones REGICOR, FRESCO cardiopatía isquémica, FRESCO enfermedad cardiovascular y SCORE.
Se analizaron 2.665 sujetos tras excluir las personas con antecedentes cardiovasculares y las pérdidas. El ITB bajo se asoció con un mayor riesgo, alcanzando una HR (IC 95%) de 6,45 (3,00 – 13,86), 2,60 (1,15 – 5,91), 3,43 (1,39 – 8,44), 2,21 (1,27 – 3,86) para ictus, cardiopatía isquémica, mortalidad cardiovascular y total, respectivamente. La inclusión del ITB mejoró el índice de reclasificación (IC 95%) en el riesgo intermedio según FRESCO cardiovascular en un 24,1% (10,1 – 38,2).
El ITB bajo está asociado con un incremento importante del riesgo de ictus, cardiopatía isquémica, mortalidad cardiovascular y total en nuestro medio. La inclusión del ITB mejoró la reclasificación de las personas con riesgo intermedio, según FRESCO cardiovascular, por lo que estaría justificada su utilización en esa categoría de riesgo.
The objectives have been to determine the prognostic value of having a low ankle-brachial index (ABI) for different cardiovascular diseases and whether it improves the predictive capacity of the main cardiovascular risk scores proposed for Spain.
Population-based cohort study
A health area of the province of Badajoz (Spain)
2,833 subjects, representative of residents, between 25 and 79 years old,
The ABI was measured at baseline and the first episode of ischemic heart disease or stroke, cardiovascular and total mortality, was recorded during 7 years of follow-up. The hazard ratio (HR) adjusted for cardiovascular risk factors and net reclassification index (NRI) by category, clinical and continuous for the risk functions REGICOR, FRESCO coronary heart disease, FRESCO cardiovascular disease and SCORE, were calculated.
2,665 subjects were analysed after excluding people with cardiovascular history and loss of follow-up. Low ABI was associated with adjusted HR (95% CI): 6.45 (3.00 - 13.86), 2.60 (1.15 - 5.91), 3.43 (1.39 - 8.44), 2.21 (1.27 - 3.86) for stroke, ischemic heart disease, cardiovascular mortality and total mortality respectively. The ABI improved the NRI (95% CI) in the intermediate risk category according to FRESCO cardiovascular equation by 24.1% (10.1 - 38.2).
Low ABI is associated with a significant increase in the risk of stroke, ischemic heart disease, cardiovascular mortality and total mortality in our population. The inclusion of ABI improved the reclassification of people at intermediate risk, according to FRESCO cardiovascular, so its use in that risk category would be justified.
Abnormally High Ankle–Brachial Index is Associated with All-cause and Cardiovascular Mortality: The REGICOR Study
2017, European Journal of Vascular and Endovascular Surgery
The clinical significance of a high ankle brachial index (ABI) and its relationship to cardiovascular disease (CVD) and mortality is controversial. The aim of this study was to estimate the association between abnormally high ABI ≥ 1.4 and coronary heart disease (CHD), cerebrovascular disease, and all-cause mortality in a Mediterranean population without CVD.
A prospective population based cohort study of 6352 subjects was followed up for a median 6.2 years. Subjects under 35 years, with a history of CVD or an ABI < 0.9 were excluded. All CHD events (angina, myocardial infarction, coronary revascularisation), cerebrovascular events (stroke, transient ischaemic attack), and all-cause mortality were recorded.
A total of 5679 subjects fulfilled the inclusion criteria, of which 5517 (97.1%) had a normal ABI whereas 162 (2.9%) had an ABI ≥ 1.4. The profile of individuals with abnormally high ABI revealed as independent related factors age (OR = 1.0; p = .045), female sex (OR = 0.4; p < .01), diabetes (OR = 1.9; p = .02), and lower diastolic blood pressure (OR = 0.9; p < .001). During follow-up 309 (5.4%) participants presented with a CV event and 286 (5.0%) died. An ABI ≥ 1.4 was associated with a higher incidence of CV events in the univariate (HR = 1.7) but not in the multivariate survival Cox regression analysis. An ABI ≥ 1.4 was independently associated with all-cause mortality (HR = 2.0; IC 95% 1.32–2.92) and cardiovascular mortality (HR = 3.1; IC 95% 1.52–6.48).
In subjects without CVD, those with abnormally high ABI do not have a greater CV event rate than those with a normal ABI. However, there seems to be a trend towards higher mortality risk, supporting the guidelines that consider this subgroup to be a high risk population.
Stable angina pectoris
2017, Coronary Artery Disease: From Biology to Clinical Practice
Stable coronary artery disease (SCAD) is generally characterized by episodes of reversible myocardial demand/supply mismatch, related to ischemia or hypoxia, which are usually inducible by exercise, emotion, or other stress and reproducible but also may be occurring spontaneously. Such episodes of ischemia/hypoxia are commonly associated with transient chest discomfort (angina pectoris). SCAD also includes the stabilized, often asymptomatic, phases that follow an acute coronary syndrome. Within the population with stable coronary artery disease, an individual's prognosis can vary considerably, depending on baseline clinical, functional, and anatomical characteristics. Prognostic assessment is an important part of the management of patients with stable angina. On the one hand, it is important to reliably identify those patients with more severe forms of disease, who may have an improvement in outcome with more aggressive investigation and—potentially—intervention, including revascularization. On the other hand, it is also important to identify those patients with a less-severe form of disease and a good prognosis, thereby avoiding unnecessary invasive and noninvasive tests and revascularization procedures.
A systematic review for the screening for peripheral arterial disease in asymptomatic patients
2015, Journal of Vascular Surgery
Peripheral arterial disease (PAD) is common and associated with significant morbidity and mortality. PAD can be detected through a noninvasive measurement of the ankle-brachial index (ABI).
We conducted a systematic review of several electronic bibliographic databases for studies that evaluated ABI as a screening test for PAD in asymptomatic individuals. We conducted random-effects meta-analysis, reporting pooled hazard ratios (HRs) when appropriate.
We included 40 individual studies, 2 systematic reviews, and 1 individual-patient data meta-analysis. We found no studies comparing ABI screening with no screening in terms of patient-important outcomes (mortality, amputations). The yield of PAD screening averaged 17% (range, 1%-42%) and was 1% to 4% in lower risk populations. Patients with PAD had higher adjusted risk of all-cause mortality (HR, 2.99; 95% confidence interval, 2.16-4.12) and of cardiovascular mortality (HR, 2.35; 95% confidence interval, 1.91-2.89). Data on benefits, harms, and cost-effectiveness of screening were limited; however, ABI screening was associated with additional prognostic information and risk stratification for heart disease. The overall quality of evidence supporting screening was low.
The current available evidence demonstrates that PAD is common in patients with multiple cardiovascular risk factors and is associated with significant morbidity and mortality, but it does not support the benefit of routine ABI screening.
Noninvasive Cardiovascular Imaging in Rheumatoid Arthritis: Current Modalities and the Emerging Role of Magnetic Resonance and Positron Emission Tomography Imaging
2012, Seminars in Arthritis and Rheumatism
Rheumatoid arthritis (RA) is associated with premature atherosclerosis and increased prevalence of cardiovascular disease. The objective of this review is to summarize current and emerging imaging modalities for the evaluation of subclinical atherosclerosis in RA, with an emphasis on potential application of novel modalities, high-resolution magnetic resonance imaging and positron emission tomography, as screening tools for early cardiovascular disease risk stratification.
A PubMed literature search was undertaken using the search terms “rheumatoid arthritis” AND “cardiovascular disease” OR “atherosclerosis” OR “plaque” and including all relevant terms for imaging modalities.
Two noninvasive imaging modalities have been widely adopted for direct visualization of arterial wall: carotid ultrasonography and cardiac computed tomography. Published studies in the RA population using these 2 modalities are reviewed. Novel cardiovascular imaging modalities are described, with an emphasis on high-resolution magnetic resonance imaging and positron emission tomography. Emerging research tools in vascular imaging, including dynamic and cardiac stress perfusion contrast-enhanced magnetic resonance imaging, are presented. The incremental imaging capabilities to characterize plaque composition and vessel wall inflammation as well myocardial abnormalities and published studies are systematically reviewed.
An increasing number of cardiovascular imaging modalities with improved characterization of features associated with plaque vulnerability have been developed. Given the heightened cardiovascular risk profile of the RA population, these novel imaging modalities offer promise for risk stratification and drug safety evaluation.
Influence of an increased ankle/brachial index on cardiovascular risk and survival in adult men with no peripheral arterial disease
2012, Angiologia
La significación clínica del índice tobillo/brazo (IT/B) elevado y su asociación a enfermedad cardiovascular es controvertida. Nuestro objetivo fue evaluar la asociación entre la elevación basal del IT/B con el riesgo de mortalidad cardiovascular (MCV), mortalidad total (MT) y aumento de evento coronario mayor (ECM) tras 5 años de seguimiento en una población mediterránea.
Estudio poblacional prospectivo de 614 varones entre 55 y 74 años sin enfermedad arterial periférica. Medición basal de factores de riesgo cardiovascular (FRCV) e IT/B categorizados. Las categorías de IT/B fueron: 0,9-1,24(A), 1,25-1,34(B), ≥ 1,35(C). Los ECM, la MCV y MT fueron evaluadas durante el seguimiento.
La distribución de los sujetos según su mayor IT/B fue: A = 441(71,8%), B = 113 (18,4%) y C = 60 (9,7%). En referencia al grupo A (IT/B normal), los sujetos del grupo B y C presentaban mayor prevalencia de hipertensión (p < 0,01), tabaquismo (p < 0,01) y colesterol elevado (p = 0,04), siendo similares otros FRCV evaluados. Tras 5 años de seguimiento, y ajustando por posibles factores confusores, el riesgo de MCV y MT para los sujetos del grupo B en relación al grupo A fue de 1,33 (0,48-3,6, p = 0,57) y 1,07 (0,55-2,08, p = 0,83), respectivamente, y para los del grupo C fue de 0,53 (0,07-4,02, p = 0,54) y 0,79 (0,28-2,22, p = 0,66). Las diferencias de riesgo de ECM entre los grupos tampoco fue significativa (p = 0,07 grupo B y p = 0,97 grupo C, respecto A).
En nuestro estudio, la elevación del IT/B se asocia con una mayor prevalencia de algunos FRCV, sin embargo, este hallazgo hemodinámico no parece asociarse con un riesgo independiente adicional de ECM o mortalidad en nuestro medio.
The clinical significance of an increased ankle/brachial index (ABI) and its association with risk factors and cardiovascular disease has been subject of controversy. Our objective was to evaluate the association between an increased baseline ABI with the risk of cardiovascular mortality (CVM), total mortality (TM) and increased major coronary events (MCE) at 5 years of follow-up in a Mediterranean population.
A prospective survey was conducted on 614 men between 55 and 74 years-old with no peripheral arterial disease and representative of an urban district near Barcelona (Spain). Baseline cardiovascular risk factors and categorised ABI were recorded. ABI categories were: 0.9-1.24 (A), 1.25-1.34 (B), ≥ 1.35 (C). MCE, mortality and their cause were evaluated during 5-years of follow-up.
The distribution of subjects according to their ABI was: A = 441 (71.8%), B = 113 (18.4%) and C = 60 (9.7%). The B and C group subjects had a higher prevalence of hypertension (P < .01), higher cholesterol plasma levels (P = .04) and smokers (P < 0.01) compared to the normal ABI group (A), with the other risk factors assessed being similar. At 5-year follow-up (mean 65 months), and after adjustment for confounding factors, CVM and TM risk for B subjects were 1.33 (0.48-3.6, P = .57) and 1.07 (0.55-2.08, P = .83) respectively, compared to the normal ABI group (A). For C subjects they were 0.53 (0.07-4.02, P = .54) and 0.79 (0.28-2.22, P = .66). There were no significant differences in MCE risk between ABI groups (P = .07 for B and P = 0.97 for C, related to A).
In our study, an increased ABI is associated with a higher prevalence of some risk factors; however this haemodynamic finding does not seem to be associated with an additional independent risk of MCE or mortality in our setting.

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ArticlesNon-invasively detected carotid stenosis and ischaemic heart disease in men with leg arteriosclerosis

Abstract

J Clin Epidemiol

Eur J Vasc Surg

Am J Cardiol

J Chron Dis

Fate of the patient with chronic leg ischaemia

J Cardiovasc Surg

Mortality over a period of 10 years in patients with peripheral arterial disease

N Engl J Med

Diagnostic accuracy of ambulatory ECG monitoring in ischaemic heart disease

Circulation

Venous occlusion plethysmography in 55-year-old men: a population study in Malmö, Sweden

Acta Med Scand

Increased mortality in men with ST-segment depression during 24 hr ambulatory long-term ECG recording: results from the prospective population study "Men born in 1914", from Malmö, Sweden

Eur Heart J

Carotid artery blood flow velocity related to transient ischaemic attack and stroke in a population study of 69-year-old men

Stroke

Segmental measurements of systolic blood pressure in the extremities including the thumb and the great toe

Acta Chir Scand

The arm-ankle pressure gradient in relation to cardiovascular risk factors in intermittent claudication

Circulation

Indirect systolic pressures and pulse waves in arterial occlusive disease of the lower extremities

Circulation

New techniques in objective arterial evaluation

Arch Surg

The measurement of atherosclerotic peripheral arterial disease in epidemiological surveys

Int J Epidemiol

Articles
Non-invasively detected carotid stenosis and ischaemic heart disease in men with leg arteriosclerosis