Frequency of lower extremity artery disease in type 2 diabetic patients using pulse oximetry and the ankle-brachial index.

Objectives: To determine the of undiagnosed lower extremity artery disease using the pulse oximetry in a type 2 diabetic population sample. Methods: Observational, cross-sectional, descriptive study that included 594 type 2 diabetic patients, with no previous history of lower extremity artery disease. Medical history, physical examination, determination of the ankle-brachial index (portable Doppler) and measurement of oxygen saturation in upper and lower extremities (pulse oximeter) were performed. Results: Frequency of lower extremity artery disease determined by ankle-brachial index was 18.4%. No significant correlations were detected between oxygen saturation and the ankle-brachial index except for the relationship between ankle-brachial index vs. oxygen saturation at 30 cm lower limb elevation vs. the supine position at no elevation (0 cm) in subjects under the age of 40. Pulse oximetry showed little diagnostic value in the screening of lower extremity artery disease. A relationship between lower extremity artery disease and age has been found. Its diagnosis was associated with a lower body mass index and lower systolic blood pressure in the lower extremities and higher in the upper extremities. Conclusions: We conclude that pulse oximetry is not useful in the screening for asymptomatic lower extremity artery disease in type 2 diabetics.

Prevalencia de enfermedad arterial oclusiva crónica de extremidades inferiores en pacientes de alto riesgo cardiovascular pertenecientes a un centro de atención primaria mediante el uso del índice tobillo-brazo / Prevalence of peripheral arterial disease of lower extremities in high cardiovascular risk patients from primary care using the ankle-brachial index

Resumen Objetivo: La enfermedad arterial oclusiva crónica de extremidades inferiores (EAOC EEII) ha sido subestimada y subdiagnosticada especialmente a nivel de atención primaria. El objetivo de este estudio fue estimar la prevalencia de EAOC EEII en pacientes de alto riesgo cardiovascular pertenecientes a un centro de salud familiar. Materiales y Método: Estudio observacional de corte transversal. Se calculó un tamaño muestral de 246 pacientes, con una potencia estadística del 80% y un nivel de confianza del 95%, seleccionándolos aleatoriamente de 1.361 pacientes con riesgo cardiovascular alto del CESFAM Cordillera Andina, a quienes se les realizó la medición del índice tobillobrazo (ITB). Se estimaron IC 95% para cada media y porcentaje reportado, considerándose un valor de p significativo menor de 0,05 en las pruebas estadísticas utilizadas. Resultados: Se observó un ITB < 0,9 en el 43,2% (114), donde el 33,7% (89) refería síntomas de claudicación intermitente, mientras que un 9,5% (25) se encontraba asintomático. El mayor porcentaje de pacientes con EAOC EEII se observó en el grupo etario entre 60 y 80 años, que en conjunto alcanzaba el 85,1% de los pacientes con esta patología, siendo significativamente menor en pacientes menores de 60 y mayores de 80 años (p < 0,001). Conclusión: Encontramos una prevalencia de enfermedad arterial oclusiva crónica de extremidades inferiores de un 43,2% en pacientes de riesgo cardiovascular alto, quienes no presentaban este diagnóstico previamente. El índice tobillobrazo corresponde a un examen simple, rápido y con una gran utilidad diagnóstica por lo que debería considerarse su incorporación en las guías ministeriales para la evaluación de pacientes cardiovasculares en atención primaria.

Aim: The peripheral arterial disease (PAD) has been underestimated and underdiagnosed particularly at primary care setting. Our aim was to calculate the prevalence of PAD in high cardiovascular risk patients from a primary care center. Materials and Method: Is an observational, cross section study. We calculated a sample size of 246 patients, with a power of 80% and a significance level of 95%, who were selected randomly from 1.361 high cardiovascular risk patients according to the Framingham score, who attended at Cordillera Andina primary care center, measuring the anklebrachial index (ABI) in this group of patients. A 95% confidence interval was calculated for each mean and proportion and a p value less than 0.05 were considered as significant for all statistic tests. Results: We found an ABI < 0.9 in the 43.2% (114) of the sample, where 33.7% (89) presented symptoms of intermittent claudication, while 9.5% (25) did not have symptoms. The highest proportion of PAD was detected in patients between 60 and 80 years, who represented 85.1% of the patients with PAD, being significantly less its prevalence in people under 60 and over 80 years (p < 0.001). Conclusion: A prevalence of PAD of 43.2% in high cardiovascular risk patients who did not have this diagnosis before was found. The anklebrachial index is an easy, fast and very useful test to diagnose PAD in the majority of patients at primary care level, as consequent, its incorporation to clinical guidelines should be evaluated.

[Use of the ankle-brachial index in the detection of peripheral arterial disease of the lower extremities in general medicine]. / Utilisation de l'index de pression systolique dans le dépistage de l'artériopathie du membre inférieur en médecine générale.

INTRODUCTION: Peripheral arterial disease of the lower extremities (PAD) is a serious condition, frequently under-evaluated. Long asymptomatic, it is easily detected by measuring the ankle-brachial index (ABI), a reference tool that is reliable, reproducible, simple and inexpensive. The objective of this thesis was to determine the rate of achievement of ABI in French Haute Autorité de santé indications, identify the associated factors and prioritize the obstacles to achieving ABI. METHODS: Descriptive and analytical epidemiological study, with analysis of practices, prospectively addressed by postal questionnaire to a randomized sample of 220 general practitioners practicing in the European Metropolis of Lille between December 15, 2016 and February 15, 2017. RESULTS: Our sample consisted of 92 GPs (42% participation). Among them, only 6 practiced ABI, notably for: intermittent claudication (n=5: 5%, IC95% [1; 10]), the existence of at least 2 cardiovascular risk factors (n=2: 2%, IC95% [0; 5]), diabetic patients over 40 years of age (n=2: 2%, IC95% [0; 5]), patients with diabetes (n=2: 2%, IC95% [0; 5]), patients with diabetes (n=2: 1%, IC95% [0; 5]), patients with diabetes (n=2: 1%, IC95% [0; 5]), and patients with diabetes (n=2: 1%, IC95% [0; 5]): 2%, CI95% [0; 5]), patients over 50 years of age with a history of diabetes or smoking (n=2: 2%, CI95% [0; 5]), or those with an unhealed lower extremity skin lesion (n=5: 5%, CI95% [1; 10]). The most frequently cited barriers were: the prescription of a routine echo-doppler (61%, 95% CI [51; 71]), lack of control (46%, 95% CI [36; 56]), time considered too long (17%, 95% CI [10; 25]), and equipment purchase or maintenance (19%, 95% CI [10.5; 26.4]). CONCLUSION: ABI is few used in our sample, mainly due to delegation to angiologists.

Empowering patients living with diabetes mellitus to cease smoking will improve lower limb perfusion.

Background: To evaluate the effect of smoking on arterial perfusion and to determine whether smoking cessation would result in a significant improvement on the circulation of persons living with type 2 diabetes mellitus (T2DM).Methods: A nonexperimental comparative quantitative research was conducted amongst 32 participants with type 2 diabetes mellitus (T2DM) and controlled hyperlipidemia [smokers (n = 11), past smokers (n = 11), and nonsmokers (n = 10); aged ≥ 40 & ≤ 85 years]. Participants were matched for age, body mass index, estimated glomerular filtration rate, packet years, duration of diabetes mellitus, and glycated hemoglobin levels (HbA1c, %) utilizing frequency distribution matching. Peripheral arterial disease (PAD) was assessed utilizing the toe brachial pressure index (TBPI). TBPI value of ≤0.7 was suggestive of PAD while >0.7 was considered normal.Results: Sixty-four limbs were included for analyses. One-way ANOVA showed significant difference in the TBPI scores between the three categories (p < 0.05), with the current smokers demonstrating the lowest TBPI means (0.544), followed by past smokers (0.649) and nonsmokers having the highest TBPI (0.781). Tukey's post-hoc analysis confirmed significant difference in TBPI between current and nonsmokers (p = 0.024). Linear regression of risk predictors identified packet years as the best predictor (p = 0.004), followed by HbA1c (0.019).Conclusions: Results suggest that smoking has a significant effect on PAD in T2DM and that improved perfusion is found in past smokers. Empowering patients to cease smoking will result in better limb perfusion.

Management of people with venous leg ulcers by Australian general practitioners: An analysis of the national patient-encounter data.

Venous Leg Ulcers cost Australia's healthcare system millions yearly, as they are underdiagnosed, and possibly undertreated. Most Venous Leg Ulcers are seen in general practice. However, it is currently unknown as to what treatment actions are most common in these contexts. Understanding how they are managed in these settings can improve healthcare delivery and patient outcomes. Using cross-sectional general practitioner patient encounter data collected April 2006 to March 2016 from the Bettering the Evaluation and Care of Health program, a continuous national study of general practice clinical activity in Australia, we aimed to describe the characteristics of venous leg ulcer management by general practitioners in Australia. Among the 972 100 general practitioner-patient encounters recorded, 3604 (0.34%) involved management of VLU. Male general practitioners managed Venous Leg Ulcers significantly more often than female general practitioners. Most Venous Leg Ulcers were treated via dressings (76%) and/or pharmacological treatments (25.7%), with few patients receiving the best practice treatment of medical compression (2.1%) or referral (4.9%). Patients with new (first visit) Venous Leg Ulcers were more likely to receive pharmacological treatments and to be referred elsewhere, and less likely to receive dressings than patients receiving follow-up care. There appears to be a large gap between best practice guidelines and actual Venous Leg Ulcers treatments, as referrals and appropriate treatment was low. Further longitudinal studies are needed to determine the effectiveness of care for people with Venous Leg Ulcers who are managed by general practitioners.

Re-evaluating the safety and effectiveness of the 0.9 ankle-brachial index threshold in penetrating lower extremity trauma.

OBJECTIVE: Current guidelines recommend additional imaging when the ankle-brachial index (ABI) is ≤0.9 after extremity trauma; however, the accuracy of this 0.9 threshold compared with other values has not been evaluated. The primary aim of this study was to compare the safety and effectiveness of various ABI thresholds in predicting lower extremity vascular injuries after penetrating trauma. We hypothesized that a lower ABI threshold can be used safely to avoid unnecessary imaging. METHODS: A retrospective cohort study was performed at a single level I trauma center from January 2015 to December 2017. All patients who presented with penetrating lower extremity trauma and who underwent computed tomography angiography (CTA) were reviewed. Patients taken directly to the operating room without first undergoing CTA or those without documented ABIs were excluded. Demographic information, clinical features of presentation, interventions performed, and outcomes were recorded. P values were obtained using the Kolmogorov-Smirnov test, and a receiver operating characteristic curve was created to compare various ABI thresholds. RESULTS: A total of 47 patients (81% male), with a mean age of 29 years (range, 14-59 years), met inclusion criteria. Of the 17 limbs (36%) with a vascular abnormality seen on CTA, 6 (35%) required an intervention. The distribution of ABIs in injured limbs requiring revascularization was significantly lower (P = .006) than in those that did not require intervention. An ABI threshold of 0.7 is most accurate, with the highest combined sensitivity (83%) and specificity (91%) for detecting vascular injuries requiring revascularization. In addition, the negative predictive value was no different between a threshold of 0.7 (98%) and a threshold of 0.9 (97%), with both thresholds missing one vascular injury (pseudoaneurysm) requiring repair. CONCLUSIONS: The ABI remains reliable in distinguishing between limbs with and limbs without vascular injury requiring revascularization after penetrating lower extremity trauma. A lower threshold can safely be used without compromising the negative predictive value of a screening ABI. Applying a threshold of 0.7 to our cohort would have avoided 51% (24) of the CTA studies performed without missing additional vascular injuries requiring repair.

Familial Hypercholesterolemia and Risk of Peripheral Arterial Disease and Chronic Kidney Disease.

Context: Individuals with familial hypercholesterolemia (FH) have a high risk of coronary artery disease, but their risk of peripheral arterial disease (PAD) and chronic kidney disease (CKD) is unknown. Objective: In individuals with clinical FH, we tested the hypotheses (1) that the risks of PAD and CKD are elevated and (2) that low ankle-brachial index (ABI) and estimated glomerular filtration rate (eGFR) are associated with a high risk of myocardial infarction. Design and Setting: Prospective cohort study of the general population. Participants: A total of 106,172 individuals, of whom 7109 were diagnosed with FH. Main Outcome Measures: PAD, CKD, and myocardial infarction. Results: Compared with individuals with unlikely FH, multivariable adjusted ORs (95% CIs) of PAD were 1.84 (1.70 to 2.00) in those with possible FH and 1.36 (1.00 to 1.84) in individuals with probable/definite FH. For CKD, the corresponding ORs (95% CIs) were 1.92 (1.78 to 2.07) and 2.42 (1.86 to 3.26). Compared with individuals with unlikely FH and ABI >0.9, the multivariable adjusted hazard ratio (95% CI) of myocardial infarction was 4.60 (2.36 to 8.97) in those with possible/probable/definite FH and ABI ≤0.9. Compared with individuals with unlikely FH and eGFR ≥60 mL/min/1.73 m2, the corresponding value was 2.19 (1.71 to 2.82) in those with possible/probable/definite FH and eGFR <60 mL/min/1.73 m2. Conclusions: Individuals with clinical FH have increased risks of PAD and CKD, and low ABI and eGFR are associated with high risk of myocardial infarction. Consequently, individuals with FH should be screened for PAD and CKD, and ABI and eGFR may be used as prognostic tools in the management and treatment of FH to identify those at very high risk of myocardial infarction.

Influence of Dietary Patterns and Inflammatory Markers on Atherosclerosis Using Ankle Brachial Index as a Surrogate.

OBJECTIVE: To examine the influence of various dietary patterns on ankle-brachial index (ABI) as a surrogate of atherosclerosis, taking into account serum levels of C-reactive protein (CRP) and factors that predispose to inflammation and/or endothelial damage (homocysteine) or may be protective (tryptophan, vitamin D), as well as age, gender, and lifestyle risk factors. DESIGN: Cross sectional analysis. SETTING: Cohort of 4000 men and women aged 65 years living in the community in Hong Kong SAR China. MEASUREMENTS: Interviewer administered questionnaire that includes dietary intake estimation by the food frequency records (from which various dietary patterns can be characterized), socioeconomic status, smoking habit, alcohol consumption, physical activity. Clinical measurements include body weight and height, and ankle-brachial index using hand-held Doppler machine. Laboratory measurements include assays of serum 25 hydroxyvitamin D, CRP, homocysteine, and tryptophan using LC/MC methods. RESULT: Compared with the lowest quintile of vitamin D level, higher quintile was associated with lower prevalence of ABI <0.9 in women only after multiple adjustments of covariates. In men the low score group of the vegetables-fruits dietary pattern was associated with increased odds of having ABI<0.9 after adjusting for all covariates (OR=16.51 (95% CI: 2.21, 123.26)). Similar findings apply to the low score group in the MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay Diet) pattern (OR=2.6 (95% CI: 1.24, 5.42)). In women, ABI<0.9 was associated with low Dietary Quality Index (DQI) score (OR=2.05 (95% CI: 1.22, 3.43)), and low score group of snacks-drinks-milk products dietary pattern (OR=3.07 (95% CI: 1.05, 9.04)). No association was observed for the Mediterranean Dietary Pattern (MDS), Dietary Approaches to Stop Hypertension (DASH), Okinawan and "meat-fish" dietary patterns in either men or women. CONCLUSION: We conclude that any dietary patterns emphasizing fruit and vegetable intake are associated with better vascular health using ABI as an indicator.

Association of Ankle-Brachial Indices With Limb Revascularization or Amputation in Patients With Peripheral Artery Disease.

Importance: The prevalence and morbidity of peripheral artery disease (PAD) are high, with limb outcomes including revascularization and amputation. In community-dwelling patients with PAD, the role of noninvasive evaluation for risk assessment and rates of limb outcomes have not been established to date. Objective: To evaluate whether ankle-brachial indices are associated with limb outcomes in community-dwelling patients with PAD. Design, Setting, and Participants: A population-based, observational, test-based cohort study of patients was performed from January 1, 1998, to December 31, 2014. Data analysis was conducted from July 15 to December 15, 2017. Participants included a community-based cohort of 1413 patients with PAD from Olmsted County, Minnesota, identified by validated algorithms deployed to electronic health records. Automated algorithms identified limb outcomes used to build Cox proportional hazards regression models. Ankle-brachial indices and presence of poorly compressible arteries were electronically identified from digital data sets. Guideline-recommended management strategies within 6 months of diagnosis were also electronically retrieved, including therapy with statins, antiplatelet agents, angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, and smoking abstention. Main Outcomes and Measures: Ankle-brachial index (index ≤0.9 indicates PAD; <.05, severe PAD; and ≥1.40, poorly compressible arteries) and limb revascularization or amputation. Results: Of 1413 patients, 633 (44.8%) were women; mean (SD) age was 70.8 (13.3) years. A total of 283 patients (20.0%) had severe PAD (ankle-brachial indices <0.5) and 350 (24.8%) had poorly compressible arteries (ankle-brachial indices ≥1.4); 780 (55.2%) individuals with less than severe disease formed the reference group. Only 32 of 283 patients (11.3%) with severe disease and 68 of 350 patients (19.4%) with poorly compressible arteries were receiving 4 guideline-recommended management strategies. In the severe disease subgroup, the 1-year event rate for revascularization was 32.4% (90 events); in individuals with poorly compressible arteries, the 1-year amputation rate was 13.9% (47 events). In models adjusted for age, sex, and critical limb ischemia, poorly compressible arteries were associated with amputation (hazard ratio [HR], 3.12; 95% CI, 2.16-4.50; P < .001) but not revascularization (HR, 0.91; 95% CI, 0.69-1.20; P = .49). In contrast, severe disease was associated with revascularization (HR, 2.69; 95% CI, 2.15-3.37; P < .001) but not amputation (HR, 1.30; 95% CI, 0.82-2.07; P = .27). Conclusions and Relevance: Community-dwelling patients with severe PAD or poorly compressible arteries have high rates of revascularization or limb loss, respectively. Guideline-recommended management strategies for secondary risk prevention are underused in the community.

Xanthelasma palpebrarum associated with increased cardio-ankle vascular index in asymptomatic subjects.

BACKGROUND: Xanthelasma palpebrarum (XP) is associated with increased risk of ischemic heart disease and myocardial infarction independent of other well-known cardiovascular risk factors. Cardio-ankle vascular index (CAVI) is a novel index of arterial stiffness and important marker of subclinical atherosclerosis. The purpose of this study was to investigate the association between XP and CAVI in asymptomatic subjects. METHODS: Consecutive 50 subjects with XP and age-gender matched 50 control subjects were enrolled. Patients with known atherosclerotic vascular disease were excluded. Arterial stiffness was assessed by CAVI and defined as abnormal if CAVI is ≥ 8. RESULTS: Subjects with XP had higher mean CAVI than control subjects (8.05 ± 1.72 vs. 6.76 ± 1.18, p < 0.001). Frequency of abnormal CAVI was higher in subjects with XP (n = 27) compared to those without XP (n = 9, 54 vs. 18 %, p < 0.001). There was a significant correlation between XP and CAVI (r = 0.42, p < 0.001). Conditional logistic regression analysis showed that XP (odds ratio OR 8.80, 95 % confidence interval CI 2.63-29.49, p < 0.001) and age (OR 1.17, 95 % CI 1.08-1.26, p < 0.001) were independent predictors for abnormal CAVI. CONCLUSION: The study suggests that XP is associated with increased arterial stiffness in asymptomatic subjects.

Outcome of patients with reduced ankle brachial index undergoing open heart surgery with cardiopulmonary bypass.

OBJECTIVES: In open heart surgery using cardiopulmonary bypass, perfusion of the lower extremities is markedly reduced which may induce critical ischaemia in patients with pre-existing peripheral artery disease. Whether these patients have an increased risk for amputation and should better undergo peripheral revascularization prior to surgery remains unclear. METHODS: From 1 January 2009 to 31 December 2010, 785 consecutive patients undergoing open heart surgery were retrospectively included. In 443 of these patients, preoperative ankle brachial index (ABI) measurements were available. The cohort was divided into four groups: (i) ABI < 0.5, (ii) ABI 0.5-0.69, (iii) ABI 0.7-0.89 or (iv) ABI ≥ 0.9. Follow-up data of 413 (93.2%) patients were analysed with regard to mortality and amputations. RESULTS: The groups differed significantly in terms of age, cardiac risk factors, performed cardiac surgery and renal function. Postoperative delayed wound healing was significantly associated with lower ABI (25.9, 15.2, 27.0 and 9.6% in Groups I-IV, respectively, P = 0.003), whereas 30-day mortality was not significantly higher in patients with lower ABI (0, 4.3, 8.1 and 3.9%, respectively, P = 0.4). Kaplan-Meier models showed a significantly lower long-term survival over 4 years in patients with reduced ABI (P = 0.001, long-rank test) while amputations occurred rarely with only one minor amputation in Group II (P = 0.023). CONCLUSIONS: Patients with reduced ABIs undergoing heart surgery showed more wound-healing disturbances, and higher long-term mortality compared with those with normal ABIs. However, no perioperative ischaemia requiring amputation occurred. Thus, reduced ABIs were not associated with increased peripheral risks in open heart surgery but ABI may be helpful in selecting the site for saphenectomy to potentially avoid delayed healing of related wounds in legs with severely impaired arterial perfusion.

Peripheral artery questionnaire improves ankle brachial index screening in symptomatic patients with peripheral artery disease.

AIM: The peripheral artery questionnaire (PAQ) is a disease-specific health status measure of patients with peripheral artery disease (PAD). Whether the PAQ scores are associated with a PAD diagnosis among patients with symptoms suspicious for PAD is unknown and could help increase the pretest probability of ankle brachial index (ABI) screening among patients with suspicious symptoms. METHODS: The PAQ was completed by 567 patients evaluated for potential intermittent claudication at six tertiary centres. Demographics, medical history, physical examination findings and the PAQ domain scores were compared with ABI. A diagnostic threshold < 0.90 for a PAD diagnosis was assessed with a ROC of PAQ scores. The correlation between the PAQ Summary Score and ABI was also calculated. RESULTS: The PAQ Summary Score was significantly lower in patients with low ABI as compared with those having a normal ABI (37.6 ± 19.0 vs. 70.1 ± 22.7, p < 0.001). The PAQ Summary Score and ABI were highly correlated (r = 0.56, p < 0.001) and the optimal PAQ Summary Score for predicting low ABI was 50.3 (AUC = 0.86, sensitivity 80.3%, specificity 78.3%). CONCLUSIONS: The PAQ Summary Score was associated with an increased likelihood of PAD in patients with suspected PAD symptoms, and a low summary score (≤ 50.3) was an optimal threshold for predicting PAD among patients referred for ABI.

Current utility of the ankle-brachial index (ABI) in general practice: implications for its use in cardiovascular disease screening.

BACKGROUND: Peripheral arterial disease (PAD) is a marker of systemic atherosclerosis and associated with a three to six fold increased risk of death from cardiovascular causes. Furthermore, it is typically asymptomatic and under-diagnosed; this has resulted in escalating calls for the instigation of Primary Care PAD screening via Ankle Brachial Index (ABI) measurement. However, there is limited evidence regarding the feasibility of this and if the requisite core skills and knowledge for such a task already exist within primary care. This study aimed to determine the current utility of ABI measurement in general practices across Wales, with consideration of the implications for its use as a cardiovascular risk screening tool. METHOD: A self-reporting questionnaire was distributed to all 478 General Practices within Wales, sent via their responsible Health Boards. RESULTS: The survey response rate was 20%. ABI measurement is primarily performed by nurses (93%) for the purpose of wound management (90%). It is infrequently (73% < 4 times per month) and often incorrectly used (42% out of compliance with current ABI guidance). Only 52% of general practitioners and 16% of nurses reported that patients with an ABI of ≤ 0.9 require aggressive cardiovascular disease risk factor modification (as recommended by current national and international guidelines). CONCLUSION: ABI measurement is an under-utilised and often incorrectly performed procedure in the surveyed general practices. Prior to its potential adoption as a formalised screening tool for cardiovascular disease, there is a need for a robust training programme with standardised methodology in order to optimise accuracy and consistency of results. The significance of a diagnosis of PAD, in terms of associated increased cardiovascular risk and the necessary risk factor modification, needs to be highlighted.

Increased tea consumption is associated with decreased arterial stiffness in a Chinese population.

BACKGROUND: Tea has attracted considerable attention for its potential cardioprotective effects. The primary chemical components of tea are thought to have a beneficial effect by reducing arterial stiffness. The objective of this study was to assess the association between tea consumption and brachial-ankle pulse wave velocity (baPWV) in a relatively healthy Chinese population. METHODS: We enrolled 3,135 apparently healthy subjects from October 2006 to August 2009. Subjects taking medication for diabetes, hypertension, or hyperlipidemia, or with a history of cardiovascular disease, were excluded from the study. The subjects were categorized into three groups according to their tea-drinking habits: (1) none to low (n = 1615), defined as non-habitual tea drinkers, or drinking for <1 year, or drinking ≤150 mL per day for ≥1 year ; (2) moderate tea consumption, defined as drinking for ≥1 year and consumption between 151 and 450 mL per day; and (3) heavy tea consumption, defined as a drinking for ≥1 year and consumption >450 mL per day. Multiple logistic regression was used to determine whether different levels of consumption were independently associated with the highest quartile of baPWV values, defined as ≥1428.5 cm/s. RESULTS: Of the 3,135 subjects, 48.5% had drunk >150 mL of tea per day for at least 1 year. In multivariate regression analysis with adjustment for co-variables, including, age, sex, current smoking, alcohol use, habitual exercise, total cholesterol/high-density lipoprotein cholesterol (TC/HDL-C) ratio >5, obesity, newly diagnosed hypertension and diabetes, subjects with high tea consumption had a decreased risk of highest quartile of baPWV by 22% (odds ratio = 0.78, 95% confidence interval = 0.62-0.98, p = 0.032), while subjects with moderate tea consumption did not (p = 0.742), as compared subjects with none to low tea consumption. CONCLUSIONS: High, but not moderate, habitual tea consumption may decrease arterial stiffness.

Older adults with heel ulcers in the acute care setting: frequency of noninvasive vascular assessment, surgical intervention, and 1-year mortality.

OBJECTIVES: To examine how often hospitalized older adults with a diagnosis of heel ulcers are evaluated with noninvasive vascular tests and to determine the impact of invasive vascular or surgical procedures on 1-year mortality. DESIGN: Retrospective review using an electronic database and chart review of all patients discharged with a diagnosis of heel ulcer between 2006 and 2009. SETTING: Urban teaching hospital. PARTICIPANTS: A total of 506 participants aged 65 years and older. MEASUREMENTS: Data collected included resident characteristics (demographics, medical history, and severity of illness using the Charlson comorbidity index), staging of heel ulcers, rates of noninvasive vascular assessments, vascular and surgical procedures, length of stay, and 1-year mortality. RESULTS: Thirty-one percent (155/506) of patients with a heel ulcer underwent noninvasive vascular testing and of these 83% (129/155) were found to have underlying ischemia. Twenty-six percent (130/506) of patients underwent at least 1 vascular or surgical procedure. The 1-year mortality rate for patients with stage 1 or 2 disease was 55%; this rose to 70% for patients with stage 3 or 4 ulcers (P = .01), and could not be explained by differences in the Charlson comorbidity index. Patients who underwent a vascular or surgical procedure had a significantly lower mortality compared with those who did not (59% vs 68% P = .04). CONCLUSION: Older adults with a heel ulcer in the acute care setting are frequently not assessed for underlying ischemia of the lower extremities. The diagnosis carries high 1-year mortality rates. Evidence-based protocols need to be developed to determine which older adults should have a vascular assessment and then undergo an invasive procedure.

Can peripheral arterial disease be early screened for in a podiatric setting? A preliminary study in a cohort of asymptomatic adults.

BACKGROUND: Peripheral arterial disease (PAD) is a strong marker of cardiovascular disease but remains an under-diagnosed problem. Moreover, PAD frequently leads to foot problems requiring particular care and surveillance. AIM: The aims of this study were (1) to determine the prevalence of undiagnosed PAD in a cohort of asymptomatic subjects referred to a podiatric clinic and (2) to evaluate whether a four-item form assessing medical history for the presence of cardiovascular risk factors could identify subjects at high risk for asymptomatic PAD. PATIENTS AND METHODS: This study included 717 consecutive subjects (121 males, age 50.9±13.9 y) referring to a podiatric clinic who were asymptomatic for PAD and free of cardiovascular disease. The ankle brachial index (ABI) was measured in all subjects. Each subject also completed a self-administered form to identify cardiovascular risk factors. RESULTS: Among the entire cohort, the prevalence of PAD was 8.3% in males and 1.2% in females. Three subgroups were identified according to the number of risk factors reported (no risk factors, one risk factor, and two or more risk factors), and the prevalence of PAD differed between each subgroup (0.2%, 3.2%, and 18.9%, respectively; p < 0.001). CONCLUSIONS: In an unselected cohort of subjects referring to a podiatric clinic, who were asymptomatic for PAD and free from cardiovascular diseases, a remarkable prevalence of PAD was found among subjects reporting a minimum of two cardiovascular risk factors. In a podiatric setting, screening with a self-administered form for the presence of cardiovascular risk factors might lead to an early diagnosis of PAD.

Therapeutical potential of autologous peripheral blood mononuclear cell transplantation in patients with type 2 diabetic critical limb ischemia.

AIM: The aim was to evaluate the therapeutic effectiveness of granulocyte colony-stimulating factor (G-CSF) mobilized peripheral blood mononuclear cells (PBMNCs) in critical limb ischemia (CLI) of type 2 diabetic patients. METHOD: Forty diabetic patients with CLI were enrolled and randomized to treatment and control groups. In the treatment group, the patients received subcutaneous injections of recombinant human G-CSF (30 MU/day) for 5 days to mobilize stem cells. PBMNCs were collected and transplanted by multiple intramuscular injections of 1 ml in 1-1.5-cm depth into ischemic limbs. RESULTS: At the end of 12 weeks of follow-up, the baseline and end point results in transplant group were as follows: Fontaine score improved from 3.8±03 to 3±0.5 (P=.0001), ankle brachial pressure index increased from 0.68±0.24 to 0.87±024 (P=.001), transcutaneous oxygen increased from 33±14 mmHg to 44±10 mmHg (P=.0001), and 6-min walking distance improved from 280±82 m to 338±98 m (P=.0001). Pain score decreased from 8.2±1.3 to 5.63±1.6 (P=.001), and the number of patients with limb ulcers was reduced from 9/20 (45%) to 3/20 (15%) (P=.031). In the control group, Fontaine score, 6-min walking distance, and pain score were improved; ankle brachial pressure index and transcutaneous oxygen pressure were not improved. The number of patients with limb ulcers did not change in the control group. There are improvement in amputation rates, collateral vessel development, and number of limb ulcers healed. CONCLUSIONS: These results indicate that the autologous transplantation of G-CSF that mobilized PBMNCs in CLI diabetic patients is safe and effective in patient compliant reduction and improved perfusion.

[Prevalence of an abnormal ankle-brachial index in the Republic of Tatarstan].

The ankle-brachial index (ABI) was determined in a total of 1,751 employees of industrial enterprises of the Republic of Tatarstan aged from 45 to 84 years old (mean age 55,3 ± 0,14 years). An abnormal ABI was registered in 5,1% of the examined people (4,1% in the age group from 45 to 55 years, 5,4% in 56-65-year-old patients, and 12,1% in subjects over 65 years (p=0,001). An abnormal ABI was registered in 8.3% of men, and 3,1% of women (p=0,000), in 4,1% of rural population, 5,9% (p=0,138) of urban population, in 14,8% (p=0,000) of smokers, and in 45,4% (p = 0,000) of patients with a history of a cardiovascular event.

Subclinical atherosclerosis, airflow obstruction and emphysema: the MESA Lung Study.

Airflow obstruction is an independent risk factor for cardiovascular events in the general population. The affected vascular bed and contribution of emphysema to cardiovascular risk are unclear. We examined whether an obstructive pattern of spirometry and quantitatively defined emphysema were associated with subclinical atherosclerosis in the carotid, peripheral and coronary circulations. The Multi-Ethnic Study of Atherosclerosis recruited participants aged 45-84 yrs without clinical cardiovascular disease. Spirometry, carotid intima-media thickness (IMT), ankle-brachial index (ABI) and coronary artery calcium (CAC) were measured using standard protocols. Percentage of emphysema-like lung was measured in the lung windows of cardiac computed tomography scans among 3,642 participants. Multiple linear regression was used to adjust for cardiac risk factors, including C-reactive protein. Decrements in forced expiratory volume in 1 s (FEV(1)) and FEV(1)/forced vital capacity ratio were associated with greater internal carotid IMT, particularly among smokers (p=0.03 and p<0.001, respectively) whereas percentage emphysema was associated with reduced ABI regardless of smoking history (p=0.004). CAC was associated with neither lung function (prevalence ratio for the presence of CAC in severe airflow obstruction 0.99, 95% CI 0.91-1.07) nor percentage emphysema. An obstructive pattern of spirometry and emphysema were associated distinctly and independently with subclinical atherosclerosis in the carotid arteries and peripheral circulation, respectively, and were not independently related to CAC.