Outcome of Femoral Angioplasty/Stenting Procedures in Different Ethnic Groups in England: A Retrospective Analysis of Hospital Episode Statistics and Review of Literature.

PURPOSE: Various studies, mainly from North America, report worse outcomes in ethnic minority populations submitted to revascularization for peripheral arterial disease (PAD). Limited nationwide data in relation to ethnicity are available from Europe. OBJECTIVE: The objective of the study is to compare the outcomes of femoral angioplasty/stenting procedures among different ethnic groups in England during the 10-year period from 2006 to 2015. MATERIALS AND METHODS: The "Hospital Episode Statistics" database has been searched using International Classification of Diseases, Tenth Revision (ICD-10) codes to identify all cases of femoral angioplasty or stenting from English NHS Hospitals between January 1, 2006, and December 31, 2015. Subsequent mortality, second open or endovascular infrainguinal procedures, and major amputations on the same side within 2 years after the first procedure have been recorded. Patients were broadly categorized according to ethnicity as whites, Asians, and blacks. Chi-square test was used to demonstrate significant differences among ethnic groups and odds ratios (ORs) were calculated using white ethnic group as reference. RESULTS: A total number of 70 887 femoral endovascular procedures were recorded in patients from the 3 ethnic groups. Two-year mortality in whites, Asians, and blacks was 18.3%, 22.1%, and 19.5% (p<0.001); rates of second endovascular procedure were 12.1%, 13.1%, and 13.5% (p=0.24); rates of open infrainguinal procedure were 5.6%, 4.5%, and 8.0% (p<0.001); and rates of major amputation were 4.8%, 4.1%, and 7.0% (p<0.001), respectively. Mortality was higher in Asians (OR=1.26, 95% confidence interval [CI]=1.10-1.45, p<0.01) compared with whites. On the contrary, blacks underwent more open arterial operations (OR=1.48, 95% CI=1.19-1.83, p<0.01) and more amputations (OR=1.49, 95% CI=1.18-1.87, p<0.01). There were no significant differences in the rates of second endovascular procedures. CONCLUSION: Two-year mortality after femoral angioplasty/stenting is higher in Asians, whereas risk of limb loss is higher in blacks compared with whites. Reasons of these ethnic differences in outcomes following femoral endovascular procedures for PAD merit further study.

The Impact of Atrial Fibrillation on Outcomes of Peripheral Arterial Disease: Analysis of Routinely Collected Primary Care Data.

BACKGROUND: The combination of peripheral arterial disease and atrial fibrillation is linked with high risk of mortality and stroke. This study aims to investigate the impact of atrial fibrillation on patients with diagnosed peripheral arterial disease. METHODS: This is a retrospective study using The Health Improvement Network database, which contains prospectively collected data from participating primary care practices. Patients with a new diagnosis of peripheral arterial disease between January 8, 1995 and January 5, 2017 were identified in the database alongside relevant demographic information, clinical history, and medications. Every patient in the dataset with peripheral arterial disease and baseline atrial fibrillation (case) was matched to a patient without atrial fibrillation (control) with similar characteristics using propensity score matching. Cox-regression analysis was performed and hazard ratios (HR) calculated for the outcomes of death, stroke, ischemic heart disease, heart failure, and major amputation. RESULTS: Prevalence of atrial fibrillation in this cohort was 10.2%. All patients with peripheral arterial disease and atrial fibrillation (n = 5685) were matched with 5685 patients without atrial fibrillation but otherwise similar characteristics. After multivariate analysis, atrial fibrillation was independently associated with mortality (HR 1.18; 95% confidence interval [CI], 1.12-1.26; P < .01), cerebrovascular events (HR 1.35; 95% CI, 1.17-1.57; P < .01), and heart failure (HR 1.87; 95% CI, 1.62-2.15; P < .01), but not with ischemic heart disease or limb loss. CONCLUSION: In peripheral arterial disease patients, atrial fibrillation is a risk factor for mortality, stroke, and heart failure. This emphasizes the need for proactive surveillance and holistic management of these patients.

Outcome of Femoral-popliteal Bypass Procedures in Different Ethnic Groups in England: A Retrospective Analysis of Hospital Episode Statistics.

BACKGROUND: Previous studies, mainly from the United States, have reported worse outcomes from lower limb bypass procedures in ethnic minority populations. Limited nationwide data are available from ethnic minority populations from Europe. The aim of this study is to investigate outcomes from lower limb bypass procedures in ethnic minorities from England. METHODS: We enquired the "Hospital Episode Statistics" database, using ICD-10 codes to identify all cases of femoral-popliteal bypass operations from English NHS Hospitals from 01/01/2006 to 31/12/2015. Every case was followed up for 2 years for subsequent events. The primary outcomes were mortality and major leg amputation. Patients were broadly categorised according to Black, Asian and White ethnicity. Chi-square test was used to the ethnic groups and odds ratios (OR) were calculated using White ethnic group with the largest numbers of participants as a reference category. RESULTS: In the examined 10-year period, 20825 femoral-popliteal bypass procedures (250 of Black, 167 of Asian, and 20.408 of White ethnicity) were recorded. Thirty-day and 2-year mortality were 2.8% and 16.8% with no significant ethnic differences. Patients of Black ethnicity had higher risk of limb loss compared to Whites (23.2% vs. 15.6%, OR = 1.63, 95% confidence interval (CI) 1.21-2.19, P < 0.01). There was no significant difference in amputation rates between Asians and Whites (16.2% vs.. 15.6%, P = 0.94). CONCLUSIONS: Patients of Black ethnicity are at higher risk of limb loss after a femoropopliteal bypass procedure. Further research is needed to identify the causes of this discrepancy.

Peripheral Arterial Disease in Patients with Atrial Fibrillation: The AFFIRM Study.

BACKGROUND: Peripheral arterial disease has been linked with worse outcomes in patients with atrial fibrillation. The aim of this study is to assess the impact of peripheral arterial disease on mortality and stroke in a cohort of patients with atrial fibrillation. METHODS: This was an ancillary analysis of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial. A comparison of baseline characteristics was made between patients with atrial fibrillation with and without diagnosed peripheral arterial disease. Multivariate cox regression analysis was performed to compare the risk of stroke, death, and cardiovascular death among the two groups. RESULTS: The prevalence of peripheral arterial disease in the whole cohort of 4060 patients with atrial fibrillation was 6.7%. Patients with peripheral arterial disease tended to be older; had higher prevalence of diabetes mellitus, hypertension, and smoking; and were more likely to have a history of coronary artery disease, heart failure, cardiac surgery or cardiac intervention, and stroke or transient ischemic attack (all P < .05). After multivariate adjustment, peripheral arterial disease was significantly associated with overall higher mortality (hazard ratio 1.34, 95% confidence interval 1.06-1.70, P = .016) in patients with atrial fibrillation, but the rates of ischemic stroke were similar in the two groups (3.9% vs 3.5%, P = 0.874). Subgroup analysis confined to the patients with non-anticoagulated atrial fibrillation showed that peripheral arterial disease was an independent predictor of ischemic stroke (hazard ratio 3.37, 95% confidence interval 1.25-9.09, P < .016). CONCLUSION: Peripheral arterial disease predicts higher mortality in atrial fibrillation, and was an independent predictor of ischemic stroke in patients with non-anticoagulated atrial fibrillation. Proactive surveillance and optimization of medical management in this group of patients is warranted, given the high risks associated with peripheral arterial disease where atrial fibrillation is also present.

An Extension of the Bollinger Scoring System to Analyse the Distribution of Macrovascular Disease of the Lower Limb in Diabetes.

OBJECTIVE: While it is generally considered that patients with diabetes mellitus (DM) have more distal peripheral arterial disease (PAD), there is little information on how individual vessels are affected. The aim of this study was to adapt Bollinger's scoring system for lower limb angiograms (DSAs) to include the distal and planter vessels. The reliability of this extension was tested and was used to compare the distribution of disease in two cohorts of patients with and without DM. METHODS: Patients who had undergone DSA ± angioplasty for PAD at a single centre between September 2010 and April 2014 were identified. Twenty-five patients' images were reviewed by four clinicians and scored using an extended version of the Bollinger score. A total of 153 patients with DM were matched, for age, sex, ethnicity, smoking, and hypertension, with 153 patients without DM. The infrainguinal vessels were divided into 16 arterial segments, including plantar vessels, and scored using the Bollinger score. The score ranges from 0 to 15. Fifteen represents an arterial segment with more than 50% of its length occluded. Interobserver reliability was tested using interclass correlation (ICC) and Cohen's kappa coefficient. RESULTS: The ICC demonstrated good agreement between observers (0.76 [0.72-0.79]) with good internal consistency (Cronbach's alpha 0.93). When the Bollinger scores were categorised, the results were weaker, Cohen's kappa ranged from 0.39 (standard error 0.033) to 0.54 (0.030). Patients with DM had a higher burden of disease in the anterior tibial and posterior tibial arteries with relative sparing of the peroneal artery and no difference in the plantar vessels. CONCLUSION: It has been demonstrated that the Bollinger score can be extended to include the distal vessels. This amended scoring system can be used to compare the burden of distal disease in patients with PAD. How the score relates to clinical presentation and outcomes needs further investigation.

Ethnic differences in the prevalence of peripheral arterial disease: a systematic review and meta-analysis.

BACKGROUND: Previous studies have demonstrated higher rates of peripheral arterial disease (PAD) in blacks and lower in Asians compared to whites. The aim of this study is to undertake a comprehensive review of literature on ethnic differences in the epidemiology of PAD. METHODS: A systemic review and meta-analysis included studies reporting PAD prevalence in general or diabetic populations, and comparing PAD prevalence in ethnic groups. RESULTS: Mean prevalence of PAD in general population for whites, blacks and Asians was 3.5%, 6.7% and 3.7% respectively. Meta-analysis demonstrated higher prevalence of PAD in blacks (p < 0.001) and lower amongst Asians (p < 0.001), compared to whites. In diabetic population, the mean prevalence of PAD for whites, blacks, east Asians and south Asians was 17%, 25.3%, 13.5% and 7.6% respectively. In diabetic population, south Asians had a lower PAD prevalence (p < 0.001) compared to whites; there was no significant difference between blacks and whites. Overall females have higher PAD rates, in general (3.8% vs 3.2%; p < 0.001) and in diabetic population (13.7% vs 10%; p < 0.001). CONCLUSION: Blacks are vulnerable to PAD, in contrast to Asians who have lower prevalence of PAD when compared to whites. Further research is needed in order to identify the factors that generate this difference.

Measuring wildland fire fighter performance with wearable technology.

Wildland (rural) fire fighting is a physically demanding and hazardous occupation. An observational study was conducted to explore the use of new technologies for the field study of fire fighters at wildfires and to understand the work pressures of wildland fire fighting. The research was carried out with two fire fighters at real fires wearing microphones, miniature video cameras, heart rate monitors and GPS units to record their actions and location at wildfire events. The fire fighters were exposed to high physiological workloads (heart rates of up to 180 beats per minute) and walked considerable distances at the fires. Results from this study have been used in presentations to fire fighters and non-operational fire personnel to understand the pressures fire fighters are under and how others complete the fire fighting tasks.