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.

Usefulness of the ratio of brachial pre-ejection period to brachial ejection time in prediction of cardiovascular and overall mortality in patients with acute myocardial infarction.

Left ventricular systolic function is a good indicator of cardiac function and a powerful predictor of adverse cardiovascular (CV) outcomes. High ratio of pre-ejection period (PEP) to ejection time (ET) is associated with reduced left ventricular systolic function. Brachial PEP (bPEP) and brachial ET (bET) can be automatically calculated from an ankle-brachial index (ABI)-form device and bPEP/bET was recently reported to be a new and useful parameter of cardiac performance. However, there were no studies evaluating the utility of bPEP/bET for prediction of CV and overall mortality in patients with acute myocardial infarction (AMI). We included 139 cases of AMI admitted to our cardiac care unit consecutively. ABI, bPEP, and bET were obtained from the ABI-form device within the 24 hours of admission. There were 87 overall and 22 CV mortality and the median follow-up to mortality event was 98 months. After multivariable analysis, high bPEP/bET was not only associated with increased long-term CV mortality (hazard ratio (HR) = 1.046; 95% confidence interval (CI): 1.005-1.088; P = 0.029), but also associated with long-term overall mortality (HR = 1.023; 95% CI: 1.001-1.045; P = 0.042). In addition, age was also a significant predictor for CV and overall mortality after the multivariable analysis. In conclusion, bPEP/bET was shown to be a significant predictor for CV and overall mortality in AMI patients after multivariable analysis. Therefore, by means of this novel parameter, we could easily find out the high-risk AMI patients with increased CV and overall mortality.

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.

Skin Carotenoid Level as an Alternative Marker of Serum Total Carotenoid Concentration and Vegetable Intake Correlates with Biomarkers of Circulatory Diseases and Metabolic Syndrome.

To confirm the usefulness of noninvasive measurements of skin carotenoids to indicate vegetable intake and to elucidate relationships between skin carotenoid levels and biomarkers of circulatory diseases and metabolic syndrome, we conducted a cross-sectional study on a resident-based health checkup (n = 811; 58% women; 49.5 ± 15.1 years). Skin and serum carotenoid levels were measured via reflectance spectroscopy and high-performance liquid chromatography, respectively. Vegetable intake was estimated using a dietary questionnaire. Levels of 9 biomarkers (body mass index [BMI], brachial-ankle pulse wave velocity [baPWV], systolic and diastolic blood pressure [SBP and DBP], homeostasis model assessment as an index of insulin resistance [HOMA-IR], blood insulin, fasting blood glucose [FBG], triglycerides [TGs], and high-density lipoprotein cholesterol [HDL-C]) were determined. Skin carotenoid levels were significantly positively correlated with serum total carotenoids and vegetable intake (r = 0.678 and 0.210, respectively). In women, higher skin carotenoid levels were significantly associated with lower BMI, SBP, DBP, HOMA-IR, blood insulin, and TGs levels and higher HDL-C levels. In men, it was also significantly correlated with BMI and blood insulin levels. In conclusion, dermal carotenoid level may indicate vegetable intake, and the higher level of dermal carotenoids are associated with a lower risk of circulatory diseases and metabolic syndrome.

Association of Arterial Stiffness With Kidney Function Among Adults Without Chronic Kidney Disease.

BACKGROUND: Our aims were to assess whether arterial stiffness is associated with a higher risk for kidney dysfunction among persons without chronic kidney disease (CKD). METHODS: We analyzed data from the national health checkup system in Japan; for our analyses, we selected records of individuals who completed assessments of cardio-ankle vascular index (CAVI) and kidney function from 2005 to 2016. We excluded participants who had CKD at baseline, defined as the presence of proteinuria or estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2. We compared 2 groups of CAVI measurements-the highest quartile (≧8.1) and the combined lower 3 quartiles (<8.1). We used Cox proportional hazards models to assess associations between these 2 groups and subsequent CKD events, proteinuria, eGFR <60 ml/min/1.73 m2, and rapid eGFR decline (greater than or equal to -3 ml/min/1.73 m2 per year). RESULTS: The mean age of the 24,297 included participants was 46.2 years, and 60% were female. Over a mean follow-up of 3.1 years, 1,435 CKD events occurred. In a multivariable analysis, the hazard ratios with 95% confidence intervals (CIs) for the highest vs. combined lower quartiles of CAVI measurements were 1.3 (1.1, 1.5) for CKD events, 1.3 (0.96, 1.62) for proteinuria, 1.4 (1.1, 1.7) for eGFR <60 ml/min/1.73 m2, and the odds ratio with 95% CI was 1.3 (1.1, 1.4) for rapid eGFR decline. CONCLUSIONS: Persons with CAVI measurements ≧8.1 had a higher risk for CKD events compared with their counterparts with CAVI measurements <8.1. Greater arterial stiffness among adults without CKD may be associated with kidney dysfunction.

The ankle brachial index in people with and without diabetes: intra-tester reliability.

BACKGROUND: The ankle-brachial index (ABI) is widely used for determining the presence and severity of peripheral arterial disease (PAD), and current guidelines suggest it should be used to monitor possible progression in affected individuals. It is therefore important that the technique demonstrates adequate reliability for repeated measurements. Existing studies suggest that the ABI is reliable in the general population however, there is a lack of evidence for the reliability of the ABI in people with diabetes. The aim of this study was to investigate the intra-tester reliability of the ABI in people with and without diabetes. METHODS: Eighty-five participants (40 with and 45 without diabetes) underwent ankle and brachial systolic blood pressure measurements by a single clinician during two testing sessions. Intraclass correlation coefficients (ICC), their 95% limits of agreement, standard error of measurement and minimal detectable change were determined. RESULTS: Intra-tester reliability of the ABI was found to be good (ICC: 0.80), however sub-group analysis of participants with and without diabetes found that ABI was slightly less reliable in people with diabetes (ICC: 0.78) than in those without (ICC: 0.82). The relatively large limits of agreement (- 0.16 to 0.16), standard error of measurement (0.03 overall, 0.04 for the diabetes group), and minimal detectable change (0.08 overall, 0.11 for the diabetes group) suggest that a large change in ABI is required for it to demonstrate a true change rather than the result of measurement variability. The minimal detectable change for the ABI was 0.08 overall, and 0.11 for the diabetes group. CONCLUSIONS: The ABI demonstrated good reliability in all groups analysed. However, the wide limits of agreement and considerable standard error of measurement obtained support the use of multiple methods of vascular assessment for ongoing monitoring of lower limb vascular status.

Epidemiological investigation of vascular etiological examinations in the diagnosis and treatment of lower-extremity ulcers in China.

The vascular causes of lower-extremity ulcers cannot be neglected because they can directly affect treatment methods. No detailed epidemiological statistics have described vascular etiological diagnosis in China. This study aimed to explore the prevalence of clinical vascular etiological examination of lower-extremity ulcers and improve the diagnosis and treatment effectiveness of lower-extremity ulcers. Data were collected from the WoundCareLog database, which includes 2413 cases of lower-extremity ulcers from 478 hospitals nationwide. Data analysis revealed that 1698 (70.4%) lower-extremity blood flow examinations (including physical examination [PE] and assistant examinations [AE]) were performed, of which 61.7% were PE, 10.4% were AE only, and 27.9% were the combined PE and AE[PAE]. The proportion of nonexaminations was higher in the nondiabetic group than in the diabetic group (χ2 = 34.5; P < .01). The positive rates of vascular etiological examination in the diabetic and nondiabetic groups were 69.7% and 70.7%, respectively. Among the four economic regions of China, there were statistically significant differences in the use of the different examination methods. The examination of vascular diseases in lower-extremity ulcers in China has not been fully popularized and requires improvement; there was no statistically significant difference between examination rates by doctors and nurses, which is mainly based on PE. However, PE has certain rates of misdiagnosis and missed diagnosis. The false-positive and false-negative rates were 25.7% and 57.6%, respectively. The use of an AE can compensate for this deficiency by making diagnosis more precise, while the quantitative diagnostic criteria allow disease diagnosis to transcend geographical and operator differences and maximize uniformity. The vascular B-ultrasound examination is more suitable for the medical environment in China because of its mature technology, high hospital penetration rate, and low cost.

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.

Arterial Stiffness Predicts Rapid Decline in Glomerular Filtration Rate Among Patients with High Cardiovascular Risks.

AIMS: Arterial stiffness is known to be an important surrogate marker for atherosclerosis and predictor of peripheral vascular and cardiovascular (CV) disease. Whether high cardio-ankle vascular index (CAVI) is associated with the development of rapid glomerular filtration rate (GFR) decline remains uncertain. The study aimed to determine the relationship between CAVI and renal function progression among patients with high CV risk. METHODS: This study employed a prospective cohort design with 1-year follow-up among patients with high CV risk. Arterial stiffness was measured using CAVI method. GFR was estimated using the chronic kidney disease (CKD) epidemiology collaboration equation, and rapid decline in GFR was defined with decrease in GFR ≥ 5 mL/min/1.73 m2 yearly. RESULTS: Of 352 patients with mean age 67.8±10.1 years, 224 patients (63.6%) were suspected to have arteriosclerosis (CAVI ≥ 9), and 208 patients (59.1%) had CKD (GFR ＜60 mL/min/1.73 m2). Annual decline of GFR was -0.75 [interquartile range (IQR), -1.16 to 6.08] mL/min/1.73 m2/year, and 30.1% of patients experienced a rapid decline in GFR. Compared with normal CAVI (CAVI ＜8), high CAVI (CAVI ≥ 9) and borderline CAVI (CAVI 8-8.9) in all subjects and subgroup of baseline GFR ＞60 mL/min/1.73 m2 were associated with rapid GFR decline. Multivariable analysis showed that high CAVI and borderline CAVI were associated with 2.47-fold (95% CI, 0.89-6.84; P=0.082) and 4.04-fold (95% CI, 1.46-11.18; P=0.007) increased odds ratio of rapid GFR decline, respectively. CONCLUSION: Among patients with high risk of CV with or without CKD, high CAVI (cut point of ≥ 9) was independently associated with a rapid decline in GFR, suggesting that systemic vascular stiffness predicted a decrease in renal function in this population.

Positive Association of Serum Adipocyte Fatty Acid Binding Protein Level With Peripheral Artery Disease in Hemodialysis Patients.

Adipocyte fatty acid binding protein is positively associated with atherosclerosis. Peripheral arterial disease is associated with an increased mortality in hemodialysis patients. This study aimed to evaluate the relationship between serum adipocyte fatty acid binding protein levels and peripheral arterial disease by ankle-brachial index in hemodialysis patients. Among the 90 chronic hemodialysis recipients, 20 patients (22.2%) were in the low ankle-brachial index group who had a higher prevalence of diabetes, hyperlipidemia, statin use, older age, higher body fat mass, higher serum adipocyte fatty acid binding protein level, and lower serum creatinine level compared with patients in the control group. After statistical analysis, body fat mass (P = 0.006) and creatinine level (P = 0.018) were shown to be the independent predictors of adipocyte fatty acid binding protein level. Serum adipocyte fatty acid binding protein (P = 0.021) was found to be positively associated with peripheral arterial disease in hemodialysis patients.

Characteristics of metabolic factors related to arterial stiffness in young and old adults.

It has not been adequately studied which biomarkers for cardiovascular risk indicate changes of atherosclerosis by aging process. The current study aimed to investigate the characteristics of metabolic factors related to arterial stiffness in young and old adults. Our cross-sectional study enrolled 851 healthy young adults and 719 old adults. Metabolic biomarkers included glucose, lipid profiles, and liver enzymes. In young adults, additional biomarkers such as C-reactive protein, apolipoproteins, lipoprotein(a), ferritin, and 25-hydroxycholecalciferol were measured. Arterial stiffness was evaluated by measuring brachial-ankle pulse wave velocity (baPWV). The mean age was 37.8 and 65.1 years old in the young and old groups, respectively. Without adjustment, most parameters were significantly correlated with baPWV in both young and old groups. Mean baPWV was significantly different according to metabolic syndrome (MetS) in both groups (13.1 and 12.1 m/s in the young subjects with and without MetS, respectively; 17.4 and 15.8 m/s, respectively, in the old group). After adjusting for age, sex, and hemodynamic factors, the difference in baPWV according to MetS was significant only in the old group. The relationship between most biomarkers and baPWV was influenced by metabolic disorders such as hypertension and diabetes in old adults. Total cholesterol (TC), low-density lipoprotein cholesterol (LDLC), and apolipoprotein B were significant in young group. In conclusion, the metabolic biomarkers related to arterial stiffness were different between young and old adults. Contrary to old adults, TC, LDLC, and apolipoprotein B were independent biomarkers for arterial stiffness in healthy young adults.

Investigation of Acoustic Cardiographic Parameters before and after Hemodialysis.

Patients with end-stage renal disease are at an increased risk of cardiovascular diseases and associated mortality. Acoustic cardiography is a technique in which cardiac acoustic data is synchronized with electric information to detect and characterize heart sounds and detect heart failure early. The aim of this study was to investigate acoustic cardiographic parameters before and after hemodialysis (HD) and their correlations with ankle-brachial index (ABI), brachial-ankle pulse wave velocity (baPWV), and ratio of brachial preejection period to ejection time (bPEP/bET) obtained from an ABI-form device in HD patients. This study enrolled 162 HD patients between October 2016 and April 2018. Demographic, medical, and laboratory data were collected. Acoustic cardiography was performed before and after HD to assess parameters including third heart sound (S3), fourth heart sound (S4), systolic dysfunction index (SDI), electromechanical activation time (EMAT), and left ventricular systolic time (LVST). The mean age of the enrolled patients was 60.4 ± 10.9 years, and 86 (53.1%) patients were male. S4 (p < 0.001) and LVST (p < 0.001) significantly decreased after HD, but EMAT (p < 0.001) increased. Multivariate forward linear regression analysis showed that EMAT/LVST before HD was negatively associated with albumin (unstandardized coefficient ß = -0.076; p = 0.004) and ABI (unstandardized coefficient ß = -0.115; p = 0.011) and positively associated with bPEP/bET (unstandardized coefficient ß = 0.278; p = 0.003). Screening HD patients with acoustic cardiography may help to identify patients at a high risk of malnutrition, peripheral artery disease, and left ventricular systolic dysfunction.

The reliability of the ankle brachial index: a systematic review.

BACKGROUND: The ankle brachial index (ABI) is widely used in clinical practice as a non-invasive method to detect the presence and severity of peripheral arterial disease (PAD). Current guidelines suggest that it should be used to monitor potential progression of PAD in affected individuals. As such, it is important that the test is reliable when used for repeated measurements, by the same or different health practitioners. This systematic review aims to examine the literature to evaluate the inter- and intra-rater reliability of the ABI. METHODS: A systematic search of MEDLINE, EMBASE and CINAHL Complete was conducted to 20 January 2019. Two authors independently reviewed and selected relevant studies and extracted the data. Methodological quality was determined using the Quality Appraisal of Reliability (QAREL) Checklist. RESULTS: Fifteen studies of ABI reliability in a range of patient populations were identified as suitable for inclusion in the review: seven considered inter-rater reliability, four intra-rater reliability, and four studies evaluated both inter- and intra-rater reliability. Inter-rater reliability was found to be highly variable, with intraclass correlation coefficients (ICC's) ranging from poor to excellent (ICC 0.42-1.00), while intra-rater also demonstrated considerable variation, with ICCs from 0.42-0.98. Meta-analysis was not possible due to the lack of statistical information reported. CONCLUSIONS: Results of included studies suggest the inter- and intra-tester reliability of the ABI is acceptable. However, inconsistencies in obtaining systolic pressure measurements, calculating ABI values, and incomplete reporting of methodologies and statistical analysis make it difficult to determine the validity of the results of included studies. Further research, with more consistent reliability methodology, statistical analysis and reporting conducted in populations at risk of PAD is needed to conclusively determine the ABI reliability.

Exercise testing criteria to diagnose lower extremity peripheral artery disease assessed by computed-tomography angiography.

BACKGROUND: The sensitivity and specificity of exercise testing have never been studied simultaneously against an objective quantification of arterial stenosis. Aims were to define the sensitivity and specificity of several exercise tests to detect peripheral artery disease (PAD), and to assess whether or not defined criteria defined in patients suspected of having a PAD show a difference dependent on the resting ABI. METHODS: In this prospective study, consecutive patients with exertional limb pain referred to our vascular center were included. All patients had an ABI, a treadmill exercise-oximetry test, a second treadmill test (both 10% slope; 3.2km/h speed) with post-exercise pressures, and a computed-tomography-angiography (CTA). The receiver-operating-characteristic curve was used to define a cut-off point corresponding to the best area under the curve (AUC; [CI95%]) to detect arterial stenosis ≥50% as determined by the CTA. RESULTS: Sixty-three patients (61+/-11 years-old) were included. Similar AUCs from 0.72[0.63-0.79] to 0.83[0.75-0.89] were found for the different tests in the overall population. To detect arterial stenosis ≥50%, cut-off values of ABI, post-exercise ABI, post-exercise ABI decrease, post-exercise ankle pressure decrease, and distal delta from rest oxygen pressure (DROP) index were ≤0.91, ≤0.52, ≥43%, ≥20mmHg and ≤-15mmHg, respectively (p<0.01). In the subset of patients with an ABI >0.91, cut-off values of post-exercise ABI decrease (AUC = 0.67[0.53-0.78]), and DROP (AUC = 0.67[0.53-0.78]) were ≥18.5%, and ≤-15mmHg respectively (p<0.05). CONCLUSION: Resting ABI is as accurate as exercise testing in patients with exertional limb pain. Specific exercise testing cut-off values should be used in patients with normal ABI to diagnose PAD.

Impaired ankle-brachial index in antiphospholipid syndrome: Beyond the traditional risk factors.

INTRODUCTION: The patients with antiphospholipid syndrome (APS) associate an increased risk of atherosclerosis. OBJECTIVE: To determine the predictors of an abnormal ankle-brachial index (ABI), surrogate measure of atherosclerosis, in patients with APS. METHODS: The ABI was measured according to standard recommendations in 106 patients. Traditional cardiovascular risk factors were assessed in all cases. A large spectrum of APS antibodies was determined in 73 patients. RESULTS: A total of 106 patients diagnosed with APS were included. 28.3% patients included were found to have low ABI. Anti-beta 2-glycoprotein I (aß2GPI) IgG antibodies [4.00 (1.00-79.00) vs 3.00 (0.00-29.00) U/mL, P = 0.02] and antiprothrombin (aPT) IgM antibodies [4.50 (0.00-82.00) vs 3.00 (0.00-14.00) U/mL, P = 0.05] titers were found to be higher in patients with abnormal ABI. However, after multivariate regression analysis, only the aß2GPI IgG titer remained predictor of low ABI (P = 0.04). CONCLUSIONS: aß2GPI IgG associated with impaired ABI in patients with APS. This relation might reflect their involvement in the atherosclerosis occurrence.

High sodium intake and sodium to potassium ratio may be linked to subsequent increase in vascular damage in adults aged 40 years and older: the Korean multi-rural communities cohort (MRCohort).

PURPOSE: Subclinical vascular damage is a chronic intermediate process in cardiovascular disease (CVD) and high sodium (Na) has been regarded as an adverse factor in subclinical vascular health; however, the longitudinal relationship between Na intake and subclinical vascular damage has not been studied. We aimed to evaluate the longitudinal relationship of dietary Na intake and sodium to potassium ratio (Na:K) with brachial-ankle pulse wave velocity (baPWV) and carotid intima media thickness (cIMT) in healthy adults aged 40 years and older in Korea. METHODS: The present study was based on participants (n = 2145 for baPWV analysis and n = 2494 for cIMT analysis) who visited three times during 2005-2013 (median 5.3 years of follow-up). We used both dietary Na intake and Na:K at baseline and its average (baseline, 2nd, 3rd), which was obtained from food frequency questionnaire (FFQ) as exposure at every visit. baPWV and cIMT levels at the third visit and change from baseline to the third visit were used to represent the level of subclinical vascular damage. RESULTS: After adjustment for potential confounders, significant positive relationships between dietary Na intake and both baPWV3rd and cIMT3rd were observed (baPWV: p for trend ≤ 0.0001 for Naaverage; cIMT: p for trend = 0.013 for Naaverage). Compared with Na:Ks less than 1.0, the levels of both baPWV and cIMT were higher for participants with Na:Ks over 1.0 (baPWV: p for trend = 0.0002 for Na:Kaverage; cIMT: p for trend = 0.005 for Na:Kaverage). Similar significant trends were shown in relationships between dietary Na intake and Na:K and changes in baPWV and cIMT levels. CONCLUSIONS: In conclusion, dietary Na intake and Na:K may be positively linked to subsequent baPWV and cIMT levels in adults aged 40 years and older in Korea. Our findings may provide informative evidence on subclinical vascular damage, particularly for populations with relatively high dietary Na intake and low dietary K intake.

Hypertension and high ankle brachial index: the overlooked combination.

OBJECTIVE: Assessment of asymptomatic organ damage in the management of hypertension includes low (<0.9) ankle brachial index (ABI) values. No recommendations are given for patients with high ABI (≥1.3), despite evidence of an association with increased risk. We aimed to study the association of high ABI with all-cause mortality and cardiovascular outcomes in a hypertensive population. METHODS: In anonymized clinical records from the Catalan Primary Care (SIDIAP) database, we designed a large cohort of hypertensive patients aged 35-85 years at the start date. Participants were excluded if they had previous heart failure, coronary heart disease, stroke, diabetes mellitus, or chronic kidney disease. The study population was categorized according to ABI values. Cox proportional hazards models were used to assess all-cause mortality, heart failure, acute myocardial infarction, and stroke. RESULTS: From 2006 through 2015, SIDIAP records included 44 657 hypertensive patients with an ABI measurement 9126 of whom met inclusion criteria. The median follow-up (first to third quartiles) was 6.0 years (4.7-7.6). High ABI (≥ 1.3) was associated with an increase in mortality risk, hazard ratio, and 95% confidence interval: 1.44 (1.10-1.88), similar to the group with ABI at least 0.9 and less than 1.1, hazard ratio 1.36 (1.12-1.65), and lower than all groups with ABI less than 0.9. High ABI values tended to associate with heart failure, hazard ratio 1.34 (0.95-1.91), but the relation of high ABI with acute myocardial infarction and stroke was nonsignificant, hazard ratios 1.30 (0.72-2.35) and 0.97 (0.65-1.42), respectively. CONCLUSION: Patients with high ABI values and hypertension presented an increased all-cause mortality risk that could be considered when advising such patients.