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1.
Angiol Sosud Khir ; 26(3): 28-36, 2020.
Artigo em Russo | MEDLINE | ID: mdl-33063749

RESUMO

This article presents a review of the literature on studying Cilostazol, a type 3 phosphodiesterase inhibitor, also providing the Russian and foreign statistics on the prevalence of peripheral artery disease. It is underlined that the majority of patients with peripheral artery disease have atherosclerotic lesions in the coronary and cerebral vascular basins. Cilostazol deservedly occupies the first lines in the sections of pharmacotherapy for intermittent claudication in international and Russian consensus documents on peripheral artery disease. The drug has an extensive evidence base for the following pharmacological effects: vasodilating, antiplatelet, endothelial protective, and vasculogenic. Clinical efficacy of Cilostazol was confirmed in 15 randomized clinical trials (3 718 patients with intermittent claudication) studying the use of Cilostazol taken twice daily at doses of 50 mg, 100 mg, and 150 mg as compared with placebo or versus pentoxifylline given in a dose of 400 mg three times daily, with a demonstrable increase in the pain-free walking distance and the maximal walking distance on the background of taking Cilostazol. The drug significantly improves the outcomes of endovascular interventions on arteries of lower extremities, decreasing the incidence of restenosis, prolonging limb survival, and reducing the frequency of major amputations. Many studies addressing the use of Cilostazol in patients with coronary and cerebral atherosclerosis have investigated the effect of the drug as a component of dual antiplatelet therapy (aspirin + Cilostazol) and triple antiplatelet therapy (aspirin + clopidogrel + Cilostazol) after endovascular interventions. The addition of Cilostazol to treatment resulted in a significant decrease in the occurrence of re-stenosis, with no increase in the incidence of haemorrhage. Cilostazol may be recommended for patients with multifocal atherosclerosis and resistance to aspirin and clopidogrel. Also presented in the article are the results of a Russian clinical trial studying comparative efficacy of Cilostazol and pentoxifylline in patients with intermittent claudication.


Assuntos
Cilostazol , Doença Arterial Periférica , Humanos , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/tratamento farmacológico , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/tratamento farmacológico , Federação Russa , Tetrazóis
3.
BMJ Case Rep ; 13(8)2020 Aug 03.
Artigo em Inglês | MEDLINE | ID: mdl-32747597

RESUMO

We describe a patient with COVID-19 who developed simultaneous pulmonary, intracardiac and peripheral arterial thrombosis. A 58-year-old man, without major comorbidity, was admitted with a 14-day history of breathlessness. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection was confirmed by laboratory testing. Initial imaging revealed COVID-19 pneumonia but no pulmonary thromboembolism (PTE) on CT pulmonary angiography (CTPA). The patient subsequently developed respiratory failure and left foot ischaemia associated with a rising D-dimer. Repeat CTPA and lower limb CT angiography revealed simultaneous bilateral PTE, biventricular cardiac thrombi and bilateral lower limb arterial occlusions. This case highlights a broad range of vascular sequalae associated with COVID-19 and the fact that these can occur despite a combination of prophylactic and treatment dose anticoagulation.


Assuntos
Infecções por Coronavirus , Enoxaparina/administração & dosagem , Cardiopatias , Pandemias , Doença Arterial Periférica , Pneumonia Viral , Embolia Pulmonar , Trombose , Varfarina/administração & dosagem , Anticoagulantes/administração & dosagem , Betacoronavirus/isolamento & purificação , Betacoronavirus/patogenicidade , Deterioração Clínica , Angiografia por Tomografia Computadorizada/métodos , Infecções por Coronavirus/complicações , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/fisiopatologia , Infecções por Coronavirus/terapia , Cardiopatias/diagnóstico , Cardiopatias/etiologia , Cardiopatias/terapia , Ventrículos do Coração/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/etiologia , Doença Arterial Periférica/terapia , Pneumonia Viral/complicações , Pneumonia Viral/diagnóstico , Pneumonia Viral/diagnóstico por imagem , Pneumonia Viral/etiologia , Pneumonia Viral/fisiopatologia , Pneumonia Viral/terapia , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/etiologia , Embolia Pulmonar/terapia , Trombose/diagnóstico , Trombose/etiologia , Trombose/terapia , Resultado do Tratamento
5.
Orv Hetil ; 161(33): 1382-1390, 2020 08.
Artigo em Húngaro | MEDLINE | ID: mdl-32749233

RESUMO

INTRODUCTION: The screening tool for diagnosing lower extremity arterial disease (LEAD) is the assessment of the ankle-brachial index (ABI). In patients at risk for LEAD, the purpose of screening is to avoid major adverse limb events, such as amputation. However, resting ABI can easily produce a false negative result. AIM: In light of this, our goal was to test the usefulness of an easily performed, fast and cost-effective screening method and to determine the proportion of subjects without definitive diagnoses among patients screened in general practice (with special attention to groups having negative ABI with symptoms and patients with non-compressible arteries). METHOD: 680 patients were screened from the region of Northern Hungary. We used the Edinburgh Questionnaire, recorded medical histories, major risk factors, current complaints, and medication. Physical examinations were performed, including ABI testing. RESULTS: 34% complained about lower extremity claudication; 23% had abnormal ABI values; 14% of the patients within the normal ABI range had complaints of dysbasia; 12% were in the non-compressible artery group. The ABI-negative symptomatic group's risk factor profile showed a close similarity to the clear LEAD-positive and non-compressible artery groups. CONCLUSION: The percentage of LEAD could be higher than the number of patients diagnosed by ABI screening. Nearly a quarter of the population fell into the non-compressible artery and ABI-negative symptomatic groups. When screening purposely for LEAD, these patients deserve special attention due to the insufficient selectivity and sensitivity of measurements. If there is a high clinical suspicion of LEAD in spite of normal ABI values, further assessment may be considered. Orv Hetil. 2020; 161(33): 1381-1389.


Assuntos
Artéria Braquial/fisiopatologia , Extremidade Inferior/irrigação sanguínea , Programas de Rastreamento/métodos , Doença Arterial Periférica/diagnóstico , Doenças Vasculares Periféricas/fisiopatologia , Tornozelo/irrigação sanguínea , Tornozelo/diagnóstico por imagem , Índice Tornozelo-Braço , Humanos , Hungria , Extremidade Inferior/diagnóstico por imagem
6.
Vasc Health Risk Manag ; 16: 271-284, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32753875

RESUMO

Introduction: Previous studies have suggested that women with chroniclimb-threatening ischemia (CLTI) may have worse outcomes than men. The aim of this study was to determine whether there are sex-related differences in outcomes of patients with CLTI undergoing endovascular treatment with current endovascular technologies. Patients and Methods: Data were derived from the LIBERTY 360 study (NCT01855412). Hazard ratios and the respective 95% confidence intervals were synthesized to examine the association between sex and all-cause mortality, target vessel revascularization (TVR), major amputation, major adverse event (MAE) and major amputation/death up to 3 years of follow-up. Results: A total of 689 patients with CLTI (female: N=252 vs male: N=437) treated with any FDA approved or cleared device were included. The mean lesion length was 126.9±117.3mm and 127.4±113.3mm for the female and male patients, respectively. Although a slightly higher incidence of in-hospital mortality was observed in the female group (1.2% vs 0.0%, p=0.049), there was no difference in female vs male survival rates during follow-up. However, the risk of major amputation at 18 months was higher for the male group (male vs female: HR: 2.36; 95% CI: 1.09-5.12; p=0.030). No difference between the two groups was detected in terms of TVR or MAE during follow-up. Discussion: Data regarding sex-related disparity in outcomes after endovascular therapy of patients with CLTI are conflicting. Gender-related characteristics rather than biological sex characteristics might be the cause of these conflicting findings. Further studies are needed to evaluate the role of sex in revascularization outcomes among this high-risk population.


Assuntos
Angioplastia com Balão , Isquemia/terapia , Doença Arterial Periférica/terapia , Idoso , Idoso de 80 Anos ou mais , Amputação , Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/mortalidade , Causas de Morte , Doença Crônica , Feminino , Mortalidade Hospitalar , Humanos , Isquemia/diagnóstico , Isquemia/mortalidade , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento
7.
Eur J Vasc Endovasc Surg ; 60(3): 462-468, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32763120

RESUMO

OBJECTIVE: Ankle brachial index (ABI) is widely used for the diagnosis of lower extremity artery disease (LEAD). The purpose of this prospective study was to validate the diagnostic ability and reproducibility of a four cuff automated oscillometric device vs. the Doppler method. METHODS: Patients with suspected LEAD or asymptomatic individuals at risk because of the presence two or more cardiovascular risk factors were enrolled. For each patient, Doppler and oscillometric ABI measurements were repeated by two observers to address intra- and interobserver reproducibility. RESULTS: In total, 118 patients were evaluated. The prevalence of Doppler ABI (Dop-ABI) ≤ 0.90 was 45.8%. Taking the Dop-ABI as the reference, the sensitivity, specificity, accuracy, positive and negative predictive values of oscillometric ABI (Osc-ABI) during the first measurement by the first observer were 89.1%, 94.4%, 94.1%, 91.8%, and 92.4%, respectively. The concordance for diagnosing ABI ≤0.90 between methods was excellent (kappa coefficients ranging from 0.80 to 0.88 with different observers). Intra-observer reproducibility assessed by intraclass correlation coefficient (ICC) between methods were 0.94 for observer 1 and 0.96 for observer 2. The intra-observer reproducibility using the same method was also excellent (ICC 0.94, 95% confidence interval [CI] 0.91-0.95) for Dop-ABI and 0.95 (95% CI 0.93-0.97) for Osc-ABI). The ICC for interobserver reproducibility using the same method was 0.95 (95% CI 0.92-0.96) for Dop-ABI and 0.96 (95% CI 0.94-0.97) for Osc-ABI. CONCLUSION: This study validates the excellent diagnostic performances of a four cuff oscillometric device specifically designed for screening for LEAD. The simple measurement method could therefore be advocated in primary care where fast, easy, and reliable methods are suitable.


Assuntos
Índice Tornozelo-Braço/instrumentação , Extremidade Inferior/irrigação sanguínea , Oscilometria/instrumentação , Doença Arterial Periférica/diagnóstico , Ultrassonografia Doppler , Idoso , Idoso de 80 Anos ou mais , Desenho de Equipamento , Feminino , França , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes
8.
Eur J Vasc Endovasc Surg ; 60(5): 687-695, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32778491

RESUMO

OBJECTIVE: The Global Vascular Guideline on chronic limb threatening ischaemia (CLTI) has introduced the Global Limb Anatomic Staging System (GLASS) as a new angiographic scoring system. However, the relationship between GLASS and outcomes following revascularisation has not previously been studied. METHODS: Using pre-intervention angiograms the relationship between GLASS and immediate technical failure (ITF), amputation free survival (AFS), limb salvage (LS), overall survival (OS), and freedom from major adverse limb events (FF-MALE) was examined in 377 patients undergoing endovascular therapy (EVT, n = 213) or bypass surgery (BS, n = 164) in the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL)-1 trial (randomised 1999-2004). RESULTS: There was no significant difference in GLASS between cohorts. There was a significant relationship between ITF and GLASS in EVT (I 14%, II 15%, III 28%, p = .049). GLASS was significantly related to AFS (hazard ratio [HR], 1.37; 95% CI 1.01-1.85; p = .042), LS (HR 1.96; 95 % CI 1.12-3.43; p = .018), and FF-MALE (HR 1.49; 95% CI 1.04-1.87; p = .028) in the EVT cohort. In BS patients, there was no relationship between GLASS and these outcomes. FF-MALE was significantly worse after EVT than BS in GLASS II (p = .038) and III (p = .001). Among the subgroup of patients with femoropopliteal (FP) disease (BS, n = 109 or EVT, n = 159), FF-MALE was significantly higher after BS than EVT (p < .001). The superiority of BS over EVT with increasing GLASS FP grade was greater in the analysis of patients using vein grafts. CONCLUSION: In the BASIL-1 cohort, GLASS is associated with outcomes following EVT but not BS. Although further validation in contemporary CLTI cohorts is required, GLASS seems likely be useful in shared decision making and for stratifying patients in future trials.


Assuntos
Angioplastia/efeitos adversos , Isquemia/diagnóstico , Salvamento de Membro/efeitos adversos , Doença Arterial Periférica/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Enxerto Vascular/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Amputação/estatística & dados numéricos , Feminino , Artéria Femoral/patologia , Artéria Femoral/cirurgia , Seguimentos , Humanos , Isquemia/mortalidade , Isquemia/patologia , Isquemia/cirurgia , Salvamento de Membro/métodos , Extremidade Inferior/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/patologia , Doença Arterial Periférica/cirurgia , Artéria Poplítea/patologia , Artéria Poplítea/cirurgia , Complicações Pós-Operatórias/etiologia , Guias de Prática Clínica como Assunto , Fatores de Risco , Índice de Gravidade de Doença , Resultado do Tratamento
9.
Vascul Pharmacol ; 131: 106764, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32629143

RESUMO

The effects of angiotensin converting enzyme inhibitors and angiotensin receptor blockers (ACEI/ARBs) on angiogenesis, myocardial remodeling and intermittent claudication have been studied. Clinical studies have shown reduced re-intervention after cardiac stenting with the use of ACEI/ARBs. We hypothesized that the use of ACEI/ARBs decreases re-interventions after endovascular revascularization in tibial artery disease (TAD) patients. This is a retrospective study comparing the effects of ACEI/ARBs on the outcomes after endovascular revascularization for TAD. We divided all patients that underwent endovascular revascularization into Angiotensin converting enzyme inhibitor/Angiotensin receptor blockers (ACEI/ARBs) and No Angiotensin converting enzyme inhibitor/Angiotensin receptor blockers (NoACEI/ARBs) groups. A total of 360 patients underwent endovascular intervention for TAD. One hundred and ninety-six (54%) patients, 124 (57%) males, were on ACEI/ARBs after endovascular intervention for TAD, whereas 164(46%) patients, 87 (53%) males were not. The groups were well matched in the demographic variables except higher incidence of congestive heart failure, coronary artery disease and dialysis in the ACEI/ARBs group (p = .001, 0.02, 0.01 respectively). Reintervention rates were not associated with ACEI/ARBs use (p = .097). Even when corrected for statin use and antiplatelet therapy, no difference was seen in the reintervention rates in the two groups (p = .535, 0.547 respectively). Primary patency, assisted primary patency and secondary patency did not differ with the use of ACEI/ARBs (p = .244 0.096,0.060 respectively). No difference was seen in overall survival between the two groups (p = .690). ACEI/ARBs do not appear to affect the patency and reintervention rates for patients undergoing endovascular revascularization for TAD.


Assuntos
Angioplastia com Balão , Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Aterectomia , Células Endoteliais/efeitos dos fármacos , Doença Arterial Periférica/terapia , Reepitelização/efeitos dos fármacos , Artérias da Tíbia/efeitos dos fármacos , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/efeitos adversos , Antagonistas de Receptores de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Aterectomia/efeitos adversos , Células Endoteliais/patologia , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/fisiopatologia , Retratamento , Estudos Retrospectivos , Artérias da Tíbia/patologia , Artérias da Tíbia/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular/efeitos dos fármacos
10.
Am J Physiol Heart Circ Physiol ; 319(2): H456-H467, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32706261

RESUMO

Peripheral artery disease (PAD) is a manifestation of atherosclerosis in the leg arteries, which causes claudication. This may be in part due to vascular mitochondrial dysfunction and excessive reactive oxygen species (ROS) production. A mitochondrial-targeted antioxidant (MitoQ) has been shown to improve vascular mitochondrial function that, in turn, led to improved vascular function in older adults and animal models. However, the roles of vascular mitochondria in vascular function including endothelial function and arterial stiffness in patients with PAD are unknown; therefore, with the use of acute MitoQ intake, this study examined the roles of vascular mitochondria in endothelial function, arterial stiffness, exercise tolerance, and skeletal muscle function in patients with PAD. Eleven patients with PAD received either MitoQ or placebo in a randomized crossover design. At each visit, blood samples, brachial and popliteal artery flow-mediated dilation (FMD), peripheral and central pulse-wave velocity (PWV), blood pressure (BP), maximal walking capacity, time to claudication (COT), and oxygen utility capacity were measured pre- and-post-MitoQ and placebo. There were significant group by time interactions (P < 0.05) for brachial and popliteal FMD that both increased by Δ2.6 and Δ3.3%, respectively, and increases superoxide dismutase (Δ0.03 U/mL), maximal walking time (Δ73.8 s), maximal walking distance (Δ49.3 m), and COT (Δ44.2 s). There were no changes in resting heart rate, BP, malondialdehyde, total antioxidant capacity, PWV, or oxygen utility capacity (P > 0.05). MitoQ intake may be an effective strategy for targeting the vascular mitochondrial environment, which may be useful for restoring endothelial function, leg pain, and walking time in patients with PAD.NEW & NOTEWORTHY The results of this study reveal for the first time that acute oral intake of mitochondrial-targeted antioxidant (MitoQ, 80 mg) is effective for improving vascular endothelial function and superoxide dismutase in patients with peripheral artery disease (PAD). Acute MitoQ intake is also effective for improving maximal walking capacity and delaying the onset of claudication in patients with PAD. These findings suggest that the acute oral intake of MitoQ-mediated improvements in vascular mitochondria play a pivotal role for improving endothelial function, the redox environment, and skeletal muscle performance in PAD.


Assuntos
Antioxidantes/uso terapêutico , Artéria Braquial/efeitos dos fármacos , Endotélio Vascular/efeitos dos fármacos , Tolerância ao Exercício/efeitos dos fármacos , Hemodinâmica/efeitos dos fármacos , Claudicação Intermitente/tratamento farmacológico , Mitocôndrias/efeitos dos fármacos , Compostos Organofosforados/uso terapêutico , Doença Arterial Periférica/tratamento farmacológico , Artéria Poplítea/efeitos dos fármacos , Ubiquinona/análogos & derivados , Idoso , Antioxidantes/metabolismo , Pressão Arterial/efeitos dos fármacos , Artéria Braquial/metabolismo , Artéria Braquial/fisiopatologia , Estudos Cross-Over , Endotélio Vascular/metabolismo , Endotélio Vascular/fisiopatologia , Feminino , Humanos , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/metabolismo , Claudicação Intermitente/fisiopatologia , Masculino , Pessoa de Meia-Idade , Mitocôndrias/metabolismo , Contração Muscular/efeitos dos fármacos , Nebraska , Compostos Organofosforados/metabolismo , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/metabolismo , Doença Arterial Periférica/fisiopatologia , Artéria Poplítea/metabolismo , Artéria Poplítea/fisiopatologia , Recuperação de Função Fisiológica , Fatores de Tempo , Resultado do Tratamento , Ubiquinona/metabolismo , Ubiquinona/uso terapêutico , Rigidez Vascular/efeitos dos fármacos , Caminhada
11.
Arterioscler Thromb Vasc Biol ; 40(9): 2322-2331, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32698688

RESUMO

OBJECTIVE: Inflammatory markers, such as hs-CRP (high-sensitivity C-reactive protein), have been reported to be related to peripheral artery disease (PAD). Galectin-3, a biomarker of fibrosis, has been linked to vascular remodeling and atherogenesis. However, its prospective association with incident PAD is unknown; as is the influence of inflammation on the association between galectin-3 and PAD. Approach and Results: In 9851 Atherosclerosis Risk in Communities Study participants free of PAD at baseline (1996-1998), we quantified the association of galactin-3 and hs-CRP with incident PAD (hospitalizations with PAD diagnosis [International Classification of Diseases-Ninth Revision: 440.2-440.4] or leg revascularization [eg, International Classification of Diseases-Ninth Revision: 38.18]) as well as its severe form, critical limb ischemia (PAD cases with resting pain, ulcer, gangrene, or leg amputation) using Cox models. Over a median follow-up of 17.4 years, there were 316 cases of PAD including 119 critical limb ischemia cases. Log-transformed galectin-3 was associated with incident PAD (adjusted hazard ratio, 1.17 [1.05-1.31] per 1 SD increment) and critical limb ischemia (1.25 [1.05-1.49] per 1 SD increment). The association was slightly attenuated after further adjusting for hs-CRP (1.14 [1.02-1.27] and 1.22 [1.02-1.45], respectively). Log-transformed hs-CRP demonstrated robust associations with PAD and critical limb ischemia even after adjusting for galectin-3 (adjusted hazard ratio per 1 SD increment 1.34 [1.18-1.52] and 1.34 [1.09-1.65], respectively). The addition of galectin-3 and hs-CRP to traditional atherosclerotic predictors (C statistic of the base model 0.843 [0.815-0.871]) improved the risk prediction of PAD (ΔC statistics, 0.011 [0.002-0.020]). CONCLUSIONS: Galectin-3 and hs-CRP were independently associated with incident PAD in the general population, supporting the involvement of fibrosis and inflammation in the pathophysiology of PAD.


Assuntos
Proteína C-Reativa/análise , Galectina 3/sangue , Mediadores da Inflamação/sangue , Claudicação Intermitente/sangue , Isquemia/sangue , Doença Arterial Periférica/sangue , Idoso , Biomarcadores/sangue , Estado Terminal , Feminino , Fibrose , Humanos , Incidência , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/epidemiologia , Claudicação Intermitente/terapia , Isquemia/diagnóstico , Isquemia/epidemiologia , Isquemia/terapia , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/epidemiologia , Doença Arterial Periférica/terapia , Prognóstico , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Estados Unidos
12.
Arterioscler Thromb Vasc Biol ; 40(9): 2018-2032, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32640905

RESUMO

OBJECTIVE: Patients with lower extremity peripheral artery disease (PAD) are at increased risk of major adverse cardiovascular events. Numerous plasma biomarkers have been investigated in lower extremity PAD, but none are used for clinical risk assessment. We aimed to provide a comprehensive overview of biomarker testing in PAD as a first step to improve risk stratification. Approach and Results: A systematic literature review in MEDLINE/PubMed, Cochrane, and Embase was performed, identifying all studies investigating plasma biomarkers in association with cardiovascular events and mortality in lower extremity PAD. Forty-seven studies comprising 21 473 PAD patients met our criteria and were included. Effect estimates were provided by the studies based on a minimum follow-up of 1 year. Meta-analyses were performed by pooling studies per biomarker for each end point. Patients with increased high-sensitivity CRP (C-reactive protein) levels had a relative risk of 1.86 (1.48-2.33) for major adverse cardiovascular events and a relative risk of 3.49 (2.35-5.19) for mortality. Increased fibrinogen and d-dimer levels were associated with an increased relative risk of mortality of 2.08 (1.46-2.97) and 2.22 (1.24-3.98), respectively. Additionally, patients with increased NT-proBNP (N-terminal pro-B-type natriuretic peptide) and high-sensitivity cTnT (cardiac troponin T) levels were at an even higher risk of mortality with relative risks of 4.50 (2.98-6.81) and 3.33 (2.70-4.10), respectively. CONCLUSIONS: This systematic review identifies promising biomarkers representing different pathophysiological processes implicated in lower extremity PAD, including high-sensitivity CRP, neutrophil-lymphocyte ratio, fibrinogen, d-dimer, NT-proBNP, and high-sensitivity cTnT. Clinical implementation should be preceded by a management study to test the utility of a combination of these markers for individual risk stratification. Ultimately, this may contribute to tailored treatment and increased effectiveness of current treatment strategies in PAD.


Assuntos
Biomarcadores/sangue , Doença Arterial Periférica/sangue , Idoso , Tomada de Decisão Clínica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/terapia , Valor Preditivo dos Testes , Prognóstico , Medição de Risco , Fatores de Risco
13.
Vasc Endovascular Surg ; 54(7): 605-611, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32691691

RESUMO

We evaluated the outcome of multimodal supervised exercise training (SET) on walking performances and different hemodynamic parameters (ankle/toe-brachial index [ABI/TBI], and transcutaneous oxygen pressure [TcPO2]) in patients with symptomatic lower extremity peripheral artery disease (PAD). Whether hemodynamic parameters predict walking performances at baseline and following SET was also investigated. Fontaine stage II PAD's patients following a 3-month SET were retrospectively included. Hemodynamic parameters and walking performances (pain-free [PFWD], maximal [MWD], and 6-minute [6MWD] walking distance) were measured in each patient. Eighty-five symptomatic PAD patients were included. Following SET, PFWD, MWD, and 6MWD significantly increased (+142%, +94%, +14%; respectively; P ≤ .001). Toe-brachial index significantly increased (MD: 0.04 ± 0.01; P = .02), whereas ABI and TcPO2 did not change significantly. At baseline, patients with higher TBI and TcPO2 performed significantly better (PFWD: ß = 0.25, P = .01 for TBI; PFWD: ß = 0.30, P = .005, and MWD: ß = 0.22, P = .04, for TcPO2). No significant relationship was observed at baseline between ABI and walking performances. Baseline values of hemodynamic parameters did not significantly correlate with changes in walking performances. Multimodal SET significantly improves walking performances. Following SET, no significant changes in ABI and TcPO2 were observed. Toe-brachial index values significantly improved after SET. However, this increase was very modest and its clinical relevance remains questionable. Although baseline TBI and supine TcPO2 values predict baseline walking performances, no association was found between baseline hemodynamic parameters and changes in walking performances following SET.


Assuntos
Terapia por Exercício/métodos , Tolerância ao Exercício , Hemodinâmica , Claudicação Intermitente/terapia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/terapia , Caminhada , Idoso , Índice Tornozelo-Braço , Monitorização Transcutânea dos Gases Sanguíneos , Feminino , Humanos , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/fisiopatologia , Masculino , Pessoa de Meia-Idade , Força Muscular , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/fisiopatologia , Recuperação de Função Fisiológica , Treinamento de Resistência , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Teste de Caminhada
14.
Cardiovasc Ther ; 2020: 3057168, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32695228

RESUMO

Aims: Acetylsalicylic acid (ASA) is widely used for the prevention of atherothrombotic events in patients with chronic coronary artery disease (CAD) and peripheral artery disease (PAD), but the risk of vascular events remains high. We aimed at identifying randomised controlled trials (RCTs) on antithrombotic treatments in patients with chronic CAD or PAD. Methods: Searches were conducted on MEDLINE, EMBASE, and CENTRAL on March 1st, 2018. This systematic review (SR) uses a narrative synthesis to summarize the evidence for the efficacy and safety of antiplatelet and anticoagulant therapies in the population of both chronic CAD or PAD patients. Results: Four RCTs from 27 publications were included. Study groups included 15,603 to 27,395 patients. ASA alone was the most extensively studied (n = 3); other studies included rivaroxaban with or without ASA (n = 1), vorapaxar alone (n = 1), and clopidogrel with (n = 1) or without ASA (n = 1). Clopidogrel alone and clopidogrel plus ASA compared to ASA presented similar efficacy with comparable safety profile. Rivaroxaban plus ASA significantly reduced the risk of the composite of cardiovascular death, myocardial infarction, and stroke compared to ASA alone, although major bleeding with rivaroxaban plus ASA increased. Conclusion: There is limited and heterogeneous evidence on the prevention of atherothrombotic events in patients with chronic CAD or PAD. Clopidogrel alone and clopidogrel plus ASA did not demonstrate superiority over ASA alone. A combination of rivaroxaban plus ASA may offer significant additional benefit in reducing cardiovascular outcomes, yet it may increase the risk of bleeding, compared to ASA alone.


Assuntos
Anticoagulantes/uso terapêutico , Doença da Artéria Coronariana/tratamento farmacológico , Fibrinolíticos/uso terapêutico , Doença Arterial Periférica/tratamento farmacológico , Inibidores da Agregação de Plaquetas/uso terapêutico , Trombose/prevenção & controle , Idoso , Anticoagulantes/efeitos adversos , Doença Crônica , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/epidemiologia , Terapia Antiplaquetária Dupla , Feminino , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/epidemiologia , Inibidores da Agregação de Plaquetas/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Trombose/diagnóstico , Trombose/epidemiologia , Resultado do Tratamento
15.
PLoS One ; 15(7): e0235228, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32658909

RESUMO

PURPOSE: To assess specific risk factors and biomarkers associated with intimal arterial calcification (IAC) and medial arterial calcification (MAC). METHODS: We conducted a cross-sectional study in patients with or at risk of vascular disease from the SMART study(n = 520) and the DCS cohort(n = 198). Non-contrast computed tomography scanning of the lower extremities was performed and calcification in the femoral and crural arteries was scored as absent, predominant IAC, predominant MAC or indistinguishable. Multinomial regression models were used to assess the associations between cardiovascular risk factors and calcification patterns. Biomarkers for inflammation, calcification and vitamin K status were measured in a subset of patients with IAC(n = 151) and MAC(n = 151). RESULTS: Femoral calcification was found in 77% of the participants, of whom 38% had IAC, 28% had MAC and 11% were scored as indistinguishable. The absolute agreement between the femoral and crural arteries was high(69%). Higher age, male sex, statin use and history of coronary artery disease were associated with higher prevalences of femoral IAC and MAC compared to absence of calcification. Smoking and low ankle-brachial-index (ABI) were associated with higher prevalence of IAC and high ABI was associated with less IAC. Compared to patients with IAC, patients with MAC more often had diabetes, have a high ABI and were less often smokers. Inactive Matrix-Gla Protein was associated with increased MAC prevalence, while osteonectin was associated with decreased risk of MAC, compared to IAC. CONCLUSIONS: When femoral calcification is present, the majority of the patients have IAC or MAC throughout the lower extremity, which have different associated risk factor profiles.


Assuntos
Artéria Femoral/patologia , Doença Arterial Periférica/epidemiologia , Túnica Íntima/patologia , Túnica Média/patologia , Calcificação Vascular/epidemiologia , Idoso , Biomarcadores/sangue , Estudos Transversais , Feminino , Artéria Femoral/diagnóstico por imagem , Humanos , Extremidade Inferior/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/sangue , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/patologia , Prevalência , Medição de Risco , Fatores de Risco , Tomografia Computadorizada por Raios X , Túnica Íntima/diagnóstico por imagem , Túnica Média/diagnóstico por imagem , Calcificação Vascular/sangue , Calcificação Vascular/diagnóstico , Calcificação Vascular/patologia , Vitamina K/sangue
16.
Eur J Vasc Endovasc Surg ; 60(5): 703-710, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32718828

RESUMO

OBJECTIVE: Opportunities for timely recognition of chronic limb-threatening ischaemia (CLTI) within primary care, such as performing cardiovascular assessment during clinical consultation, are possibly being missed. This study aimed to investigate for potential "missed opportunities" within primary care. METHODS: This was a population based cohort study, using the UK's Clinical Practice Research Datalink (CPRD). Patients undergoing a major amputation for CLTI between 1 January 2000 and 31 December 2016 were included. Primary care consultation and patient clinical data within the one year period prior to amputation were extracted from the CPRD. Dates of last primary care consultation and cardiovascular assessment prior to amputation were evaluated. Timings of latest cardiovascular assessments were stratified into "recent" (7-90 days before amputation) and "late" (> 91 days). RESULTS: In total, 3 260 patients were included. In the year prior to amputation, patients attended a median of 19 (range 9-32) primary care consultations; however, prescription of secondary preventive medications was poor (antiplatelet 49.7%; lipid lowering agent 40.7%). Overall, 2 175 patients (66.7%) attended a primary care consultation 7-30 days before their amputation. However, only 416 (12.8%) underwent a cardiovascular assessment within this period, with 2 073 (63.6%) undergoing no assessment within 90 days of their amputation. Of these 2 073 patients, 1 230 (59.3%) had a primary care consultation 7-30 days before their procedure. Patients undergoing "late" assessment were younger (p = .003), with higher systolic (p = .008) and diastolic (p = .001) blood pressures than those undergoing "recent" assessment. Differences were also observed between assessment timings by deprivation (p = .003) and ethnicity (p = .006). CONCLUSION: Missed opportunities for timely recognition potentially exist and may be related to age, deprivation, and ethnicity. Further work is required to investigate these factors, as well as individual amputations to identify the causes precipitating amputation. Greater emphasis on the medical management of peripheral arterial disease and identifying cardiovascular risk factors in patients who may not fit the "at risk" stereotype, are also required.


Assuntos
Amputação/estatística & dados numéricos , Isquemia/diagnóstico , Diagnóstico Ausente/estatística & dados numéricos , Doença Arterial Periférica/diagnóstico , Atenção Primária à Saúde/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Doença Crônica/terapia , Diagnóstico Precoce , Grupos Étnicos/estatística & dados numéricos , Feminino , Humanos , Isquemia/prevenção & controle , Isquemia/cirurgia , Extremidade Inferior/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Diagnóstico Ausente/prevenção & controle , Doença Arterial Periférica/tratamento farmacológico , Doença Arterial Periférica/cirurgia , Encaminhamento e Consulta/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Fatores Socioeconômicos , Reino Unido
17.
J Endovasc Ther ; 27(4): 599-607, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32633651

RESUMO

Purpose: To report the outcomes of bypass grafting (BG) vs endovascular therapy (EVT) in patients with non-dialysis-dependent chronic kidney disease (CKD) and chronic limb-threatening ischemia (CLTI). Materials and Methods: The CRITISCH Registry is a prospective, national, interdisciplinary, multicenter registry evaluating the current practice of all available treatment options in 1200 consecutive CLTI patients. For the purposes of this analysis, only the 337 patients with non-dialysis-dependent CKD treated by either BG (n=86; median 78 years, 48 men) or EVT (n=251; median age 80 years, 135 men) were analyzed. The primary composite outcome was amputation-free survival (AFS); secondary outcomes were overall survival (OS) and amputation-free time (AFT). All outcomes were evaluated in Cox proportional hazards models; the results are reported as the hazard ratio (HR) and 95% confidence interval (CI). Results: The Cox regression analysis revealed a significantly greater hazard of amputation or death after BG (HR 1.78, 95% CI 1.05 to 3.03, p=0.028). The models for AFT and overall survival also suggested a higher hazard for BG, but the differences were not significant (AFT: HR 1.66, 95% CI 0.78 to 3.53, p=0.188; OS: HR 1.41, 95% CI 0.80 to 2.47, p=0.348). The absence of runoff vessels (HR 1.73, 95% CI 1.15 to 2.60, p=0.008) was associated with a decreased AFS. The likelihood of amputation was higher in male patients (HR 2.21, 95% CI 1.10 to 4.45, p=0.027) and was associated with a lack of runoff vessels (HR 1.95, 95% CI 0.96 to 3.95, p=0.065) and myocardial infarction (HR 3.74, 95% CI 1.23 to 11.35, p=0.020). Death was more likely in patients without runoff vessels (HR 1.76, 95% CI 1.11 to 2.80, p=0.016) and those with a higher risk score (HR 1.73, 95% CI 1.03 to 2.91, p=0.038). Conclusion: This analysis suggested that BG was associated with poorer AFS than EVT in patients with non-dialysis-dependent CKD and CLTI. Male sex, previous myocardial infarction, and the absence of runoff vessels were additionally identified as predictors of poorer outcomes.


Assuntos
Procedimentos Endovasculares , Isquemia/terapia , Doença Arterial Periférica/terapia , Insuficiência Renal Crônica/terapia , Enxerto Vascular , Idoso , Idoso de 80 Anos ou mais , Amputação , Doença Crônica , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Alemanha/epidemiologia , Humanos , Isquemia/diagnóstico , Isquemia/mortalidade , Salvamento de Membro , Masculino , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Estudos Prospectivos , Sistema de Registros , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/mortalidade , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidade
18.
PLoS One ; 15(6): e0234065, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32502190

RESUMO

BACKGROUND: The association between sodium-glucose cotransporter 2 inhibitors (SGLT2i's) and lower extremity amputation is unclear. PURPOSE: To systematically review randomized control trials (RCTs) and observational studies quantifying risk of lower extremity amputations associated with SGLT2i use. DATA SOURCES AND STUDY SELECTION: We searched PubMed, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials from January 2011 to February 2020 for RCTs and observational studies including lower extremity amputation outcomes for individuals with type 2 diabetes mellitus treated with SGLT2i's vs. alternative treatments or placebo. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently extracted data. MAIN OUTCOMES AND MEASURES: Our primary outcome was risk of lower limb amputation. Secondary outcomes included peripheral arterial disease, peripheral vascular disease, venous ulcerations, and diabetic foot infections. We also evaluated the risk of bias. We conducted random and fixed effects relative risk meta-analysis of RCTs. RESULTS: After screening 2,006 studies, 12 RCTs and 18 observational studies were included, of which 7 RCTs and 18 observational studies had at least one event. The random effects meta-analysis of 7 RCTs suggested the absence of a statistically significant association between SGLT2i exposure with evidence of substantial statistical heterogeneity (n = 424/23,716 vs n = 267/18,737 in controls; RR 1.28, CI's 0.93-1.76; I2 = 62.0%; p = 0.12) whereas fixed effects analysis showed an increased risk with statistical heterogeneity (RR 1.27, 1.09-1.48; I2 = 62%; p = 0.003). Subgroup analysis of canagliflozin vs placebo showed a statistically significantly increased risk in a fixed effects meta-analysis (n = 2 RCTs, RR 1.59, 1.26-2.01; I2 = 88%; p = 0.0001) whereas the meta-analysis of dapagliflozin or empagliflozin (n = 2 RCTs each) and a single RCT for ertugliflozin did not show a significantly increased risk. The findings from observational studies were too heterogeneous to be pooled in a meta-analysis and draw meaningful conclusions. Both randomized and observational studies were of generally good methodological quality. CONCLUSIONS: Overall, there was no consistent evidence of SGLT2i exposure and increased risk of amputation. The increased risk of amputation seen in the large, long-term Canagliflozin Cardiovascular Assessment Study (CANVAS) trial for canagliflozin, and select observational studies, merits continued exploration.


Assuntos
Amputação , Inibidores do Transportador 2 de Sódio-Glicose/efeitos adversos , Compostos Benzidrílicos/efeitos adversos , Compostos Benzidrílicos/uso terapêutico , Glucosídeos/efeitos adversos , Glucosídeos/uso terapêutico , Humanos , Extremidade Inferior , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Risco , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico , Compostos de Sulfonilureia/efeitos adversos , Compostos de Sulfonilureia/uso terapêutico
19.
Cardiovasc Diabetol ; 19(1): 75, 2020 06 11.
Artigo em Inglês | MEDLINE | ID: mdl-32527273

RESUMO

BACKGROUND: Although an increased arterial stiffness has been associated with traditional coronary risk factors, the risk factors and pathology of arterial stiffness remain unclear. In this study, we aimed to identify the plasma metabolites associated with arterial stiffness in patients with type 2 diabetes mellitus. METHODS: We used the metabolomic data of 209 patients with type 2 diabetes as the first dataset for screening. To form the second dataset for validation, we enlisted an additional 31 individuals with type 2 diabetes. The non-targeted metabolome analysis of fasting plasma samples using gas chromatography coupled with mass spectrometry and the measurement of brachial-ankle pulse wave velocity (baPWV) were performed. RESULTS: A total of 65 annotated metabolites were detected. In the screening dataset, there were statistically significant associations between the baPWV and plasma levels of indoxyl sulfate (r = 0.226, p = 0.001), mannitol (r = 0.178, p = 0.010), mesoerythritol (r = 0.234, p = 0.001), and pyroglutamic acid (r = 0.182, p = 0.008). Multivariate regression analyses revealed that the plasma levels of mesoerythritol were significantly (ß = 0.163, p = 0.025) and that of indoxyl sulfate were marginally (ß = 0.124, p = 0.076) associated with baPWV, even after adjusting for traditional coronary risk factors. In the independent validation dataset, there was a statistically significant association between the baPWV and plasma levels of indoxyl sulfate (r = 0.430, p = 0.016). However, significant associations between the baPWV and plasma levels of the other three metabolites were not confirmed. CONCLUSIONS/INTERPRETATION: The plasma levels of indoxyl sulfate were associated with arterial stiffness in Japanese patients with type 2 diabetes. Although the plasma levels of mannitol, mesoerythritol, and pyroglutamic acid were also associated with arterial stiffness, further investigation is needed to verify the results.


Assuntos
Diabetes Mellitus Tipo 2/sangue , Indicã/sangue , Doença Arterial Periférica/sangue , Rigidez Vascular , Idoso , Índice Tornozelo-Braço , Biomarcadores/sangue , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/fisiopatologia , Eritritol/análogos & derivados , Eritritol/sangue , Feminino , Cromatografia Gasosa-Espectrometria de Massas , Humanos , Masculino , Manitol/sangue , Metabolômica , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/fisiopatologia , Ácido Pirrolidonocarboxílico/sangue
20.
Cardiovasc Diabetol ; 19(1): 97, 2020 06 22.
Artigo em Inglês | MEDLINE | ID: mdl-32571352

RESUMO

BACKGROUND: The influence of intensive glucose control in diabetic patients on the macrovascular outcomes is controversial. Thus, this study aimed to elucidate the effect of preprocedural hemoglobin A1c (HbA1c) on clinical outcomes after endovascular therapy for lower extremity artery disease (LEAD) in diabetic patients. METHODS: Diabetic patients were enrolled from the retrospective cohorts of a Korean multicenter endovascular therapy registry and were divided according to the HbA1c level during index admission into the optimal (< 7.0%) or suboptimal (≥ 7.0%) glycemic control groups. The primary endpoints were major adverse limb events (MALE, a composite of major amputation, minor amputation, and reintervention). RESULTS: Of the 1103 patients enrolled (897 men, mean age 68.2 ± 8.9 years), 432 (39.2%) were classified into the optimal glycemic control group and 671 (60.8%) into the suboptimal glycemic control group. In-hospital events and immediate procedural complications were not different between the two groups. The suboptimal group showed a trend towards a higher incidence of MALE than the optimal group (log-rank p = 0.072). Although no significant differences were found between the two groups in terms of overall survival or amputation, the risk of reintervention was significantly higher in the suboptimal group (log-rank p = 0.048). In the multivariate Cox regression model, suboptimal glycemic control was one of the independent predictors for reintervention. When our data were analyzed according to the initial presentation, suboptimal preprocedural HbA1c significantly increased the incidence of MALE compared with optimal preprocedural HbA1c only in patients with intermittent claudication. CONCLUSION: In diabetic patients undergoing endovascular therapy for LEAD, suboptimal preprocedural HbA1c is associated with an increased risk of adverse limb events, especially in patients with intermittent claudication. Further prospective research will be required to validate the role of more intensive glycemic control on the reduction of adverse limb events in diabetic patients undergoing endovascular therapy for LEAD.


Assuntos
Glicemia/efeitos dos fármacos , Diabetes Mellitus/tratamento farmacológico , Procedimentos Endovasculares , Hipoglicemiantes/uso terapêutico , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/terapia , Idoso , Amputação , Biomarcadores/sangue , Glicemia/metabolismo , Diabetes Mellitus/sangue , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/epidemiologia , Procedimentos Endovasculares/efeitos adversos , Feminino , Hemoglobina A Glicada/metabolismo , Humanos , Hipoglicemiantes/efeitos adversos , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/epidemiologia , Sistema de Registros , República da Coreia/epidemiologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
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