[Physical diagnostics--peripheral arterial disease].
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Algorithms↗
Biomedical subjects
H E Stoffers
Publications and source records attributed to H E Stoffers.
Incidence of and risk factors for asymptomatic peripheral arterial occlusive disease: a longitudinal study.
The current study describes the age- and sex-specific incidence rates and risk factors for asymptomatic and symptomatic peripheral arterial occlusive disease (PAOD) among 2,327 subjects and the incidence of intermittent claudication in asymptomatic PAOD subjects. The study population was selected from 18 general practice centers in the Netherlands. PAOD was assessed with the ankle-brachial blood pressure index, and intermittent claudication was assessed with a modified version of the Rose questionnaire. After 7.2 years, the overall incidence rate for asymptomatic PAOD, using the person-years method, was 9.9 (95% confidence interval (CI): 7.3, 18.8) per 1,000 person-years at risk. The rate was 7.8 (95% CI: 4.9, 20.3) for men and 12.4 (95% CI: 7.7, 24.8) for women. For symptomatic PAOD, the incidence rate was 1.0 (95% CI: 0.7, 7.5) overall, 0.4 (95% CI: 0.3, 10.0) for men, and 1.8 (95% CI: 1.0, 10.3) for women. Multivariate analyses showed that increasing age, smoking, hypertension, and diabetes mellitus were the most important risk factors. The overall incidence rate for intermittent claudication among PAOD subjects who were asymptomatic at baseline was 90.5 per 1,000 person-years at risk (95% CI: 36.4, 378.3). The incidence of asymptomatic PAOD was higher than the incidence of symptomatic PAOD, with women developing PAOD more often than men. In the development of preventive strategies, modification of atherosclerotic risk factors, such as smoking, hypertension, and diabetes, should be the main goals.
Adult↗
A primary care walking exercise program for patients with intermittent claudication.
PURPOSE: In a pilot study, the hypothesis was tested that a home-based walking exercise program with structured coaching would improve walking performance and adherence in patients with intermittent claudication (IC). METHODS: Thirty-one IC patients with a rest ankle-brachial pressure index < 0.90 started a 24-wk walking program in the home environment. They were coached according to the Health Counseling Model (HCM). Patients were instructed to walk at least 9 bouts.wk-1 and to walk through the pain. The main effect measures were pain-free (initial claudication distance (ICD)) and maximum walking distance (absolute claudication distance (ACD)) measured with a graded treadmill test, a corridor exercise test, a walking-diary, and the score on the Walking Impairment Questionnaire (WIQ). RESULTS: Twenty-four participants completed the program. The reported walking frequency was 7.4 times.wk-1. The average ICD improved from 289 m (95% CI, 209-369) to 347 m (95% CI, 244-449) (P < 0.05) and from 241 m (95% CI, 171-310) to 373 m (95% CI, 273-472) on the treadmill and the corridor test, respectively. The average ACD improved from 490 m (95% CI, 397-583) to 544 m (95% CI, 438-650) and from 564 m (95% CI, 412-717) to 726 m (95% CI, 546-906) (P < 0.01) on the treadmill and the corridor test, respectively. The average maximum distance reported in the walking-diary improved from 957 m (95% CI, 291-1623) to 1294 m (95% CI, 646-1941). The score of the walking distance on the WIQ improved from 57% (95% CI, 42-71%) to 60% (95% CI, 46-74%). CONCLUSION: IC patients improved their average ICD and ACD. The walking exercise program in the home environment with coaching according to the HCM seems a promising intervention to be tested in a randomized controlled trial.
Adult↗
Asymptomatic peripheral arterial occlusive disease and erection problems.
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Adult↗
The influence of experience on the reproducibility of the ankle-brachial systolic pressure ratio in peripheral arterial occlusive disease.
OBJECTIVES: to estimate the intra-observer variability of the measurement of the ankle-brachial systolic pressure index (ABPI) and to compare the reproducibility of the measurements by experienced vascular laboratory assistants and by less-experienced general practice personnel. DESIGN: repeated measurement of ABPI by general practitioners (GPs), GP-assistants and vascular laboratory assistants using a pocket Doppler device and a random-zero sphygmomanometer. METHODS AND MATERIALS: ABPI was measured in six patients with various degrees of PAOD by two experienced observers (vascular laboratory assistants) and by 24 less-experienced observers (18 practice assistants, six GPs). RESULTS: the total number of measurements was 354. The overall intra-observer variability estimate was 11.8% ABPI. The intra-observer variability was 7.3% in the experienced observers and 12.0% in the less-experienced observers. The difference of variability between experienced and less-experienced observers was significant. CONCLUSIONS: the ABPI is suitable in follow-up studies where repeated measurements are needed. Differences between measurements can be minimised by performing repeated measurements or by using more experienced observers.
Aged↗
The prognosis of non-critical limb ischaemia: a systematic review of population-based evidence.
BACKGROUND: Peripheral arterial occlusive disease (PAOD) is the most common peripheral vascular disorder in the elderly. A clear picture of the disease's course, especially in patients with non-critical limb ischaemia (Fontaine stages I and II), is essential for the general practitioner, who plays a key role in the diagnosis and management of PAOD. AIM: To evaluate the population-based evidence on the course and prognosis of PAOD. METHODS: An exhaustive literature search yielded 16 population-based studies on the prognosis of PAOD. The methodological qualities of the studies were assessed according to eight criteria. RESULTS: Thirteen studies of high methodological quality show that data on the course, cardiovascular morbidity, and mortality of asymptomatic PAOD are scarce. Only a small group of asymptomatic patients seem to develop intermittent claudication symptoms. However, asymptomatic patients appear to have the same increased risk for cardiovascular morbidity and mortality when compared with claudicants. No data were available on prognostic factors for intermittent claudication and cardiovascular morbidity in asymptomatic patients. The course, cardiovascular morbidity, and mortality of symptomatic PAOD are better documented. A small group of claudicants experience symptom progression. Smoking, hypertension, increasing age, and diabetes are the most relevant risk factors for intermittent claudication. Claudicants are at a higher risk for developing other cardiovascular diseases, resulting in a significantly increased mortality mainly owing to coronary heart disease. Intermittent claudication and a low ankle-brachial pressure index are significant predictors of mortality. Men had intermittent claudication and symptom progression more often than women. Cardiovascular (co-)morbidity was common in both male and female PAOD patients, but male PAOD patients had a higher mortality compared with female PAOD patients. CONCLUSION: Given the current knowledge on the prognosis of PAOD in the general population, an important task for (secondary) prevention is reserved for the general practitioner. Further research is required to document the course and prognosis of asymptomatic PAOD patients.
Adult↗
Risk factors and cardiovascular diseases associated with asymptomatic peripheral arterial occlusive disease. The Limburg PAOD Study. Peripheral Arterial Occlusive Disease.
OBJECTIVES: To describe the risk-factor profile and cardiovascular comorbidity of asymptomatic peripheral arterial occlusive disease (PAOD). DESIGN: A cross-sectional survey. Asymptomatic PAOD was defined as an ankle-brachial pressure index < 0.95, measured on two consecutive occasions, without intermittent claudication. Logistic regression analyses were performed to investigate independent associations between age, gender, smoking status, hypertension, obesity, diabetes, hypercholesterolaemia, physical activity, a family history of cardiovascular disease, the occurrence of ischaemic heart disease and cerebrovascular disease (CeVD) and asymptomatic PAOD. SETTING: 18 general practices in the province of Limburg, the Netherlands. SUBJECTS: A total of 3650 subjects, aged 40-78 years. MAIN RESULTS: Asymptomatic PAOD was present in 8.6% (n = 314) and symptomatic disease in 3.8% (n = 138) of the participants. Age, smoking status, hypertension, and diabetes were significantly associated with asymptomatic PAOD. The ratio of asymptomatic to symptomatic PAOD was higher among the younger age groups. Male gender, hypertension and smoking status were stronger associated with symptomatic PAOD compared with asymptomatic PAOD. Asymptomatic subjects had more IHD and CeVD comorbidity compared with the healthy population. CONCLUSION: Our findings suggest that the risk-factor profile and cardiovascular comorbidity of asymptomatic subjects is comparable to claudicants. Preventive efforts could be made to diminish the influence of especially smoking, diabetes and hypertension in asymptomatic subjects.
Adult↗
Economic evaluation of cholesterol-related interventions in general practice. An appraisal of the evidence.
STUDY OBJECTIVE: To investigate and evaluate published data on cost effectiveness of cholesterol lowering interventions, and how this information could be interpreted in a rational approach of cholesterol management in general practice. DESIGN: A systematic review of the literature. SETTING: No restriction on setting. MATERIALS: Papers reporting on the cost effectiveness or cost utility of prevention of (recurrent) coronary heart disease by reduction of hypercholesterolaemia in adults. MAIN RESULTS: Thirty nine studies, most cost effectiveness analyses, were included. In 24 studies drug interventions only were analysed. Costs of screening to target cholesterol lowering interventions to persons with hypercholesterolaemia were considered in nine studies. Adjustments of the efficacy of the intervention for community effectiveness were described in seven studies. In four studies life years gained were adjusted for quality of life. Despite large variation in the outcomes, there is a constant tendency towards a less favourable cost effectiveness ratio for intervening in persons without coronary heart disease compared with persons with coronary heart disease and for women compared with men. CONCLUSIONS: There is lack of data on cost effectiveness of cholesterol lowering interventions in the general practice setting. The cost effectiveness of cholesterol lowering in general practice deteriorates when all relevant costs are taken into account and when efficacy is corrected for community effectiveness. Cholesterol lowering intervention is more cost effective in men compared with women and in patients with coronary heart disease compared with persons without coronary heart disease. Considerations from cost effectiveness analyses should be incorporated into the development and implementation of national cholesterol guidelines for general practitioners. Standardisation of cost effectiveness studies is important for future economic evaluations.
Coronary Disease↗
The diagnostic value of the measurement of the ankle-brachial systolic pressure index in primary health care.
We investigated the value of the ankle-brachial systolic pressure index (ABPI) as a test for the diagnosis of peripheral arterial occlusive disease (PAOD) in general practice. ABPI measurements on 231 legs of 117 subjects performed in three general practice centers (GPC) were compared with the diagnostic conclusions of a Vascular Laboratory. The optimum cutoff value for the ABPI, its accuracy and diagnostic value were estimated. In a subpopulation of 51 subjects for whom repeated measurements were available, we checked whether taking the mean of three consecutive ABPIs for test outcome would enhance diagnostic performance. Receiver Operating Characteristic analysis showed that overall performance of the GPC ABPI was good (area under the curve approximately 0.9). Performing repeated ABPI measurements was superior to performing a single measurement. The optimum cutoff value for the ABPI was 0.97, associated with a diagnostic odds ratio (OR) of 17 and an accuracy of 81%. In a somewhat more selected subpopulation, the optimum cutoff value was 0.92 (OR 70, accuracy 90%). On the basis of our results, we suggest the following rule of thumb: if the ABPI < 0.8 or if the mean of three ABPIs < 0.9, it is highly probable that PAOD is present (PV+ > or = 95%); if the ABPI > 1.1 or if the mean of three ABPIs > 1.0, PAOD can be ruled out (PV- > or = 99%). In conclusion, in primary health care, the ABPI measurement can be a useful supplementary test in ambiguous diagnostic situations with regard to PAOD.
Adult↗
The prevalence of asymptomatic and unrecognized peripheral arterial occlusive disease.
BACKGROUND: The prevalence of peripheral arterial occlusive disease (PAOD), including asymptomatic cases and cases unknown to the general practitioner (GP) was estimated in 18,884 men and women, aged 45-74 years, on the list of 18 general practice centres (GPC). METHODS: The study population (n = 3171) consisted of a stratified sample of the total population. In the GPC data were collected on intermittent claudication (IC), peripheral pulses, vascular risk factors, cardio- and cerebrovascular disease (CCVD) and the ankle brachial systolic pressure ratio (AB ratio) and PAOD was defined as an AB ratio < 0.95 on two consecutive occasions. Results were recalculated for the total population. RESULTS: The prevalence of PAOD was 6.9 percent (95 percent Cl:5.2-7.9 percent), a quarter of which (1.6 percent) met the classic WHO criteria. Peripheral arterial occlusive disease did not occur significantly more often among men than among women but men suffered more often from an advanced stage of PAOD. Of all PAOD cases, 22 percent were symptomatic. The proportion of symptomatic cases correlated positively with higher age, male gender and lower AB ratio. Among asymptomatic PAOD cases the prevelance of concomitant CCVD was three to four times as high as in the group of subjects without PAOD. Of all PAOD cases 68 percent were unknown to the GP and this group mainly represented less advanced cases of atherosclerosis. However, among PAOD cases with an AB ratio <0.75, 42 percent were unknown to the GP. CONCLUSIONS: Our data on asymptomatic and unknown PAOD cases show that GPs can still enhance their efforts towards (secondary) prevention of atherosclerosis.
Adult↗
Computerized long-menu questions as an alternative to open-ended questions in computerized assessment.
To optimally avoid cueing effects and computer scoring problems in computerized examinations a computerized long-menu question (CLM) was developed. This question type was compared to open-ended questions in one treatment group and to multiple-choice questions in another treatment group. Also, scores were compared to self-perceived computer anxiety of the participants. CLMs yield comparable scores to open-ended questions, but the scores differ significantly from those on multiple-choice tests. Correlations in the first comparison (CLMs with multiple-choice) were higher than those in the second camparison (CLMs with open-ended questions). The amount of positive and negative cueing was considerably higher in the first than in the second comparison. Response times of CLMs were higher than those of multiple-choice questions and open-ended questions, differing significantly from both. Computer anxiety did not influence the mean scores in either comparison. Therefore, in computerized testing CLMs seem to offer an acceptable replacement of open-ended questions.
Adult↗
[Treatment of distal arterial vascular diseases].
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Arterial Occlusive Diseases↗
Diagnostic value of signs and symptoms associated with peripheral arterial occlusive disease seen in general practice: a multivariable approach.
OBJECTIVES: To assess the diagnostic values of single and combined data from the history, physical examination, and medical record with regard to peripheral arterial occlusive disease (PAOD) in patients with leg complaints; to construct a multivariable model for the clinical diagnosis of PAOD by primary care physicians. SETTING: 18 general practice centers in The Netherlands. DESIGN: Cross-sectional comparison of signs, symptoms, and data from the medical record with the independently assessed ankle-brachial systolic pressure index (ABPI; cutoff point < 0.90); analysis: bivariate, multiple logistic regression (MLR). POPULATION: 2,455 individuals with leg complaints, aged 40.7-78.4 years; ABPI < 0.90 present in 9.2% of legs (11.7% of individuals). OUTCOME MEASURES: Clinical variables: sensitivity, specificity, positive and negative predictive values (PV+, PV-), diagnostic odds ratio (OR); models: likelihood ratio test, area under the receiver operating characteristic curve (AUC). RESULTS: Bivariate analysis: highest sensitivity: age more than 60 years (77.3%); highest specificity: wounds or sores on toes and foot (99.7%); highest PV+: typical intermittent claudication (IC) (45.0%) (abnormal foot pulses 41.3%); highest PV-: strong pulses of both foot arteries (97.7%). MRL: the best-performing model (AUC 0.89) consisted of ten clinical variables: gender (OR 1.5), age more than 60 (OR 2.2); IC (OR 3.5); palpation of the skin temperature of the feet (OR 2.5), palpation of both foot pulses [OR 16.4 (abnormal) and 7.0 (doubtful)], auscultation of the femoral artery (OR 3.5); previous diagnosis of IHD (OR 1.7) or diabetes (OR 1.6), history of smoking (OR 2.1), and elevated blood pressure (OR 1.5). The range of predicted probabilities was 0.4-98%. The Hosmer-Lemeshow goodness-of-fit test indicated good overall fit (p = 52). CONCLUSIONS: Palpation of both foot pulses is the key procedure for the clinical diagnosis of PAOD. Traditional clinical evaluation enables the general practitioner to exclude the diagnosis of PAOD in many individuals with a high degree of certainly, to establish the diagnosis in a small group of patients, and to define a limited group of patients where supplementary noninvasive testing is appropriate. The MLR model can be used as a diagnostic checklist and as a reference for the physician's clinical hypothesis.
Adult↗