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PubMed1999

Low rates of preventive practices in patients with peripheral vascular disease.

BACKGROUND: Patients with peripheral vascular disease (PVD) have a three-fold increased risk of myocardial infarction, stroke and death. Recently, a number of therapies have been demonstrated to prevent morbidity or mortality in patients with PVD or other arterial disease. Given the scarcity of data on the preventive practice patterns of this high risk patient group, the in-hospital management of patients admitted to hospital for a peripheral vascular intervention was reviewed. PATIENTS AND METHODS: Charts of 195 patients with a diagnosis of peripheral arteriosclerotic disease (International Classification of Diseases, 9th revision, code 440.2) who were hospitalized at a tertiary care hospital in Ontario between June 1996 and June 1998 were reviewed. RESULTS: The average age of patients admitted was 70.6 years, and 39% of patients were women. The main reason for admission was peripheral artery bypass graft surgery in 88% (172 of 195). Fifty-four per cent (106 of 195) of patients had clinically apparent coronary or cerebrovascular disease, and 92% (180 of 195) of patients had at least one cardiovascular disease risk factor. Fewer than half of all patients (49%) were discharged on any antithrombotic therapy (antiplatelet agent or anticoagulant), and a small proportion of patients were treated with a beta-blocker (20%) and cholesterol-lowering medications (16%). CONCLUSIONS: The leading cause of morbidity and mortality in PVD patients is coronary and cerebrovascular disease. Despite this, the use of proven antithrombotic agents and other cardiac medications is suboptimal. Health professionals need to be aware of the high risk nature of the PVD population and to develop strategies to ensure that patient care is optimized.

Aged↗
PubMed1988

The apoprotein pattern in normolipemic peripheral vascular disease.

The relationship between peripheral vascular disease (PVD) and plasma apoproteins has still not been well defined. The lipid and apoprotein pattern of a group of 20 normolipemic patients affected by peripheral vascular disease has been compared with 20 healthy normolipemic subjects. Mean triglyceride plasma levels were higher in normolipemic patients than in the healthy controls (107.8 +/- 31.5 mg% vs 73.3 +/- 28.6 mg%; p less than 0.03) while mean HDL-cholesterol values were significantly lower (36.5 +/- 5.4 mg% vs 44.4 +/- 7.1 mg%; p less than 0.003). No significant difference was observed between the two groups in the mean values of the apoproteins AI (112.1 +/- 41.2 mg% in PVD vs 117.2 +/- 17.7 mg% in controls), AII (45.1 +/- 12.2 mg% vs 50.1 +/- 11.1 mg%), B (93.7 +/- 23.5 mg% vs 91.3 +/- 21.6 mg%), CII (3.9 +/- 2.6 mg% vs 2.6 +/- 1.7 mg%), CIII (6.7 +/- 1.5 vs 5.9 +/- 1.4 mg%) and E (3.09 +/- 1.4 mg% vs 3.3 +/- 0.9 mg%). On the contrary the mean triglyceride/Apo-E ratio was higher in PVD patients than in the controls (52.3 +/- 42 vs 23.3 +/- +/- 10; p less than 0.03).

Aged↗
PubMed1991

Effect of postural change on common femoral artery volume flow, measured by duplex ultrasound, in normal subjects and patients with peripheral vascular disease.

Regulatory peripheral vasoconstriction occurs in response to adoption of the erect posture. Mildly ischaemic limbs are thought to exhibit near normal responses, but patients with rest pain show increases in blood flow on limb dependency. Previous methods of limb blood flow quantification (xenon clearance and venous occlusion plethysmography) have inherent difficulties when applied in these situations. We studied orthostatic responses in 12 normal subjects (aged 22-74 years (median 52) and 16 patients (aged 21-83 (median 48) with mild and severe peripheral vascular disease, using a duplex flowmeter system. In the normal subjects changes in the 60s mean, common femoral artery volume flow values were as follows (ml min-1 (1 SD]: 77 (83), -78 (116) and -190 (136), for elevation, dependency, and standing respectively. For claudicants (n = 7) the values were 18 (37), -112 (123) and -216 (103) respectively. In rest pain patients (n = 9) the responses were reversed, being -252 (124), 131 (89) and 184 (85) respectively. Significant differences were apparent between elevation, dependency and standing flows in each of the three groups (P less than 0.0001). Normal subject and claudicant responses on elevation and dependency differed significantly (P less than 0.0001 and 0.03 respectively). On standing, the responses were similarly significantly different. The rest pain group displayed characteristically different responses compared with both normal subjects and claudicants for each postural change (P less than 0.0001 in all cases). Duplex ultrasound volume flowmetry is non-invasive and offers an excellent method of quantifying physiological changes.

Adult↗
PubMed1991

Quickscan: Doppler ultrasound emulation of angiography--its value prior to arteriography in peripheral vascular disease.

The prevalence of peripheral vascular disease demands a quick, reliable, non-invasive technique for initial assessment. We have devised a new method which combines the two physical principles that (1) Doppler shift is proportional to blood velocity and (2) blood velocity is inversely proportional to arterial cross-section with the ability to track probe position using a non-contacting method. An image of the probe track and any arterial narrowing is shown superimposed on an outline of the patient. Pressure measurement, scan and graphics with final report take about 20 minutes. The accuracy of this system in peripheral vascular disease was evaluated. Thirty-one patients underwent quickscan (QS) and arteriography within an average time of 7 days. Abdominal aorta, common iliac-common femoral, superficial femoral and popliteal artery segments were graded independently as normal, significant stenosis (greater than 50% of diameter) or occluded by both techniques. Of 197 segments, QS correctly assessed 106 normal, 22 stenosed and 28 occluded segments. Four equivocal angiographic stenoses were normal on QS and three severe stenoses were graded occlusion. Fifteen segments on angiography and five on QS were not assessed. For the iliac and superficial femoral artery segments, sensitivity and specificity averaged 77% and 86%, respectively, for all grades. Aortic statistics were invalid (only one significant lesion). Six out of eight popliteal occlusions were correctly diagnosed by QS, but no popliteal stenoses were detected out of six shown on arteriography. Low numbers may contribute to this discrepancy but an improved popliteal scanning method may be necessary. We find initial QS an invaluable aid to direct percutaneous angiography and to indicate potential sites for angioplasty.

Adult↗
PubMed1984

Effects of two "lipid-lowering" diets on plasma lipid levels of patients with peripheral vascular disease.

Fifty subjects with peripheral vascular disease were randomly assigned to either the American Heart Association Hyperlipidemia Diet C (AHA, N = 23) or a higher fiber, low fat diet based on the Pritikin maintenance diet (HFD, N = 27) and studied for a 12-month period. Diet counseling was provided, and the subjects were encouraged to exercise regularly, to decrease their consumption of salt, alcohol, and caffeine, and to restrict cigarettes as much as possible. Dietary intake data showed that energy distribution was approximately 49% and 64% carbohydrate, 20% and 22% protein, and 31% and 14% fat for the AHA and HFD groups, respectively. Cholesterol and dietary fiber intakes averaged 201 mg and 23 gm per day, respectively, for the AHA group and 108 mg and 43 gm per day, respectively, for the HFD group. Generally, both groups showed tendencies toward decreased serum triglycerides, cholesterol, and LDL cholesterol and increased HDL cholesterol. The HFD group achieved a significant decrease in serum cholesterol (at month 12) (p less than .01). The only significant between-group difference was in serum cholesterol at 4 months (p less than .01), with the lower value in the HFD group. There was a consistent negative correlation between dietary fiber and serum cholesterol levels (p less than .01). Average weight loss was 4.1 kg for the AHA group and 6 kg for the HFD group. We concluded that both dietary regimens, combined with exercise, can be of benefit to patients with peripheral vascular disease.

Aged↗
PubMedDate not supplied

Disease-based assessment of peripheral vascular disease in nursing facility patients.

OBJECTIVE: To determine the frequency of diagnosis of peripheral vascular disease (PVD) and selected related conditions in patients in a nursing facility, to determine the frequency of patients with risk factor(s) for or clinical evidence of PVD but without a diagnosis of PVD or a related condition, and to determine the frequency with which patients with and without a diagnosis of PVD or a related condition were treated with drug and nondrug therapies. DESIGN: A multicenter, disease-based, retrospective evaluation. SETTING: 41 nursing facilities in 6 regions of the US. PATIENTS: 4038 patients in a nursing facility: 827 patients with a PVD or related diagnosis; 2719 patients without a PVD or related diagnosis but with risk factor(s) for or clinical evidence of PVD; and 492 patients without a PVD or related diagnosis, risk factor(s), and clinical evidence. MAIN OUTCOME MEASURES: Evidence of disease and drug therapy for PVD. RESULTS: PVD was documented in 21% of patients; another 67% had risk factor(s) for or clinical evidence of PVD but no diagnosis of PVD or a related condition. Pentoxifylline was prescribed for 3% of the total sample and 12% of patients with PVD or a related condition. CONCLUSIONS: PVD appears to be inadequately evaluated in patients in a nursing facility. Disease treatment strategies should be developed and implemented to educate healthcare professionals and the general public about the need to acknowledge, assess, and treat PVD and related conditions.

Adult↗
PubMed1994

Coronary artery disease is highly prevalent among patients with premature peripheral vascular disease.

PURPOSE: This study was designed to document the prevalence of coronary artery disease (CAD) and associated cardiac complications among patients with symptoms of premature peripheral vascular disease. METHODS: We studied the peripheral and coronary arterial circulations of 59 consecutive male military veterans diagnosed with premature peripheral vascular disease (age of onset < or = 45 years) affecting the lower extremity. Patients who had not previously undergone coronary angiography underwent exercise stress testing. Patients unable to perform exercise testing and those with abnormal exercise test results underwent coronary angiography. RESULTS: There was no evidence of CAD in 16 patients (29%) on the basis of normal exercise test results (n = 12) or normal coronary angiography results (n = 4). Forty-three patients (71%) had significant (> or = 50% lesion) CAD by coronary catheterization. Cardiac complications were frequent among the 43 patients. Eleven (65%) of the 17 patients with single-vessel CAD had previously documented myocardial infarctions, as did three (75%) of the four patients with two-vessel CAD and 18 (82%) of the 22 patients with three vessel or greater CAD. Three (18%) patients with one-vessel CAD had undergone coronary artery bypass grafting or percutaneous transluminal coronary angioplasty for symptoms, as had one patient (25%) with two-vessel CAD and 19 patients (86%) with three-vessel or greater CAD. Five patients died during the study period, four of myocardial infarction and one of stroke. CONCLUSIONS: Premature peripheral atherosclerosis is associated with a high prevalence of CAD. Detection of CAD is important in this group, because cardiac complications are frequent.

Adult↗
PubMedDate not supplied

Peripheral vascular disease.

This article discusses peripheral vascular disease and its associated risk factors. It outlines clinical patient assessment, medical interventions and the role of the nurse in secondary prevention.

Education, Nursing, Continuing↗
PubMed1995

Surgical therapy for coronary artery disease among patients with combined coronary artery and peripheral vascular disease.

BACKGROUND: Among patients with combined coronary artery and peripheral vascular disease, long-term benefits of surgical therapy compared with medical therapy for coronary artery disease are unknown. METHODS AND RESULTS: Using prospectively collected data from the Coronary Artery Surgery Study registry, we performed a retrospective cohort analysis of 1834 patients (mean age, 56 years; 20% women) with both coronary artery and peripheral vascular disease and evaluated their long-term outcomes. Of these patients, 986 received (nonrandomly) coronary artery bypass graft surgery, and 848 were treated medically. Perioperative mortality was 4.2% (2.9% in the absence of peripheral vascular disease; P = .02). In a mean follow-up period of 10.4 years, 1100 deaths occurred (80% due to cardiovascular causes). For the surgical group, 4-, 8-, 12-, and 16-year estimated probabilities of survival were 88%, 72%, 55%, and 41%, respectively, and 73%, 57%, 44%, and 34%, respectively, for the medical group (P < .0001). Multivariate analysis demonstrated that type of therapy was independently associated with survival (P = .0001; chi 2 = 15.34). Subgroup analysis suggested that benefits of surgical treatment on survival were limited to patients with three-vessel coronary artery disease and were inversely related to ejection fraction. Survival free of death or myocardial infarction was also significantly better among the surgical group. Type of therapy was significantly associated with occurrence of late events (P = .01; chi 2 = 6.55). Subgroup analysis again demonstrated that beneficial effects of surgery were limited to patients with three-vessel coronary artery disease and were inversely related to ejection fraction. CONCLUSIONS: Surgical treatment provides long-term benefit for certain subgroups of patients with combined coronary artery and peripheral arterial vascular disease.

Coronary Disease↗
PubMed1997

A comparison between aspirin and pentoxifylline in relieving claudication due to peripheral vascular disease in the elderly.

Peripheral vascular disease (PVD) commonly presents with leg claudication during walking and eventually limits the walking distance and daily activities. Aspirin or pentoxifylline are commonly prescribed to improve blood flow. Aspirin works through its antiplatelet aggregation mechanism, and pentoxifylline increases the red blood cell flexibility, which leads to increased tissue perfusion. Data on comparative studies of these drugs for improving claudication in the elderly are limited. The objective of this study was to compare pain relief offered by either aspirin or pentoxifylline for walking leg pain in the elderly with PVD. Patients sixty-five years or older with claudication were randomly assigned to receive aspirin or pentoxifylline. Their reported level of walking claudication pain with use of the visual analogue scale (0-5) and the distance walked during exercises were recorded. Six weeks later the same parameters were recorded and results were compared with Student's t test, and a P value less than 0.05 was considered a statistically significant difference. Of the 90 patients who participated, 45 received aspirin (325 mg daily) and 45 were prescribed pentoxifylline (400 mg tid) for six weeks. Both the aspirin and the pentoxifylline groups reported a moderate level of pain (2/5) and remained about the same (2/5 for aspirin and 1/5 for pentoxifylline, P = 0.9, NS) after six weeks. However, the pentoxifylline group reported a farther walking distance of 2 miles compared with the aspirin group of 1.2 miles (P < 0.05). The level of pain did not change significantly with either aspirin or pentoxifylline, but the walking distance was farther with the pentoxifylline group.

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PubMed2006

Incidental renal artery stenosis is an independent predictor of mortality in patients with peripheral vascular disease.

In patients with peripheral vascular disease (PVD), mortality is high and renal artery stenosis (RAS) is a frequent incidental finding. RAS carries a high risk for mortality, but whether incidentally discovered RAS is a risk factor for mortality is unknown. The prognostic impact of incidental RAS for mortality was studied in 550 consecutive patients who underwent intra-arterial digital subtraction angiography for PVD in a single center between 1997 and 2000. In 491 patients (336 men, 155 women; mean follow-up 3.8 +/- 1.9 yr), the renal arteries were visualized and follow-up data were available. RAS (diameter reduction > 50%) was present in 26% of the patients. Mortality in the RAS group was 59 versus 28% in the non-RAS group (odds ratio 3.8; 95% confidence interval 2.5 to 5.7; P < 0.0001). Diabetes, previous myocardial infarction, history of PVD, stroke, and hypertension were more frequent in the RAS group; age was higher and GFR was lower in the RAS group. Therefore, RAS was associated with elevated mortality and increased prevalence of cardiovascular risk factors. Cox regression analysis showed that RAS was an independent predictor for mortality (P = 0.005), along with age, diabetes, smoking, previous myocardial infarction, history of PVD, and stroke. In patients who were evaluated for PVD by digital subtraction angiography, mortality was high. Incidental RAS was a frequent finding and an independent predictor for mortality. Whether RAS is a marker for or, alternatively, a mediator of the poor prognosis and whether prognosis can be improved by specific intervention should be the subject of future prospective studies.

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PubMed2004

Differences in diabetic co-morbidity between Aboriginal and non-Aboriginal people living in Bella Coola, Canada.

INTRODUCTION OBJECTIVES: (1) To identify which medical disorders are significantly associated with being a diabetic in the setting of an isolated, rural community; and (2) to determine if there are differences between Aboriginal and non-Aboriginal diabetics. METHODS DESIGN: population based retrospective chart review. STUDY POPULATION: people living in the Bella Coola Valley, Canada, and having a chart at the Bella Coola Medical Clinic as at September 2001. MAIN OUTCOME MEASURES: known diabetes related co-morbidity (retinopathy, nephropathy, coronary artery disease, peripheral vascular disease, neuropathy). RESULTS: There were 126 adult (>18 years old) diabetics living in the Bella Coola Valley. Prevalence rates for history of alcohol issues, retinopathy, coronary artery disease, cerebrovascular disease, peripheral vascular disease, peripheral neuropathy, hypertension, hypercholesterolemia, and nephropathy were 44%, 14%, 19%, 8%, 7%, 10%, 54%, 47%, and 7% respectively. For the 1597 non-diabetics living in the Bella Coola Valley, respective prevalence rates for these same co-morbidities were 20%, 0.3%, 2%, 1.5%, 1%, 1%, 10%, 6%, and 0.6%. The study did not demonstrate that Aboriginal people living in the Bella Coola Valley have an increased prevalence of diabetes associated co-morbidities over and above that found in the non-Aboriginal diabetic population. This was despite the fact the smoking rate was higher in the Aboriginal population. CONCLUSIONS: The development of diabetes in both Aboriginal and non-Aboriginal people living in the Bella Coola Valley was clearly associated with the presence of multiple co-morbidities, including hypertension, hypercholesterolemia, coronary artery disease, cerebrovascular disease, and neuropathy. Rates of diabetes associated co-morbidities were similar for both Aboriginal and non-Aboriginal diabetic populations. The authors speculate that a diet rich in fish oils (omega-3 fatty acids) accounted for the lower than expected rates of cardiovascular disease among this Aboriginal population.

Journal Article↗
PubMed2002

Prospective multicentre study of the natural history of atherosclerotic renal artery stenosis in patients with peripheral vascular disease.

BACKGROUND: Many patients with peripheral vascular disease have coincident renal artery stenosis. The present study characterized the natural history of the condition. METHODS: Some 98 patients (71 men) with more than 50 per cent atherosclerotic renal artery stenosis (unilateral 64, bilateral 34) were recruited prospectively. Measurements of serum creatinine, blood pressure and renal size were recorded at baseline and every 6 months, for a minimum of 2 years. RESULTS: Data were available for 85 patients with a minimum follow-up of 2 years. The mean age was 71 (range 51-87) years. All 52 patients with unilateral renal artery stenosis were managed conservatively (group 1); 21 of the 33 patients with bilateral disease had no intervention (group 2) and the remaining 12 had angioplasty or reconstruction (group 3). The overall mortality rate was 32 per cent at 2 years (27 patients) and this was similar in all three groups. In only three patients was death related directly to renovascular disease; coronary disease accounted for the majority of deaths. All three patients who needed dialysis died within 1 year. In survivors from groups 1 and 3 there was a significant increase in serum creatinine concentration at follow-up. Blood pressure did not increase significantly. CONCLUSION: Patients with renal artery stenosis and peripheral vascular disease had a poor prognosis, but this was not directly attributable to renal failure.

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PubMedDate not supplied

Noninvasive testing in the evaluation of peripheral vascular disease.

Noninvasive testing for peripheral vascular disease is a simple and painless method to detect and localize arterial and venous pathology. It is recommended for clients experiencing symptoms of muscle or tissue ischemia and for clients who have a history of atherosclerosis prior to any operative procedure of the lower extremity where the potential for healing is in question. Postoperatively, noninvasive testing is used to assess graft patency after lower extremity revascularization. Venous evaluation for deep vein thrombosis is also performed. This article discusses techniques involved in noninvasive testing.

Exercise Test↗