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PubMed1995

Exercise rehabilitation for patients with peripheral arterial disease.

Intermittent claudication, resulting from PAD, impairs functional status. Reducing the disability result from the disease is therefore an important goal of treatment. To evaluate the efficacy of an intervention designed to improve functional status requires that appropriate outcome measures be developed to assess all treatments. Such outcome measures include graded treadmill testing and questionnaire assessment. These methodologies are important because they have a high degree of precision and accuracy and are practical and reproducible. Thus, functional status changes resulting from any intervention can be evaluated, and interventions can be compared with one another using the same methodologies. Currently, interventional therapies are often used to treat a portion of patients with claudication [49]. Such therapies restore blood flow and improve functional status, but with a high associated cost: morbidity and mortality. Pharmacological therapies currently are being developed, but the role of drugs in the overall management of claudication needs further study. Importantly, exercise therapy has been shown in numerous studies to be efficacious and very well tolerated by patients. Patients improve both their walking ability in the laboratory and their community-based functional status. Because of the efficacy of this treatment, in addition to the low associated morbidity, exercise therapy is recommended as a major treatment option for persons with intermittent claudication due to PAD.

Arteriosclerosis↗
PubMedDate not supplied

Ineffective peripheral tissue perfusion: Clinical validation in patients with hypertensive cardiomiopathy.

PURPOSE: To validate defining characteristics of ineffective peripheral tissue perfusion using vasomotor function assessment. METHODS: Twenty-four patients with hypertensive cardiomiopathy were evaluated for 18 defining characteristics of ineffective peripheral tissue perfusion and underwent vasomotor function assessment with induction of reactive hyperemia, intra-arterial infusion of acetylcholine, and pulse wave velocity measurement. The Student's t test and Kruskall-Wallis test were used to assess the significance of relationships between defining characteristics and vasomotor function data. FINDINGS: Diminished lower extremity pulses were associated with diminished forearm blood flow during acetylcholine infusion; left ventricular overload, intermittent claudication, and diminished skin moisture were associated with elevated pulse wave velocity values. CONCLUSION: The defining characteristics of ineffective peripheral tissue perfusion were highly associated with vasomotor function data as "gold standards" for that diagnosis. PRACTICE IMPLICATIONS: Nurses should be able to accurately assess diminished lower extremity pulses, intermittent claudication, and diminished skin moisture as relevant characteristics of ineffective peripheral tissue perfusion in patients with hypertensive cardiomiopathy.

Acetylcholine↗
PubMed1986

The association of dyslipoproteinemia with symptoms and signs of peripheral arterial disease. The Lipid Research Clinics Program Prevalence Study.

Intermittent claudication, leg pain during a graded exercise test (GXT), and resting systolic pressures in the upper and lower extremities were recorded as indicators of peripheral arterial disease at visit 2 of the Lipid Research Clinics (LRC) Prevalence Study. Systolic pressures of the upper and lower extremities were measured in a subsample of participants. We compared lipid levels of persons with and without claudication and with or without GXT-induced leg pain. We also compared lipid levels between groups with high and low arm:ankle systolic blood pressure ratios. Twenty-one (1.0%) men, 10 (1.0%) female nonusers and six (1.0%) female users of gonadal hormones had intermittent claudication determined by standardized questionnaire. Men with claudication had lower high-density lipoprotein (HDL)-cholesterol (35.6 vs 46.4 mg/dl), and their mean triglyceride level and cigarette consumption were higher and regular exercise less frequent. Men with type IIb dyslipoproteinemia were more likely to report claudication. One hundred sixty-nine (4.0%) men, 101 (3.8%) female nonusers, and 47 (4.1%) female users of hormones stopped the GXT because of leg pain. Mean HDL-cholesterol levels were lower for those with GXT-induced leg pain in all three sex-hormone usage groups (42.0 vs 46.9, p less than .001; 53.9 vs 59.4, p less than .001; 65.3 vs 67.2, p = NS) and mean low-density lipoprotein cholesterol levels were higher in those with leg pain on GXT in two of three groups (146.4 vs 146.2, p = NS; 155.7 vs 144.6, p less than .01; 144.4 vs 133.5, p less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1996

Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population.

BACKGROUND: Intermittent claudication is associated with a poor prognosis, but less is known of the risks associated with asymptomatic peripheral arterial disease. The aims of this study were to determine the incidence and natural history of claudication, and the incidence of cardiovascular events in symptomatic and asymptomatic peripheral arterial disease. METHODS: In 1988, 1592 subjects aged 55-74 years were selected randomly from the age-sex register of 10 general practices in Edinburgh, Scotland. The presence of peripheral arterial disease was determined by the World Health Organization questionnaire on intermittent claudication, the ankle brachial pressure index and a reactive hyperaemia test. This cohort was followed prospectively over 5 years for subsequent cardiovascular events and death. RESULTS: One hundred and sixteen new cases of claudication were identified (incidence density 15.5 per 1000 person-years). Of those with claudication at baseline, 28.8% and still had pain after 5 years, 8.2% underwent vascular surgery or amputation, and 1.4% developed leg ulceration. Claudicants had a significantly increased risk of developing angina compared with normals (RR: 2.31, 95% CI: 1.04-5.10), and asymptomatic subjects had a slightly increased risk of myocardial infarction and stroke. Deaths from cardiovascular disease were more likely in both claudicants (RR: 2.67, 95% CI: 1.34-5.29) and subjects with major (RR: 2.08, 95% CI: 1.13-3.83) or minor asymptomatic disease (RR: 1.74, 95% CI: 1.09-2.76). Subjects with major asymptomatic disease also had an increased risk of non-cardiovascular death (RR: 2.19, 95% CI: 1.33-3.59), and therefore had the highest overall risk of death (RR: 2.44, 95% CI: 1.59-3.74). CONCLUSIONS: Subjects with asymptomatic peripheral arterial disease appear to have the same increased risk of cardiovascular events and death found in claudicants.

Aged↗
PubMed1984

Lack of effect of cyclandelate in peripheral arterial disease.

While cyclandelate is widely used in the therapy of peripheral arterial disease, objective evidence of its efficacy remains controversial. For this reason, 12 patients with intermittent claudication (average age of 66.8 years) received both cyclandelate 400 mg qid and placebo in a double-blind crossover trial lasting two months. During the cyclandelate and placebo periods, the following peripheral hemodynamic measurements were obtained using a plethysmograph and treadmill claudication testing: mean calf blood flow, vascular resistance and venous capacitance; finger and toe blood flow, pulsation amplitude and temperature before and after vasodilating maneuvers; arm and leg arterial pulsation amplitudes, one and ten minute calf reactive hyperemia reaction; 30 pound/30 second calf active hyperemia reactions and times of onset of claudication as measured on a treadmill. No major significant difference could be demonstrated between placebo and cyclandelate on any subjective symptom or any objective measurement. It is concluded that cyclandelate 400 mg qid for 4 weeks was of little objective value in treating this group of 12 patients with peripheral arterial disease and suffering from intermittent claudication.

Aged↗
PubMed2000

Nutritional therapy for peripheral arterial disease: a double-blind, placebo-controlled, randomized trial of HeartBar.

We investigated the clinical effects of a food bar enriched with L-arginine and a combination of other nutrients known to enhance the activity of endothelium-derived nitric oxide (EDNO) in individuals with claudication from atherosclerotic peripheral arterial disease. The study was a 2-week, double-blind, placebo-controlled trial of subjects randomized to three groups (two active bars, one active and one placebo bar, and two placebo bars per day) followed by an 8-week open-label period. Subjects (n=41) were outpatient volunteers with intermittent claudication. Pain-free and total walking distances were measured by variable-grade, treadmill exercise testing. Quality of life was assessed using the Medical Outcome Survey (SF-36). After 2 weeks of treatment, the pain-free walking distance increased 66% while the total walking distance increased 23% in the group taking two active bars/day. The general and emotional/social functioning components of the SF-36 also improved. These effects were not observed in the one active bar/day and placebo groups. The effects were maintained after 10 weeks and, in addition, an improvement in walking distance was observed in the group taking one active bar. These findings reveal that use of a nutrient bar designed to enhance EDNO activity improves pain-free and total walking distance as well as quality of life in individuals with intermittent claudication.

Aged↗
PubMed1997

Vascular claudication: how to individualize treatment.

The development of angioplasty and stenting, along with the improvement of surgical procedures, have given physicians more options for treating claudication. However, most patients with intermittent claudication do not need a revascularization procedure, or even angiography. They do need an assessment of their coronary and carotid arteries. We present a treatment approach based on risk factor modification, symptom severity, and the risks and benefits of various procedures.

Adult↗
PubMedDate not supplied

Nine year patent femorotibial expanded polytetrafluoroethylene graft bypass.

A 65-year-old patient with a trophic lesion and severe intermittent claudication in the right lower extremity was surgically treated by femoro-distal-tibial bypass employing a prosthetic 6 mm diameter PTFE (Gore-Tex) graft. It is still patent nine years later as shown by a follow-up arteriogram. The patient's trophic lesion disappeared, and there are presently no symptoms of intermittent claudication. When arterial revascularization in the leg is indicated, an option to a saphenous vein graft for long bypass is the use of a PTFE graft.

Aged↗
PubMed1985

The prevalence of peripheral arterial disease in a defined population.

Because patients with peripheral arterial disease (PAD) may be asymptomatic or may present with atypical symptoms or findings, the true population prevalence of PAD is essentially unknown. We used four highly reliable, sophisticated noninvasive tests (segmental blood pressure, flow velocity by Doppler ultrasound, postocclusive reactive hyperemia, and pulse reappearance half-time) to assess the prevalence of large-vessel PAD and small-vessel PAD in an older (average age 66 years) defined population of 613 men and women. A total of 11.7% of the population had large-vessel PAD on noninvasive testing, and nearly half of those with large-vessel PAD also had small-vessel PAD (5.2%). An additional 16.0% of the population had isolated small-vessel PAD. Large-vessel PAD increased dramatically with age and was slightly more common in men and in subjects with hyperlipidemia. Isolated small-vessel PAD, by contrast, was essentially unrelated to sex, hyperlipidemia, or age, although it was somewhat less common before age 60. Intermittent claudication rates in this population were 2.2% in men and 1.7% in women, and abnormalities in femoral or posterior tibial pulse were present in 20.3% of men and 22.1% of women compared with the noninvasively assessed large-vessel PAD rate of 11.7%. Thus assessment of large-vessel PAD prevalence by intermittent claudication dramatically underestimated the true large-vessel PAD prevalence and assessment by peripheral pulse examination dramatically overestimated the true prevalence.

Adult↗
PubMedDate not supplied

Hostile personality and risks of peripheral arterial disease in the general population.

The relationships between personality and risks of coronary heart disease have been studied widely, but little attention has been paid to other forms of atherosclerotic disease. The objective of this study was to determine relationships in the general population between hostile personality and Type A behavior pattern with asymptomatic and symptomatic chronic peripheral arterial disease. The Edinburgh Artery Study comprises a cross-sectional random sample survey of 1592 men and women aged 55 to 74 years sampled from age-sex registers of 10 general practices throughout the city. Peripheral arterial disease was measured using the WHO questionnaire on intermittent claudication, the ankle brachial pressure index, and a reactive hyperemia test. The Bedford Foulds personality deviance questionnaire was used to elicit extrapunitiveness, intropunitiveness, and dominance (including hostile acts); and the Bortner self-administered questionnaire was used to determine Type A/B personality. Hostile acts increased with severity of peripheral arterial disease; there was a mean score of 13.9 in normals and 14.6 in claudicants (p < .05). An increased risk of claudication associated with a one SD increase in hostile acts was significant (p < .05) only in males, odds ratio, 1.41 (95% confidence interval 1.01, 1.96) and was independent of cigarette smoking, alcohol consumption, obesity, and diabetes mellitus. Dominance was also related to asymptomatic peripheral arterial disease in subjects who had neither intermittent claudication nor angina. Contrary to expectations, Type A personality behaviour scores decreased with the severity of peripheral arterial disease. We conclude that hostile personality may be an independent risk factor for chronic peripheral arterial disease in the general population, particularly among men.

Aged↗
PubMed1999

Microcirculation and tissue metabolism in peripheral arterial disease.

It is now clear that different pathophysiologic mechanisms have a profound influence on the extent of the functional impairment in intermittent claudication. In particular, metabolic derangements, including impaired oxygen delivery and/or extraction, reduced nitric oxide synthesis, reduced glucose oxidation, accumulation of toxic metabolites and reduction in carnitine availability are correlated with disease severity. Therefore, metabolic interventions aimed at counteracting these alterations may represent a valid therapeutic approach to the treatment of this condition. To date, verapamil and L-arginine efficacy has been proven in few patients; a large scale clinical trial, conversely, reports that propionyl-L-carnitine appears to be an effective and well tolerated drug for the treatment of intermittent claudication.

Animals↗
PubMed1996

Medical status and complications in relation to periodontal disease experience in insulin-dependent diabetics.

The aim of this study was to define a population of diabetics exhibiting an increased risk of developing severe periodontitis by comparing the medical status of 2 groups of diabetics, 1 with no/minor periodontal disease and 1 with severe periodontal disease. The case-control study consisted of 2 parts, a baseline study and a follow-up study. 39 case-control pairs were selected. They were adult, long-duration, insulin-dependent diabetics matched according to sex, age and diabetes duration. One individual in each pair (the CASE) exhibited severe periodontal disease while the other (the CONTROL) exhibited gingivitis or only minor alveolar bone loss. The median age of the cases was 58 years (range 36 to 70 years) and of the controls 59 years (range 37 to 69 years). The median disease duration in cases and controls was 24 years and 25 years, respectively. The median follow-up time was 6 years. The medical variables analysed were weight, insulin dose, systolic and diastolic blood pressure, vibratory threshold, triglycerides, total-cholesterol, HDL-cholesterol, creatinine, HbA1, proteinuria, ECG, retinopathy, stroke, transient ischemic attacks (TIA), angina, myocardial infarct, heart failure, hypertension, intermittent claudication, foot ulcer, death, cause of death, and smoking habit. Biochemical analyses and clinical variables used as a routine in the monitoring of diabetics failed to differentiate between diabetics with severe and minor periodontal disease. In the follow-up study, significantly higher prevalences of proteinuria and cardiovascular complications such as stroke, TIA, angina, myocardial infarct and intermittent claudication were found in the case group. An association between renal disease, cardiovascular complications and severe periodontitis seems to exist. This indicates that a closer cooperation between the diabetologist and the dentist is necessary in monitoring the diabetic patient.

Adult↗
PubMed2004

Hypertension in peripheral arterial disease.

Peripheral arterial disease (PAD) of the lower limbs is associated with a high cardiovascular morbidity and mortality. Intermittent claudication is the most common symptomatic manifestation of PAD, but is in its own value an important predictor of cardiovascular death, increasing it by three-fold, and increasing all-cause mortality by two-to-five fold. Hypertension is a risk factor for vascular disorders, including PAD. Of hypertensives at presentation, about 2-5% have intermittent claudication, with increasing prevalence with age. Otherwise, 35-55% of patients with PAD at presentation also show hypertension. Patients who suffer from hypertension with PAD have a greatly increased risk of myocardial infarction and stroke. There is no consensus on the specific treatment of hypertension in PAD because of the limited controlled studies on antihypertensive therapy in such specific PAD population. There is an obvious need of such outcome studies, especially since the two conditions are frequently encountered together. However, as risk is high in all PAD patients, the most important goal remains to decrease the global cardiovascular risk in such patients rather than to focus on the control of blood pressure only and on the reduction of symptoms of PAD. Therefore, treatment with antiplatelet drugs, ACE-inhibitors and statins should be considered.

Animals↗
PubMed2001

Analysis of the cilostazol safety database.

Cilostazol, a type III phosphodiesterase inhibitor, was approved in the United States in 1999 for the reduction of the symptoms of intermittent claudication. This article summarizes the safety data from 8 cilostazol phase 3 controlled clinical trials, involving 2,702 patients: 1,374 receiving cilostazol, 973 assigned to placebo, and 355 taking pentoxifylline. The trials ranged from 12 to 24 weeks in duration. There were a total of 475 patient-exposure years on cilostazol, 357 patient-exposure years on placebo, and 135 patient-exposure years on pentoxifylline. Headache, diarrhea, and other gastrointestinal complaints were seen more often in cilostazol-treated than placebo-treated patients; pharyngitis and nausea were more common in pentoxifylline-treated than placebo-treated patients. Headache requiring discontinuation occurred in 1.3% of patients taking cilostazol 50 mg bid and 3.7% of those receiving cilostazol 100 mg bid, compared with 0.3% of placebo-treated patients. Discontinuations due to diarrhea, palpitations, or myocardial infarction were similar in cilostazol-, placebo-, and pentoxifylline-treated patients. The rate of serious cardiovascular events was similar in all 3 treatment groups. Myocardial infarction occurred in 1.0% of cilostazol-treated, 0.8% of placebo-treated, and 1.1% of pentoxifylline-treated patients. The incidence of stroke was 0.5% in both cilostazol- and placebo-treated patients and 1.1% in pentoxifylline-treated patients. Total cardiovascular morbidity and all-cause mortality was 6.5% for cilostazol 100 mg bid, 6.3% for cilostazol 50 mg bid, and 7.7% for placebo. There were 16 deaths occurring in 0.6%, 0.5%, and 0.6% of cilostazol-, placebo-, and pentoxifylline-treated patients, respectively. The evaluations showed no trend toward increased cardiovascular morbidity or mortality risk in patients receiving cilostazol. In addition, postmarketing surveillance in the United States, representing 70,430 patient-years of cilostazol exposure, has shown minimal accounts of myocardial infarction, stroke, or death. The safety profile of cilostazol in doses of 50 mg bid and 100 mg bid appears to offer an acceptable risk-benefit ratio in patients with intermittent claudication.

Adverse Drug Reaction Reporting Systems↗
PubMed1988

The measurement of atherosclerotic peripheral arterial disease in epidemiological surveys.

In cardiovascular surveys, the WHO questionnaire on intermittent claudication has traditionally been used as a measure of atherosclerotic peripheral arterial disease of the lower limbs. But the questionnaire is of limited value because atherosclerotic disease is frequently asymptomatic. Research on the validity and reliability of the questionnaire and the simpler non-invasive tests of peripheral arterial disease are reviewed. These tests include measurement of the ankle-brachial systolic pressure ratio, a treadmill exercise test, a reactive hyperaemia test, and assessment of toe-pulse reappearance time. The performance of these non-invasive tests is such that they should be used, in conjunction with the intermittent claudication questionnaire, in epidemiological studies of atherosclerotic peripheral arterial disease of the lower limbs.

Arteriosclerosis↗
PubMed2005

Association of anger proneness, depression and low social support with peripheral arterial disease: the Atherosclerosis Risk in Communities Study.

There is mounting evidence to suggest that psychosocial factors, including anger proneness, depression and social isolation, are risk factors for cardiovascular disease. Nevertheless, evidence relating these factors to peripheral arterial disease (PAD) and intermittent claudication remains sparse. Using data from the Atherosclerosis Risk in Communities Study, we analyzed the relationship of psychosocial variables (Spielberger anger score, depression score from the Maastricht questionnaire, and a perceived social support scale) at study visit 2 with incident PAD (ankle-brachial index < or = 0.9; a hospital discharge diagnosis of PAD, leg amputation, or leg revascularization procedures; or intermittent claudication). In 12,965 middle-aged adults with no prior history of PAD, 854 developed PAD over a mean follow-up time of 9.7 years, yielding an incidence rate of 6.8 per 1000 person years. A modest, monotonic dose-response, positive association between anger proneness and incident PAD was observed in a multivariable model: relative risk (RR) = 1.15 (95% confidence interval (CI) 0.99-1.38) in the moderate anger group and RR = 1.38 (95% CI 1.08-1.76) in the high anger group, compared with the low anger group. When compared with a low level of depressive symptoms, moderate and high levels of depressive symptoms were also associated with greater incident PAD, with multi-variable RRs of 1.20 (95% CI 0.99-1.45) and 1.44 (95% CI 1.19-1.74) respectively. There was no association of perceived level of social support with the occurrence of PAD. Anger proneness and depressive symptoms may be associated with the occurrence of PAD, as for other atherosclerotic syndromes. These findings may warrant confirmation in further studies and, if causal, could serve as a unique target for a PAD prevention trial.

Anger↗
PubMed2005

Methylenetetrahydrofolate reductase polymorphism 677C>T is associated with peripheral arterial disease in type 2 diabetes.

BACKGROUND: Individuals with diabetes are twice as likely to develop peripheral arterial disease (PAD), the manifestation of extensive atherosclerosis throughout the lower extremities. One putative determinant of PAD is the 677C>T polymorphism in the gene encoding methylenetetrahydrofolate reductase (MTHFR), which has previously been found to associate with various diabetic complications including retinopathy, nephropathy, atherosclerosis and coronary heart disease. The objective of this study was to investigate a possible role for the MTHFR 677C>T gene polymorphism with PAD in subjects with type 2 diabetes from an isolated aboriginal Canadian population. METHODS: The 677C>T MTHFR gene polymorphism was genotyped in 138 subjects of Oji-Cree descent. Participants were selected from a community-wide survey that included PAD assessment by ankle-brachial index (ABI) measurement, and also intermittent claudication assessment by the Rose questionnaire. RESULTS: MTHFR 677T allele carriers had an increased risk of PAD with an odds ratio of 3.54 (95% CI 1.01, 12.4), P = 0.049, after adjustment for age, sex, duration of diabetes, hypertension, current smoking habits, and use of insulin or oral treatment for diabetes. None of these additional co-variables was significantly associated with PAD. No association was found between MTHFR genotype and intermittent claudication. CONCLUSION: The genetic influence of the MTHFR 677C>T genotype on diabetic PAD is modest, yet for the Oji-Cree it is a major risk factor in comparison to other traditional risk factors.

Brachial Artery↗
PubMed1980

[Reversed vein bypass for the femoro-popliteal axis (author's transl)].

One hundred and twenty nine saphenous femoro-popliteal or infra-popliteal bypass were realised in 125 patients, 55 for very short distance intermittent claudication, 32 for rest pain, 38 for distal gangrene. A one to seven years follow up allows to draw four conclusions: -- In spite of a 4% mortality and a decrease of permeability from 88% at one year to 58% at 5 years, one must consider that in most cases the limb was saved, pain disappeared and the patient was able to work again. -- In case of intermittent claudication, operative indication should be very limited to severe socio-professional disturbance. In contrast, one should not hesitate in case of limb threatening. -- If a thrombosis of the bypass occurs, the spontaneous prognosis is hazardous and the patient should immediately be sent back to the surgical team that first operated. -- Since preventive reoperations have better prognosis than curative reoperations, the authors emphazise the interest of a systematic research of late stenosis or aneurism at the bypass level or up or down in order to correct the trouble prior to acute ischemic complication.

Adult↗