High prevalence of peripheral arterial disease in hypertensive patients: the Evaluation of Ankle-Brachial Index in Hungarian Hypertensives screening program Using ankle-brachial index to detect peripheral arterial disease: prevalence and associated risk factors in a random population sample. Distribution of ankle—brachial index and the risk factors of peripheral artery disease in a multi-ethnic Asian population Mortality and Vascular Morbidity in Older Adults With Asymptomatic Versus Symptomatic Peripheral Artery Disease Effect of nebivolol vs. hydrochlorothiazide on the walking capacity in hypertensive patients with intermittent claudication Microalbuminuria and peripheral arterial disease are independent predictors of cardiovascular and all-cause mortality, especially among hypertensive subjects: five-year follow-up of the Hoorn Study. Ten Year Mortality in Different Peripheral Arterial Disease Stages: A Population Based Observational Study on Outcome. Screening of unrecognized peripheral arterial disease (PAD) using ankle-brachial index in high cardiovascular risk patients free from symptomatic PAD. Peripheral Arterial Disease as an Independent Predictor for Excess Stroke Morbidity and Mortality in Primary-Care Patients: 5-Year Results of the getABI Study Cardioprotective medication is associated with improved survival in patients with peripheral arterial disease. Mortality over four years in SHEP participants with a low ankle-arm index. Prevalence of Peripheral Arterial Disease and Related Risk Factors in an Urban Mexican Population Prevention of serious vascular events by aspirin amongst patients with peripheral arterial disease: randomized, double-blind trial. Telmisartan improves absolute walking distance and endothelial function in patients with peripheral artery disease Cognitive-behavioral treatment of women's body-image dissatisfaction. Outcomes Among Hypertensive Patients With Concomitant Peripheral and Coronary Artery Disease: Findings From the INternational VErapamil-SR/Trandolapril STudy Ankle-brachial index and the incidence of cardiovascular events in the Mediterranean low cardiovascular risk population ARTPER cohort A population-based study of peripheral arterial disease prevalence with special focus on critical limb ischemia and sex differences. Asymmetric dimethylarginine correlates with measures of disease severity, major adverse cardiovascular events and all-cause mortality in patients with peripheral arterial disease Functional decline in peripheral arterial disease: associations with the ankle brachial index and leg symptoms. Ankle–Brachial Index Screening for Peripheral Artery Disease in Asymptomatic Patients between 50 and 70 Years of Age Low-Density Lipoprotein Cholesterol Lowering With Evolocumab and Outcomes in Patients With Peripheral Artery Disease: Insights From the FOURIER Trial (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk) Autologous Bone-Marrow Mononuclear Cell Implantation Reduces Long-Term Major Amputation Risk in Patients With Critical Limb Ischemia: A Comparison of Atherosclerotic Peripheral Arterial Disease and Buerger Disease
Aims : Peripheral arterial disease ( PAD ) can be diagnosed in asymptomatic stage , measuring ankle-brachial index ( ABI ) . Low ABI is an indicator of increased cardiovascular risk and its inclusion to traditional risk factors can improve risk prediction . The objective of the present cross-sectional part of our large-scale , multicenter , observational study was to evaluate the prevalence of PAD in a large cohort of hypertensive patients . Methods and results : A total of 21 892 hypertensive men and women ( 9162 men ; mean age 61.45 years ) were included in our prospect i ve study in hypertension clinics . Clinical history , physical examination , and blood analysis were taken , and the ABI was measured with the Doppler method in all patients . The prevalence of PAD ( ABI ⩽0.9 ) was 14.4 % . In 15.6 % of the patients an ABI of 0.91–0.99 , and in 9.4 % of the patients high ABI ( > 1.3 ) was measured . In the low , moderate , high , and very high Systematic Coronary Risk Evaluation risk groups , the prevalence of low ABI was 8.1 , 11.1 , 16.3 , and 26 % , respectively . The prevalence of PAD was lower in hypertensive patients achieving their blood pressure target ( 9.6 vs. 16.8 % ; P < 0.001 ) . Conclusions : Asymptomatic PAD was highly prevalent in the studied hypertensive population . The use of ABI screening may improve cardiovascular risk prediction . Optimal blood pressure goal values in PAD patients and cardiovascular morbidity/mortality data will be evaluated after the 5-year long prospect i ve phase of the Evaluation of Ankle-Brachial Index in Hungarian Hypertensives program BACKGROUND AND AIM The ankle-brachial index ( ABI ) is being used increasingly to diagnose peripheral arterial disease ( PAD ) that predicts cardiovascular morbidity and mortality . The aim of this study is to determine the prevalence of PAD  and associated risk factors in a Spanish r and om population sample of age > or = 40 . METHODS AND RESULTS PAD is defined as an ABI<0.9 in either leg . 784 participants of age > or = 40 were r and omly selected in a Spanish province . 55.4 % of them were female . The prevalence of PAD in this sample was 10.5 % ( 95 % confidence interval ( CI ) 8.4 - 12.8 ) ; 9.7 % in females and 11.4 % in males . In logistic regression analyses , adjusted for age and gender , smoking per 10 pack-years ( odds ratio ( OR ) 1.40 , 95 % CI 1.23 - 1.58 ) , hypertension ( OR 1.85 , 95 % CI 1.05 - 3.28 ) , hypercholesterolemia ( OR 1.76 , 95 % CI 1.04 - 2.98 ) , and diabetes ( OR 1.80 , 95 % CI 1.04 - 3.11 ) were positively associated with prevalent PAD . More than 91 % of persons with PAD had one or more cardiovascular disease risk factors . CONCLUSIONS We conclude that in our study hypertension , hypercholesterolemia , diabetes mellitus and smoking are associated with PAD . The majority of individuals with PAD had at least one important cardiovascular risk factor advanced enough to be considered eligible for an aggressive treatment Peripheral artery disease ( PAD ) is a manifestation of systemic atherosclerosis and is associated with increased cardiovascular morbidity and mortality . We describe the prevalence and risk factors of PAD in a multi-ethnic Asian population ( Chinese , Malays and Indians ) in Singapore . The Singapore Prospect i ve Study Program recruited 4132 individuals between 2004 and 2006 in which the ankle — brachial index ( ABI ) was measured using the  Smartdop ™ 20EX bi-directional blood flow detector . PAD was defined as ≤ 0.9 and a high ABI > 1.4 , with ABI 1.11—1.20 as reference . The mean age ( SD ) of individuals in the study was 49.9 ( 11.8 ) years , with 51.8 % females . PAD was present in 4.3 % of the population and a high ABI ( > 1.4 ) was rare . Malays and Indians had a higher risk ( especially in females ) . Compared to those with an ABI between 1.11 and 1.20 , those with PAD were more likely to be of Malay and Indian ethnicity , female sex , with higher systolic blood pressure and pulse pressure , with increased prevalence of diabetes mellitus , hypertension , albuminuria and renal impairment , and with a past history of stroke . In conclusion , in this large multi-ethnic Asian population , we document the distribution and risk factor associations for PAD . PAD shows an ethnic distribution similar to that of coronary artery disease in Singapore , with differences in sex distribution . Apart from traditional vascular risk factors , pulse pressure , renal impairment and a past history of stroke are important determinants of PAD Background — Our aim was to assess the mortality and vascular morbidity risk of elderly individuals with asymptomatic versus symptomatic peripheral artery disease ( PAD ) in the primary care setting . Methods and Results — This prospect i ve cohort study included 6880 representative unselected patients ≥65 years of age with monitored follow-up over 5 years . According to physician diagnosis , 5392 patients had no PAD , 836 had asymptomatic PAD ( ankle brachial index < 0.9 without symptoms ) , and 593 had symptomatic PAD ( lower-extremity peripheral revascularization , amputation as  a  result  of PAD , or intermittent claudication symptoms regardless of ankle brachial index ) . The risk of symptomatic compared with asymptomatic PAD patients was significantly increased for the composite of all-cause death or severe vascular event ( myocardial infa rct ion , coronary revascularization , stroke , carotid revascularization , or lower-extremity peripheral vascular events ; hazard ratio , 1.48 ; 95 % confidence interval , 1.21 to 1.80 ) but not for all-cause death alone ( hazard ratio , 1.13 ; 95 % confidence interval , 0.89 to 1.43 ) , all-cause death/myocardial infa rct ion/stroke ( excluding lower-extremity peripheral vascular events and any revascularizations ; hazard ratio , 1.18 ; 95 % confidence interval , 0.92 to 1.52 ) , cardiovascular events alone ( hazard ratio , 1.20 ; 95 % confidence interval , 0.89 to 1.60 ) , or cerebrovascular events alone ( hazard ratio , 1.33 ; 95 % confidence interval , 0.80 to 2.20 ) . Lower ankle brachial index categories were associated with increased risk . PAD was a strong factor for the prediction of the composite end point in an adjusted model . Conclusions — Asymptomatic PAD diagnosed through routine screening in the offices of primary care physicians carries a high mortality and /or vascular event risk . Notably , the risk of mortality was similar in symptomatic and asymptomatic patients with PAD and was significantly higher than in those without PAD . In the primary care setting , the diagnosis of PAD has important prognostic value Aims Whereas product labels of beta blockers list peripheral arterial disease ( PAD ) as a contraindication , current PAD guidelines state otherwise . We aim ed to evaluate the clinical efficacy and safety of the ß1 selective blocker nebivolol in hypertensive patients with PAD . Methods and results This multicentre , prospect i ve , double-blind , active controlled , parallel-group study compared once-daily treatment with nebivolol ( Neb ) 5 mg vs. hydrochlorothiazide ( HCTZ ) 25 mg , in hypertensive patients with Fontaine stage II ( intermittent claudication ) . The primary endpoint was the initial claudication distance ( ICD ) during treadmill exercise after 24-week treatment in the per protocol population , using a noninferiority statistical approach . A total of 177 patients ( mean age was 66.3 ± 9.2 years , 76.7 % men ) were r and omized to study treatment and 127 completed the study ; the intent-to-treat ( ITT ) analysis was performed on 163 patients , the per protocol analysis on 127 patients . Both drugs lowered blood pressure significantly . After 24-week treatment , ICD increased in the Neb group in the ITT population by 28.3 % ( 95 % CI 15.6–41.0 ) vs. in the HCTZ group by 26.5 % ( 14.4–38.5 ) , and in the per protocol population in the Neb group by 26.4 % ( 13.4–39.4 ) vs. in the HCTZ group by 32.1 % ( 18.4–45.7 ) . Thus , noninferiority of Neb could neither be confirmed nor rejected . An increase of absolute claudication distance ( ACD , mean percentage increase after 24 weeks on Neb 15.8 ± 33.2 vs. on HCTZ 20.2 ± 46.6 ) was observed without statistical differences between groups . Ankle-brachial index ( ABI ) increased slightly in both groups . Generally , both treatments were well tolerated . Conclusion The increases in ICD , ACD and ABI with nebivolol suggest that this medication does not have negative effects on hypertensive patients with symptomatic PAD , and can be used for treatment of hypertension in these patients at high cardiovascular risk without reducing the walking ability Microalbuminuria ( MA ) is associated with increased  cardiovascular and all-cause mortality .  It has been proposed that MA reflects generalized atherosclerosis and may thus predict mortality . To investigate this hypothesis , we studied the associations between , on the one h and , MA and peripheral arterial disease ( PAD ) , a generally accepted marker of generalized atherosclerosis , and , on the other h and , cardiovascular and all-cause mortality in an age- , sex- , and glucose tolerance-stratified sample ( n=631 ) of a population -based cohort aged 50 to 75 years followed prospect ively for 5 years . At baseline , the  albumin-to-creatinine ratio ( ACR ) was measured in an overnight spot urine sample ; MA was defined as ACR > 2.0 mg/mmol . PAD was defined as an ankle-brachial pressure index below 0.90 and /or a history of a peripheral arterial bypass or amputation . After 5 years of follow-up , 58 subjects had died ( 24 of cardiovascular causes ) . Both MA and PAD were associated with a 4-fold increase in cardiovascular mortality . After adjusting for age , sex , diabetes mellitus , hypertension , levels of total and HDL-cholesterol and triglyceride , body mass index , smoking habits , and preexistent ischemic heart disease , the relative risks ( RR ) ( 95 % confidence intervals ) were 3.2 ( 1.3 to 8.1 ) for MA and 2.4 ( 0.9 to 6.1 ) for PAD . When both MA and PAD were included in the multivariate analysis , the RRs were 2.9 ( 1.1 to 7.3 ) for MA and 2.0 ( 0.7 to 5.7 ) for PAD . MA and PAD were both associated with an about 2-fold increase in all-cause mortality . The RRs of all-cause mortality associated with MA and PAD were about 4 times higher among hypertensive than among normotensive subjects . We conclude that both MA and PAD are associated with an increased risk of cardiovascular mortality . MA and PAD are mutually independent risk indicators . The associations of MA and PAD with all-cause mortality are somewhat weaker . They are more pronounced in the presence of hypertension than in its absence . These data suggest that MA affects mortality risk through a mechanism different from generalized atherosclerosis OBJECTIVE The aim was to determine long-term mortality rates and the underlying cause of death for subjects with different peripheral arterial disease ( PAD ) stages in a population based setting . METHODS A r and omly selected population sample of 5080 subjects was enrolled in the study in 2004 - 2005 . Participants completed health state question naires and underwent ankle brachial index ( ABI ) measurements for classification into PAD severity stages and reference subjects . A follow-up was conducted by the end of 2015 using data from Swedish governmental national registers for cause of death , which was then compared with PAD stage determined at baseline in 2005 . RESULTS The 10 year all cause mortality was 27 % for reference cases , 56 % for asymptomatic PAD ( APAD ) , 63 % for intermittent claudication ( IC ) , and 75 % for severe limb ischaemia ( SLI ) . Among all PAD subjects , cardiovascular ( CV ) causes were the most common main cause of death ( 45 % ) and a CV event was present as either the main or one of the three most common contributing causes of death in 64 % of the cases . The age adjusted hazard ratios for a main cause of death by a CV event were 1.9 ( 95 % CI 1.5 - 2.3 ) for APAD , 2.6 ( 95 % CI 2.1 - 3.4 ) for IC , and 3.5 ( 95 % CI 2.3 - 5.2 ) for SLI . CONCLUSION PAD subjects , including the APAD subjects , are still at high risk of CV death . The mortality risks are more than doubled in symptomatic PAD patients compared with reference subjects and increase by severity of PAD stage . Awareness and improved risk reduction management of PAD are still warranted OBJECTIVE To determine the utility of  ankle-brachial index ( ABI )  in screening for unrecognized peripheral arterial disease ( PAD ) . Although PAD is a consistent predictor of cardiovascular morbidity and mortality , it is often under-diagnosed and under-treated . METHODS In this prospect i ve , observational , real-life , epidemiologic study ( ELLIPSE ) the prevalence of  PAD ( ABI < 0.9 )  was calculated in 2146 asymptomatic patients > or = 55 years of age who were at high cardiovascular risk and who were hospitalized in departments of cardiology , diabetology , geriatrics , internal medicine , or neurology in metropolitan France .  Univariate and multivariate analyses were performed to identify PAD risk factors . The discriminatory power of the model was evaluated by calculating the area under the curve ( AUC ) of the receiver operating characteristic curve . RESULTS The ABI was < 0.9 in 41.1 % of patients . In the multivariate analysis , absence of > or = 1 pulse ( odds ratio [ OR ] , 2.18 ; 95 % confidence interval [ CI ] , 1.81 to 2.63 ; P < .0001 ) , arterial bruit ( OR , 1.92 ; 95%CI , 1.34 to 2.75 ; P < .0004 ) , previous non-Q-wave myocardial infa rct ion ( OR , 1.50 ; 95%CI , 1.08 to 2.08 ; P = .02 ) , regular smoking ( OR , 1.49 ; 95%CI , 1.22 to 1.80 ; P < .0001 ) , age > or = 81 years ( OR , 1.45 ; 95%CI , 1.15 to 1.82 ; P = .001 ) , creatinine clearance < 60 mL/min ( OR , 1.33 ; 95%CI , 1.08 to 1.63 ; P = .008 ) , and treated hypertension ( OR , 1.28 ; 95%CI , 1.03 to 1.59 ; P = .03 ) were significantly associated with PAD . Although risk increased with the number of variables , the model , based on clinical symptoms and on medical history parameters , was not discriminatory ( AUC = 0.66 ) . On average , physicians took 15 minutes to perform the ABI test . CONCLUSIONS The high prevalence of asymptomatic PAD in this patient population suggests that ABI should systematic ally be performed in high-risk hospitalized patients to ensure that appropriate secondary prevention programs are initiated Background : There is controversial evidence with regard to the significance of peripheral arterial disease ( PAD ) as an indicator for future stroke risk . We aim ed to quantify the risk increase for mortality and morbidity associated with PAD . Methods : In an open , prospect i ve , noninterventional cohort study in the primary care setting , a total of 6,880 unselected patients ≧65 years were categorized according to the presence or absence of PAD and followed up for vascular events or deaths over 5 years . PAD was defined as ankle-brachial index ( ABI ) < 0.9 or history of previous peripheral revascularization and /or limb amputation and /or intermittent claudication . Associations between known cardiovascular risk factors including PAD and cerebrovascular mortality/events were analyzed in a multivariate Cox regression model . Results : During the 5-year follow-up [ 29,915 patient-years ( PY ) ] , 183 patients had  a stroke ( incidence per 1,000 PY : 6.1 cases ) . In  patients with PAD  ( n = 1,429 ) compared to those without PAD ( n = 5,392 ) , the incidence of all stroke types st and ardized per 1,000 PY , with the exception of hemorrhagic stroke , was about doubled ( for fatal stroke tripled ) . The corresponding adjusted hazard ratios were 1.6 ( 95 % confidence interval , CI , 1.1–2.2 ) for total stroke , 1.7 ( 95 % CI 1.2–2.5 ) for ischemic stroke , 0.7 ( 95 % CI 0.2–2.2 ) for hemorrhagic stroke , 2.5 ( 95 % CI 1.2–5.2 ) for fatal stroke and 1.4 ( 95 % CI 0.9–2.1 ) for nonfatal stroke . Lower ABI categories were associated with higher stroke rates . Besides high age , previous stroke and diabetes mellitus , PAD was a significant independent predictor for ischemic stroke . Conclusions : The risk of stroke is substantially increased in PAD patients , and PAD is a strong independent predictor for stroke OBJECTIVES We sought to investigate the effect of cardiac medication on long-term mortality in patients with peripheral arterial disease ( PAD ) . BACKGROUND Peripheral arterial disease is associated with increased cardiovascular morbidity and mortality . Treatment guidelines recommend aggressive management of risk factors and lifestyle modifications . However , the potential benefit of cardiac medication in patients with PAD remains ill defined . METHODS In this prospect i ve observational cohort study , 2,420 consecutive patients ( age , 64 + /- 11 years , 72 % men ) with PAD ( ankle-brachial index < or = 0.90 ) were screened for clinical risk factors and cardiac medication . Follow-up end point was death from any cause . Propensity scores for statins , beta-blockers , aspirin , angiotensin-converting enzyme ( ACE ) inhibitors , calcium channel blockers , diuretics , nitrates , coumarins , and digoxin were calculated . Cox regression models were used to analyze the relation between cardiac medication and long-term mortality . RESULTS Medical history included diabetes mellitus in 436 patients ( 18 % ) , hypercholesterolemia in 581 ( 24 % ) , smoking in 837 ( 35 % ) , hypertension in 1,162 ( 48 % ) , coronary artery disease in 1,065 ( 44 % ) , and a history of heart failure in 214 ( 9 % ) . Mean ankle-brachial index was 0.58 ( + /-0.18 ) . During a median follow-up of eight years , 1,067 patients ( 44 % ) died . After adjustment for risk factors and propensity scores , statins ( hazard ratio [ HR ] 0.46 , 95 % confidence interval [ CI ] 0.36 to 0.58 ) , beta-blockers ( HR 0.68 , 95 % CI 0.58 to 0.80 ) , aspirins ( HR 0.72 , 95 % CI 0.61 to 0.84 ) , and ACE inhibitors ( HR 0.80 , 95 % CI 0.69 to 0.94 ) were significantly associated with a reduced risk of long-term mortality . CONCLUSIONS On the basis of this observational longitudinal study , statins , beta-blockers , aspirins , and ACE inhibitors are associated with a reduction in long-term mortality in patients with PAD OBJECTIVES To assess the risk of total and cardiovascular mortality in older adults with systolic hypertension and with a low ankle-arm index ( AAI ) as a marker of sub clinical peripheral arterial disease ( PAD ) . DESIGN Prospect i ve observational study PARTICIPANTS A subgroup of 1537 participants in the Systolic Hypertension in the Elderly Program ( SHEP ) were screened for lower extremity arterial disease using the AAI . Participants were evaluated at 4 years to determine vital status and cause of death . Total and cardiovascular disease ( CVD ) mortality rates were assessed in relationship to clinical CVD at baseline , cardiovascular risk factors and the presence of a low AAI ( sub clinical PAD ) . RESULTS Total mortality rates increased as the AAI decreased in those with and without clinical CVD at baseline . In those without clinical CVD at baseline , the presence of an AAI < or = .9 was associated with an age-adjusted relative risk ( RR ) of 3.00 for total mortality in men and 2.67 in women . Results were similar for CVD mortality and persisted after adjustment for cardiovascular risk factors including the presence of an abnormal electrocardiogram . CONCLUSIONS A low ankle arm-index predicted a two to three-fold increase in total and cardiovascular mortality in older adults with systolic hypertension of risk for incident cardiovascular disease . In this study of older adults with systolic hypertension , 19.7 % of the participants had sub clinical PAD . Risk factor modification could be targeted to older adults based on markers of asymptomatic atherosclerosis Peripheral arterial disease ( PAD ) is a growing and often underdiagnosed health problem that predicts cardiovascular events and mortality . Estimating its prevalence in the general popula tion is a major issue for assessing health needs and planning health services . The aim of this study was to determine the prevalence of PAD and its risk factors in an urban Mexican popu lation . A r and om sample of 400 adult subjects was selected from a Family Medical Unit of the Mexican Institute of the Social Security .  Clinical examination was performed and a question naire was applied to all subjects . After an overnight fast , serum glucose , triglyceride , and cholesterol concentrations were measured . Blood pressure was taken and the ankle-brachial index ( ABI ) was calculated by Doppler examination in both sides . PAD was diagnosed if one of the ABIs was less than 0.90 . Prevalence was estimated with 95 % confidence intervals ( CI95 % ) , and odds ratios ( OR ) with CI95 % were obtained to assess association with some atherogenic risk factors in a multiple logistic regression analysis . The prevalence of PAD was 10.0 % ( CI95 % , 7.24%-13.37 % ) , and it was higher in men . Most subjects with PAD had no signs or symptoms , although the presence of either signs or symptoms was more frequent in subjects with PAD . The main risk factors related to PAD were serum triglycerides ≥150 mg/dL ( OR 2.25 ; CI95 % 1.0 - 5.1 ) , heavy smoking ( OR 2.5 ; CI95 % 0.9 - 6.7 ) and a history of diabetes mellitus for longer than 7 years ( OR 1.9 ; CI95 % 0.6 - 5.8 ) . The prevalence of PAD is high in this Mexican urban population . Asymptomatic PAD may be highly frequent , and low-cost , noninvasive Doppler ultrasonography should be considered as an adequate screening procedure in primary care to detect individuals at high risk for major cardiovascular events OBJECTIVE To assess the prophylactic efficacy of aspirin and a high-dose antioxidant vitamin combination in patients with peripheral arterial disease ( PAD ) in terms of reduction of the risk of a first vascular event ( myocardial infa rct ion , stroke , vascular death ) and critical limb ischaemia . DESIGN R and omized , placebo-controlled , double-blind clinical trial with 2 x 2 factorial design . SETTING Thirty-seven European angiology/vascular medicine units . SUBJECTS A total of 366 out patients with stage I-II PAD documented by angiography or ultrasound , with ankle/brachial index < 0.85 or toe index < 0.6 ; 210 patients completed the follow-up . INTERVENTIONS Four treatment groups : ( i ) oral aspirin ( 100 mg daily ) , ( ii ) oral antioxidant vitamins ( 600 mg vitamin E , 250 mg vitamin C and 20 mg beta-carotene daily ) , ( iii ) both or ( iv ) neither , given for 2 years . MAIN OUTCOME MEASURE Major vascular events ( cardiovascular death , myocardial infa rct ion or stroke ) and critical leg ischaemia . RESULTS Seven of 185 patients allocated aspirin and 20 of 181 allocated placebo suffered a major vascular event ( risk reduction 64 % , P = 0.022 ) ; five and eight patients , respectively , suffered critical leg ischaemia ( total 12 vs. 28 , P = 0.014 ) . There was no evidence that antioxidant vitamins were beneficial ( 16/185 vs. 11/181 vascular events ) . Neither treatment was associated with any significant increase in adverse events . Inclusion of this trial in a meta- analysis of other r and omized trials of anti-platelet therapy in PAD makes the overall results highly significant ( P < 0.001 ) and suggests that low-dose aspirin reduces the incidence of vascular events by 26 % . CONCLUSIONS For the first time direct evidence shows that low-dose aspirin should routinely be considered for PAD patients , including those with concomitant type 2 diabetes Background Peripheral artery disease ( PAD ) is associated with high cardiovascular mortality and a poor quality of life . The AT1-receptor blocker telmisartan has been shown to have pleiotropic effects and it may also improve endothelial function . The aim of this study was to analyze the effects of telmisartan on absolute walking distance ( WD ) and endothelial function in patients with PAD . Methods In a single centre , single-blinded , prospect i ve study , 36 patients with PAD at stage Fontaine II or higher and mild to moderate arterial hypertension were treated with telmisartan 40/80 mg once daily or placebo for 12 months . Primary endpoint was the improvement of the absolute treadmill WD . Flow-mediated vasodilation ( FMD ) , carotid intima-media thickness ( IMT ) , ankle-brachial index ( ABI ) and disease-related quality of life ( DRQL ) were examined as well . Results After 12 months , maximum WD increased by 26 % in the telmisartan group ( P < 0.001 ) . However , in the placebo group it was comparable to baseline . FMD rose by 40 % in the telmisartan group while it deteriorated in the placebo group ( P < 0.001 ) . IMT and ABI were comparable in both groups at baseline and did not change considerably after 12 months . In non-diabetic patients ( 72.2 % ) , the ABI did not change in the placebo group , whereas it increased by 11 % in the telmisartan group ( P < 0.001 ) . While the DRQL remained stable in the telmisartan group , placebo treatment was associated with a marked deterioration ( P < 0.01 ) . Conclusion Telmisartan improves WD and endothelial function , the ABI in non-diabetic patients and it may prevent further loss of quality of life in patients with advanced PAD Body-image dissatisfaction is a problem that affects a substantial minority ofwomen and cuts across various diagnostic groups . College women with a significant level ofbody-image dissatisfaction were r and omly assigned to either a cognitive-behavioral treatment ( CBT ) program  ( n = 15 ) or to a waiting-list control group  ( n = 16 ) . The CBT program consisted of six structured , individual sessions that applied cognitive-behavioral procedures to the problem of negative body image . At pretest , posttest , and 7-week foUow-up , multiple aspects of body image and other areas of psychosocial functioning were assessed . Relative to the control condition , the CBT program successfully improved affective body image , weakened maladaptive body-image cognitions , and enhanced social self-esteem and feelings about physical fitness and sexuality . Treatment effects were largely maintained at followup . After posttest , the control group received a 3-week treatment with immediate effects that generally replicated those obtained in the 6-wer program Hypertension is a common risk factor for peripheral arterial disease ( PAD ) . Guidelines suggest treating PAD patients to a blood pressure < 130/80 mm Hg ; therefore , our objective was to explore whether attainment of this target blood pressure is associated with improved outcomes . We performed a post hoc analysis of the INternational VErapamil-SR/Tr and olapril STudy , a r and omized clinical trial , which included hypertensive patients with concomitant PAD and coronary artery disease . There were 2699 PAD patients followed for a mean of 2.7 years ( 60 970 patient-years ) . The primary outcome , all-cause death , nonfatal myocardial infa rct ion , or nonfatal stroke , occurred in 16.3 % of PAD patients versus 9.2 % without PAD ( adjusted hazard ratio : 1.26 [ 95 % CI : 1.13 to 1.40 ] ; P<0.0001 ) . The primary outcome occurred least frequently among PAD patients treated to an average systolic blood pressure of 135 to 145 mm Hg and an average diastolic blood pressure of 60 to 90 mm Hg . PAD patients displayed a J-shape relationship with systolic blood pressure and the primary outcome , although individuals without PAD did not . PAD patients may require a different target blood pressure than those without PAD Background Peripheral arterial disease ( PAD ) of the lower limbs is a cardiovascular disease highly prevalent particularly in the asymptomatic form . Its prevalence starts to be a concern in low coronary risk countries like Spain . Few studies have analyzed the relationship between ankle-brachial index ( ABI ) and cardiovascular morbi-mortality in low cardiovascular risk countries like Spain where we observe significant low incidence of ischemic heart diseases together with high prevalence of cardiovascular risk factors . The objective of this study is to determine the relationship between pathological ABI and incidence of cardiovascular events ( coronary disease , cerebrovascular disease , symptomatic aneurism of abdominal aorta , vascular surgery ) and death in the > 49 year population -based cohort in Spain ( ARTPER ) . Methods  Baseline ABI  was measured in 3,786 r and omly selected patients from 28 Primary Health Centers in Barcelona , distributed as : ABI<0.9 peripheral arterial disease ( PAD ) , ABI ≥1.4 arterial calcification ( AC ) , ABI 0.9 - 1.4 healthy ; and followed during 4 years . Results 3,307 subjects were included after excluding those with previous vascular events . Subjects with abnormal ABI were older with higher proportion of men , smokers and diabetics . 260 people presented cardiovascular events ( incidence 2,117/100,000 person-years ) and 124 died from any cause ( incidence 978/100,000 person-years ) . PAD had two-fold greater risk of coronary disease ( adjusted hazard ratio ( HR ) = 2.0 , 95 % confidence interval ( CI ) 1.3 - 3.2 ) and increased risk of vascular surgery ( HR = 5.6 , 95%CI 2.8 - 11.5 ) and mortality ( HR = 1.8 , 95%CI 1.4 - 2.5 ) . AC increased twice risk of cerebrovascular events ( HR = 1.9 , 95%CI 1.0 - 3.5 ) with no relationship with ischemic heart disease . Conclusions PAD increases coronary disease risk and AC cerebrovascular disease risk in low cardiovascular risk Mediterranean population . ABI could be a useful tool to detect patients at risk in Primary Health Care OBJECTIVE A population -based point-prevalence study was conducted to determine the prevalence of peripheral arterial disease ( PAD ) in Sweden , with special attention to critical limb ischemia and sex differences . METHODS An age-st and ardized r and omly selected population sample of 8000 women and men , aged 60 to 90 years , from four different regions in Sweden was invited to participate . The sample had the same age and gender distribution as the Swedish population in this age group . Participating subjects completed question naires on medical history , present medication , and symptoms , and their ankle-brachial index ( ABI ) was measured . Subjects were analyzed for presence of PAD according to reported symptoms and an ABI<0.9 . RESULTS A total of 5080 subjects were included , giving a participation rate of 64 % . The prevalence of any PAD , asymptomatic PAD , intermittent claudication , and severe limb ischemia was , respectively , 18 % ( 95 % confidence interval [ CI ] , 16 % to 20 % ) 11 % ( 9 % to 13 % ) , 7 % ( 6.5 to 7 % ) and 1.2 % ( 1 % to 1.5 % ) . Women had a higher prevalence than men when PAD was diagnosed with ABI only ; that is , asymptomatic PAD ( 12.6 % vs 9.4 % , P=.03 ) and severe limb ischemia ( 1.5 % vs 0.8 % , P<.008 ) . The prevalence of any PAD was 7.9 % in the age group 60 to 65 years and increased to 47.2 % among the age group 85 to 90 years . Severe limb ischemia occurred in 0.3 % in the youngest age group , was highest in the age group 80 to 84 years at 3.3 % , and declined to 2.5 % among the oldest . The prevalence of PAD differed between regions ( P<.0001 ) . CONCLUSIONS PAD is common in Sweden , and almost a fifth of all elderly individuals have some stage of this disease . Women are more often afflicted than men . The prevalence of severe ischemia , as a measure of critical limb ischemia , is about 1 % the population Peripheral arterial disease ( PAD ) is associated with major cardiovascular morbidity and mortality . Abnormalities in nitric oxide metabolism due to excess of the NO synthase inhibitor asymmetric dimethylarginine ( ADMA ) may be pathogenic in PAD . We explored the association between ADMA levels and markers of atherosclerosis , function , and prognosis .  A total of 133 patients with symptomatic PAD were enrolled .  Ankle — brachial index ( ABI ) , walking time , vascular function measures ( arterial compliance and flow-mediated vasodilatation ) and plasma ADMA level  were assessed for each patient at baseline . ADMA correlated inversely with ABI ( r = —0.238 , p = 0.003 ) and walking time ( r = —0.255 , p = 0.001 ) , independent of other vascular risk factors . We followed up 125 ( 94 % ) of our 133 initial subjects with baseline measurements ( mean 35 months ) . Subjects with ADMA levels in the highest quartile ( > 0.84 μmol/l ) showed a significantly greater occurrence of a major adverse cardiovascular event ( MACE ) compared to those with ADMA levels in the lower three quartiles ( p = 0.001 ) . Cox proportional-hazards regression analysis revealed that ADMA was a significant predictor of MACE , independent of other risk factors including age , sex , blood pressure , smoking history , diabetes and ABI ( hazard ratio = 5.1 , p < 0.001 ) . Measures of vascular function , such as compliance , flow-mediated vasodilatation ( FMVD ) and blood pressure , as well as markers of PAD severity , including ABI and walking time , were not predictive . In conclusion , circulating levels of ADMA correlate independently with measures of disease severity and major adverse cardiovascular events . Agents that target this pathway may be useful for this patient population . Clinical Trial Registration — URL : http:// www . clinical trials.gov . Unique identifier : CONTEXT Among individuals with lower-extremity peripheral arterial disease ( PAD ) , specific leg symptoms and the ankle brachial index ( ABI ) are cross-sectionally related to the degree of functional impairment . However , relations between these clinical characteristics and objective ly measured functional decline are unknown . OBJECTIVE To define whether PAD , ABI , and specific leg symptoms predict functional decline at 2-year follow-up . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort study among 676 consecutively identified individuals ( aged > or = 55 years ) with and without PAD ( n = 417 and n = 259 , respectively ) , with baseline functional assessment s occurring between October 1 , 1998 , and January 31 , 2000 , and follow-up assessment s scheduled 1 and 2 years thereafter . PAD was defined as ABI less than 0.90 , and participants with PAD were categorized at baseline into 1 of 5 mutually exclusive symptom groups . MAIN OUTCOME MEASURES Mean annual changes in 6-minute walk performance and in usual-paced and fast-paced 4-m walking velocity , adjusted for age , sex , race , prior-year functioning , comorbid diseases , body mass index , pack-years of cigarette smoking , and patterns of missing data . RESULTS Lower baseline ABI values were associated with greater mean ( 95 % confidence interval ) annual decline in 6-minute walk performance ( -73.0 [ -142 to -4.2 ] ft for ABI < 0.50 vs -58.8 [ -83.5 to -34.0 ] ft for ABI 0.50 to < 0.90 vs -12.6 [ -40.3 to 15.1 ] ft for ABI 0.90 - 1.50 , P = .02 ) . Compared with participants without PAD , PAD participants with leg pain on exertion and rest at baseline had greater mean annual decline in 6-minute walk performance ( -111 [ -173 to -50.0 ] ft vs -8.67 [ -36.9 to 19.5 ] ft , P = .004 ) , usual-pace 4-meter walking velocity ( -0.06 [ -0.09 to -0.02 ] m/sec vs -0.01 ( -0.03 to 0.003 ] m/sec , P = .02 ) , and fastest-pace 4-meter walking velocity ( -0.07 [ -0.11 to -0.03 ] m/sec vs -0.02 [ -0.04 to -0.006 ] m/sec , P = .046 ) . Compared with participants without PAD , asymptomatic PAD was associated with greater mean annual decline in 6-minute walk performance ( -76.8 ( -135 to -18.6 ] ft vs -8.67 ( -36.9 to 19.5 ] ft , P = .04 ) and an increased odds ratio for becoming unable to walk for 6 minutes continuously ( 3.63 ; 95 % confidence interval , 1.58 - 8.36 ; P = .002 ) . CONCLUSIONS Baseline ABI and the nature of leg symptoms predict the degree of functional decline at 2-year follow-up . Previously reported lack of worsening in claudication symptoms over time in patients with PAD may be more related to declining functional performance to than lack of disease progression Asymptomatic peripheral arterial disease ( PAD ) can be easily identified using the  ankle – brachial index ( ABI ) . This study was design ed to investigate the benefits of performing ABI in patients aged 50 - 70 years . A r and om sample of 107 patients was chosen and data on gender , age , risk factors and laboratory tests were collected and the ABI measured . Twenty ( 19 % ) patients were found to have PAD . Smoking , high total cholesterol , high triglycerides and diabetes mellitus were shown to be associated with a low ABI and the presence of PAD . Age , diabetes and smoking were identified as the strongest predictors of PAD . Having more risk factors for PAD also predicted a lower ABI . These results suggest that measuring ABI  is not necessary in patients aged 50 - 70 years if they only have one risk factor , with the exception of patients with diabetes and those who smoke . In contrast , measuring ABI seems to be useful for patients with multiple risk factors for PAD , although additional studies are required Background : The PCSK9 ( proprotein convertase subtilisin/kexin type 9 ) inhibitor evolocumab reduced low-density lipoprotein cholesterol and cardiovascular events in the FOURIER trial ( Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk ) . We investigated the efficacy and safety of evolocumab in patients with peripheral artery disease ( PAD ) as well as the effect on major adverse limb events . Methods : FOURIER was a r and omized trial of evolocumab versus placebo  in 27 564 patients with atherosclerotic disease on statin therapy followed for a median of 2.2 years . Patients were identified as having PAD at baseline if they had intermittent claudication and an ankle brachial index of < 0.85 , or if they had a prior peripheral vascular procedure . The primary end point was a composite of cardiovascular death , myocardial infa rct ion , stroke , hospital admission for unstable angina , or coronary revascularization . The key secondary end point was a composite of cardiovascular death , myocardial infa rct ion , or stroke . An additional outcome of interest was major adverse limb events defined as acute limb ischemia , major amputation , or urgent peripheral revascularization for ischemia . Results : Three thous and six hundred forty-two patients ( 13.2 % ) had PAD ( 1505 with no prior myocardial infa rct ion or stroke ) . Evolocumab significantly reduced the primary end point consistently in patients with PAD ( hazard ratio [ HR ] 0.79 ; 95 % confidence interval [ CI ] , 0.66–0.94 ; P=0.0098 ) and without PAD ( HR 0.86 ; 95 % CI , 0.80–0.93 ; P=0.0003 ; Pinteraction=0.40 ) . For the key secondary end point , the HRs were 0.73 ( 0.59–0.91 ; P=0.0040 ) for those with PAD and 0.81 ( 0.73–0.90 ; P<0.0001 ) for those without PAD ( Pinteraction=0.41 ) . Because of their higher risk , patients with PAD had larger absolute risk reductions for the primary end point ( 3.5 % with PAD , 1.6 % without PAD ) and the key secondary end point ( 3.5 % with PAD , 1.4 % without PAD ) . Evolocumab reduced the risk of major adverse limb events in all patients ( HR , 0.58 ; 95 % CI , 0.38–0.88 ; P=0.0093 ) with consistent effects in those with and without known PAD . There was a consistent relationship between lower achieved low-density lipoprotein cholesterol and lower risk of limb events ( P=0.026 for the beta coefficient ) that extended down to < 10 mg/dL. Conclusions : Patients with PAD are at high risk of cardiovascular events , and PCSK9 inhibition with evolocumab significantly reduced that risk with large absolute risk reductions . Moreover , lowering of low-density lipoprotein cholesterol with evolocumab reduced the risk of major adverse limb events . Clinical Trial Registration : URL : https://www . clinical trials.gov . Unique identifier : NCT01764633 Background —Bone-marrow mononuclear cell ( BM-MNC ) implantation improves ischemic symptoms in patients with critical limb ischemia ( CLI ) . The purpose of this study was to evaluate long-term clinical outcomes after autologous BM-MNC implantation in patients with CLI . Methods and Results —We assessed long-term clinical outcomes after BM-MNC implantation in 51 patients with CLI , including 25 patients with peripheral arterial disease ( PAD ) and 26 patients with Buerger disease . Forty-six CLI patients who had no BM-MNC implantation served as control subjects . Median follow-up period was 4.8 years . The 4-year amputation-free rates after BM-MNC implantation were 48 % in PAD patients and 95 % in Buerger disease , and they were 0 % in control PAD patients and 6 % in control Buerger disease . The 4-year overall survival rates after BM-MNC implantation  were 76 % in PAD patients and 100 % in Buerger disease , and they were 67 % in control PAD patients and 100 % in control Buerger disease . Multivariable Cox proportional hazards analysis revealed that BM-MNC implantation correlated with prevention of major amputation and that hemodialysis and diabetes mellitus correlated with major amputation . In Buerger disease , ankle brachial pressure index and transcutaneous oxygen pressure were significantly increased after 1 month and remained high during 3-year follow-up . However , in patients with PAD , ankle brachial pressure index and transcutaneous oxygen pressure significantly increased after 1 month and gradually decreased during 3-year follow-up and returned to baseline levels . Conclusions —These findings suggest that BM-MNC implantation is safe and effective in patients with CLI , especially in patients with Buerger disease . Clinical Trial Registration —URL : http://home.hiroshima-u.ac.jp/angio/. Unique identifier : 001769
However , lack of data specifically examining outcomes in PAD patients should not detract from the overwhelming evidence on the benefit of treating hypertension and lowering blood pressure
BACKGROUND Peripheral arterial disease ( PAD ) causes considerable morbidity and mortality .
Hypertension is a risk factor for PAD .
Treatment for hypertension must be compatible with the symptoms of PAD .
Controversy regarding the effects of beta-adrenoreceptor blockade for hypertension in patients with PAD has led many physicians to stop prescribing beta-adrenoreceptor blockers .
Little is known about the effects of other classes of anti-hypertensive drugs in the presence of PAD .
This is the second up date of a Cochrane review first published in 2003 .
OBJECTIVES To determine the effects of anti-hypertensive drugs in patients with both raised blood pressure and symptomatic PAD in terms of the rate of cardiovascular events and death , symptoms of claudication and critical leg ischaemia , and progression of atherosclerotic PAD as measured by ankle brachial index ( ABI ) changes and the need for revascularisation ( reconstructive surgery or angioplasty ) or amputation .