Self-Reported Peripheral Arterial Disease Predicts Future Vascular Events in a Community-Based Cohort

BACKGROUND: Lower extremity peripheral arterial disease (PAD) is highly prevalent and strongly associated with cardiovascular morbidity and mortality. The ankle-brachial index used to screen for PAD is not routinely performed in primary care settings. OBJECTIVE: To determine if self-reported PAD is an independent predictor of combined vascular events (myocardial infarction, ischemic stroke, and vascular death). DESIGN: Ongoing population-based prospective cohort (the Northern Manhattan Study). Subjects enrolled between July 1993 and June 2001 with a mean follow-up time of 7.1 years. PATIENTS: Subjects (n = 2,977), aged 40 years or older and free of prior stroke or myocardial infarction, were classified as having self-reported PAD if they answered affirmatively to one of two questions regarding exercise-induced leg pain or a prior diagnosis of PAD. MAIN OUTCOME MEASURES: Combined vascular outcome defined as incident myocardial infarction, incident ischemic stroke, or vascular death. RESULTS: The mean age of the cohort was 68.9 ± 10.4 years; 64% were women; 54% Hispanic, 25% African-American, 21% Caucasian; 15% reported having PAD. After a mean follow-up of 7.1 years, self-reported PAD was significantly predictive of combined events (n = 484) in the univariate model (HR 1.5, 95% CI, 1.2–1.9) and after adjustment for traditional cardiovascular risk factors (HR 1.3, 95% CI, 1.0–1.7). CONCLUSION: Self-reported PAD is an independent risk factor for future vascular events in this predominantly non-white cohort. The addition of two simple PAD questions to the routine medical history in general medicine settings could identify high-risk patients who would benefit from further vascular evaluation and risk factor modification

Carotid bruit for detection of hemodynamically significant carotid stenosis: the Northern Manhattan Study

Objective: The prevalence of carotid bruits and the utility of auscultation for predicting carotid stenosis are not well known. We aimed to establish the prevalence of carotid bruits and the diagnostic accuracy of auscultation for detection of hemodynamically significant carotid stenosis, using carotid duplex as the gold standard. Methods: The Northern Manhattan Study (NOMAS) is a prospective multiethnic community-based cohort designed to examine the incidence of stroke and other vascular events and the association between various vascular risk factors and subclinical atherosclerosis. Of the stroke-free cohort (n=3298), 686 were examined for carotid bruits and underwent carotid duplex. Main outcome measures included prevalence of carotid bruits and sensitivity, specificity, positive predictive value, negative predictive value and accuracy of auscultation for prediction of ipsilateral carotid stenosis. Results: Among 686 subjects with a mean age of 68.2 ± 9.4 years, the prevalence of ≥60% carotid stenosis as detected by ultrasound was 2.2% and the prevalence of carotid bruits was 4.1%. For detection of carotid stenosis, sensitivity of auscultation was 56%, specificity was 98%, positive predictive value was 25%, negative predictive value was 99% and overall accuracy was 97.5%. Discussion: In this ethnically diverse cohort, the prevalence of carotid bruits and hemodynamically significant carotid stenosis was low. Sensitivity and positive predictive value were also low, and the 44% false-negative rate suggests that auscultation is not sufficient to exclude carotid stenosis. While the presence of a bruit may still warrant further evaluation with carotid duplex, ultrasonography may be considered in high-risk asymptomatic patients, irrespective of findings on auscultation

Cigarette Smoking, Smoking Cessation, and Long-Term Risk of 3 Major Atherosclerotic Diseases

BackgroundPublic statements about the effect of smoking on cardiovascular disease are predominantly based on investigations of coronary heart disease (CHD) and stroke, although smoking is recognized as a strong risk factor for peripheral artery disease (PAD). No study has comprehensively compared the long-term association of cigarette smoking and its cessation with the incidence of 3 major atherosclerotic diseases (PAD, CHD, and stroke).ObjectivesThe aim of this study was to quantify the long-term association of cigarette smoking and its cessation with the incidence of the 3 outcomes.MethodsA total of 13,355 participants aged 45 to 64 years in the ARIC (Atherosclerosis Risk In Communities) study without PAD, CHD, or stroke at baseline (1987 to 1989) were included. The associations of smoking parameters (pack-years, duration, intensity, and cessation) with incident PAD were quantified and contrasted with CHD and stroke using Cox models.ResultsOver a median follow-up of 26 years, there were 492 PAD cases, 1,798 CHD cases, and 1,106 stroke cases. A dose-response relationship was identified between pack-years of smoking and 3 outcomes, with the strongest results for PAD. The pattern was consistent when investigating duration and intensity separately. A longer period of smoking cessation was consistently related to lower risk of PAD, CHD, and stroke, but a significantly elevated risk persisted up to 30 years following smoking cessation for PAD and up to 20 years for CHD.ConclusionsAll smoking measures showed significant associations with 3 major atherosclerotic diseases, with the strongest effect size for incident PAD. The risk due to smoking lasted up to 30 years for PAD and 20 years for CHD. Our results further highlight the importance of smoking prevention and early smoking cessation, and indicate the need for public statements to take PAD into account when acknowledging the impact of smoking on overall cardiovascular health