Prognosis of Patients with Peripheral Arterial Disease

Peripheral arterial disease (PAD) is becoming an increasingly important health issue in Western Society. PAD is affecting approximately 8 to 12 million adults in the USA and more than 30 million adults worldwide1. These symptomatic patients represent the ‘top of the ice-berg’, creating a major health burden. For every patient with symptomatic PAD, 3 to 4 patients have PAD without clinical complaints like claudication intermittens2. Especially in patients with PAD undergoing major vascular surgery, a high incidence of coronary artery disease (CAD) has been observed, which also may be asymptomatic or symptomatic. In patients with PAD requiring aortic or lower limb revascularization procedure surgery, the prevalence of CAD is about 50 to 70%3-5. Hence, it is not surprising that these patients are at increased risk for perioperatieve and long-term cardiac complications. Cardiac death accounts for approximately 40% of all 30-day mortality after surgery and for 65% of all deaths during longterm follow-up6. Importantly, the prognosis of patients with PAD is related to the presence and extent of CAD, as well as the regulation of cardiovascular risk factors

The prevalence and prognostic implications of polyvascular atherosclerotic disease in patients with chronic kidney disease

Background. Atherosclerotic disease is often extended to multiple affected vascular beds (AVB). Polyvascular disease (PVD) and chronic kidney disease (CKD) have both separately been associated with an adverse cardiovascular outcome. We assessed the prevalence of PVD in vascular surgery patients with preoperative CKD and studied the influence on long-term cardiovascular survival. Methods. Consecutive patients (2933) were preoperatively screened for PVD, defined as 1-, 2- or 3-AVB. Preoperative glomerular filtration rate (GFR in ml/min/1.73 m(2) body-surface area) was estimated by the Modification of Diet in Renal Disease (MDRD) prediction equation, and patients were categorized according their estimated GFR. Primary end point was (cardiovascular) mortality during a median follow-up of 6.0 years (IQR 2-9). Results. Preoperative MDRD-GFR was classified as normal kidney function (GFR >= 90) or mild (GFR 60-89), moderate (GFR 30-59) and severe (GFR < 30) kidney disease in 779 (27%), 1423 (48%), 605 (21%) and 124 (4%) patients, respectively. One-vessel disease was present in 54% of the patients with normal kidney function, while 62% of the patients with CKD (GFR < 60) had PVD. In patients with moderate or severe kidney disease, the presence of PVD was independently associated with even higher cardiovascular mortality rates (2-AVB: HR 1.65 95%CI 1.09-2.48; 3-AVB: 2.07 95%CI 1.08-3.99), compared to 1-AVB. Conclusion. Patients with CKD had a high prevalence of PVD, which was independently associated with increased all-cause and cardiovascular mortality.Vascular Biology and Interventio

Long-term prognosis of patients with peripheral arterial disease with or without polyvascular atherosclerotic disease

Aims Patients with peripheral atherosclerotic disease often have multiple affected vascular beds (AVB), however, data on long-term follow-up and medical therapy are scarce. We assessed the prevalence and prognostic implications of polyvascular disease on long-term outcome in symptomatic peripheral arterial disease (PAD) patients. Methods and results Two thousand nine hundred and thirty-three consecutive patients were screened prior to surgery for concomitant documented cerebrovascular disease and coronary artery disease. The number of AVB was determined. Cardiovascular medication as recommended by guidelines was noted at discharge. Single, two, and three AVB were detected in 1369 (46%), 1249 (43%), and 315 (11%) patients, respectively. During a median follow-up of 6 years, 1398 (48%) patients died, of which 54% secondary to cardiovascular cause. After adjustment for baseline cardiac risk factors and discharge-medication, the presence of 2-AVB or 3-AVB was associated with all-cause mortality (HR 1.3 95% Cl 1.2-1.5; HR 1.8 95% Cl 1.5-2.2) and cardiovascular mortality (HR 1.5 95% Cl 1.2-1.7; HR 2.0 95% Cl 1.6-2.5) during long-term follow-up, respectively. Patients with 2- and 3-AVB received extended medical treatment compared with 1-AVB at the time of discharge. Conclusion Polyvascular atherosclerotic disease in PAD patients is independently associated with an increased risk for all-cause and cardiovascular mortality during long-term follow-up.Vascular Biology and Interventio

Renal insufficiency and mortality in patients with known or suspected coronary artery disease

It remains unclear whether mild renal dysfunction is associated with adverse cardiovascular outcome. We investigated whether estimated glomerular filtration rate (eGFR) was associated with mortality and cardiac death among 6447 patients with known or suspected coronary artery disease over a mean follow-up of 7 yr. Cumulative 5- and 10-yr survival rates decreased in a graded fashion from 88% and 70%, respectively, for those with normal renal function to 43% and 33% for those with eGFR <30 ml/min. Compared with patients with normal renal function, the multivariable adjusted hazard ratios for all-cause mortality among patients with mild, moderate, and severe renal impairment were 1.33 (95% confidence interval [CI], 1.21-1.48), 1.67 (95% CI, 1.44-1.93), and 3.38 (95% CI, 2.73-4.19), respectively. Similar relationships between cardiac death and decreasing renal function were found. In conclusion, renal function is a graded and independent predictor of long-term mortality in patients with known or suspected coronary artery disease. Intense treatment and close surveillance of these patients is encouraged. Copyrigh

The Influence of Aging on the Prognostic Value of the Revised Cardiac Risk Index for Postoperative Cardiac Complications in Vascular Surgery Patients

ObjectiveThe Lee-risk index [Lee-index] was developed to predict major adverse cardiac events [MACE]. However, age is not included as a risk factor. The aim was to assess the value of the Lee-index in vascular surgery patients among different age categories.MethodsOf 2 642 patients cardiovascular risk factors were noted to calculate the Lee-index. Patients were divided into four age categories; ≤ 55(n=396), 56–65 (n=650), 66–75 (n=1 058) and >75 years (n=538). Outcome measures were postoperative MACE (cardiac death, MI, coronary revascularization and heart failure). The performance of the Lee-index was determined using C-statistics within the four age groups.ResultsThe incidence of MACE was 10.9%, for Lee-index 1, 2 and ≥3; 6%, 13% and 20%, respectively. However, the prognostic value differed among age groups. The predictive value for MACE was highest among patients under 55 year (0.76 vs 0.62 of patients aged>75). The prediction of MACE improved in elderly (aged>75) after adjusting the Lee-index with age, revised risk of operation (low, low-intermediate, high-intermediate and high-risk procedures) and hypertension (0.62 to 0.69).ConclusionThe prognostic value of the Lee-index is reduced in elderly vascular surgery patients, adjustment with age, risk of surgical procedure, and hypertension improves the Lee-index significantly

β-Blockers improve outcomes in kidney disease patients having noncardiac vascular surgery

β-Blockers are known to improve postoperative outcome after major vascular surgery. We studied the effects of β-blockers in 2126 vascular surgery patients with and without kidney disease followed for 14 years. Creatinine clearance was calculated using the Cockcroft–Gault equation, and kidney function was categorized as Stage 1 for a reference group of 550 patients, Stage 2 with 808 patients, Stage 3 with 627 patients, and combined Stages 4 and 5 with 141 patients. Outcome measures were 30-day and long-term all-cause mortality with a mean follow-up of 6 years. Cox proportional hazards models were used to control cardiovascular risk factors, including propensity for β-blocker use. In all, 129 (6%) and 1190 (56%) patients died respectively. Mortality rates were three- and two-fold higher, respectively, for patients at Stages 3–5 compared to the reference group for the two outcomes. β-Blocker use was significantly associated with a lower risk of mortality after surgery. The overall adjusted hazard ratio was 0.35 and 0.62, respectively, for individuals at Stages 3–5 compared to the reference group for 30-day and long-term mortality. This study shows that kidney function is a predictor of all-cause mortality and β-blocker use is associated with a lower risk of death in kidney disease patients undergoing elective vascular surgery