European Heart Journal Advance Access originally published online on October 9, 2006
European Heart Journal 2006 27(21):2495-2496; doi:10.1093/eurheartj/ehl283
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Subclinical atherosclerosis of lower limb arteries: a strong predictor for cardiovascular mortality
1 Division of Clinical and Interventional Angiology, Swiss Cardiovascular Center, University of Bern, Switzerland
2 Department of Internal Medicine/Vascular Medicine, SRH-Klinikum Karlsbad-Langensteinbach, University of Heidelberg, Germany
* Corresponding author. Tel: +41 31 632 2111; fax: +41 31 632 4793. E-mail address: diehm{at}gmx.ch
This editorial refers to ‘Association of ankle-brachial index and plaques in the carotid and femoral arteries with cardiovascular events and total mortality in a population-based study with 13 years of follow-up’
by C. Lamina et al., on page 2580
The prognostic systemic implications of lower limb atherosclerosis have previously been widely underestimated. However, the importance of peripheral arterial disease (PAD), as a major public health problem, has increasingly been acknowledged in recent years.
PAD is known to be associated with a major decrease of patient quality of life and functional impairment1 and it is the leading cause of non-traumatic amputations throughout Europe and the United States.
Very importantly, PAD has been shown to be rarely an isolated disease of the lower limb arteries, but rather a manifestation of generalized atherosclerotic burden: detailed patient examination often reveals a substantial overlap of (a)symptomatic atherothrombosis in the coronary, cerebral, and peripheral arteries2,3 and widespread similarities in prevalent risk factors.
In contrast to the coronary arterial or cerebrovascular manifestations of the disease, PAD lends itself for simple non-invasive and reliable diagnostics: determination of the ankle brachial index (ABI, the ratio between the systolic blood pressures in the arm and the ankle) quantifies impairment of arterial leg perfusion and easily identifies patients at high vascular risk.
Population-based data on PAD are currently sparse. However, its detailed understanding is a critical prerequisite for the development of strategies enhancing the treatment and prevention of progression of lower limb as well as systemic atherosclerosis.
Lamina et al. have investigated the outcomes of 1325 participants aged 25–74 years of a population-based study (from WHO MONICA) carried out in southern Germany (Lamina et al.).4 They confirmed that low ABI is an independent risk factor for myocardial infarction as well as cardiovascular and overall mortality throughout long-term follow-up.
Furthermore, the authors added the evidence that plaque burden in the femoral and carotid arteries independently influences on incidence of major cardiovascular events and mortality. Interestingly, risk of myocardial infarction as well as cardiovascular and total mortality directly correlated with a stepwise decrease of ABI and increase in the number of plaque-affected arteries. Taken together, these data importantly underline that presence of peripheral arterial lesions is highly indicative of a generalized atherosclerotic burden.
Indeed, in the largest PAD study in primary care to date (getABI, more than 20 000 patient-years in elderly subjects), reported by us in a recent issue of this journal, showed that low ABI (even after adjustment for many other risk factors) is associated with doubled mortality and cardiovascular events at 3-years follow-up.5 We found a clear inverse association between ABI category and risk increase thereby confirming findings of previous studies in other settings.
In comparison to the getABI study, Lamina et al. studied a population-based cohort which was younger and was followed over a longer time period.
The fact that the current study was population-based and contained younger patients might explain that prevalence of PAD was substantially lower as compared with the getABI study. Furthermore, the crude incidence of adverse cardiovascular events was lower despite the fact that the lower ABI had been applied to classify patients.
In contrast to the getABI study, the present series applied the lower of the two ABI values measured in one patient to classify PAD, thereby lowering the threshold for the diagnosis of PAD. Interestingly, current guidelines on ABI measurement do not uniformly define whether the higher or the lower ankle pressure should be applied for screening and follow-up of patients with PAD. Our group has recently shown that using the lower systolic ankle pressure for ABI measurement is associated with a substantial increase in sensitivity in PAD screening.6 Whether the lower or the higher ABI will better reflect severity of systemic atherosclerosis and specific patient prognosis is currently unknown. The impact of large-scale ABI screening on preventive strategies and patient outcomes will have to be investigated in further prospective studies.
The current study once again emphasizes that the presence of a slight impairment of lower limb arterial perfusion as measured by a simple and non-invasive test can be reliably used as a marker of an excessively increased mortality. Therefore, ABI screening should be implemented at the primary care level to help identify patients at increased risk for cardiovascular events.
Conflict of interest: none declared.
Footnotes
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
doi:10.1093/eurheartj/ehl228 
References
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- Lamina C, Meisinger C, Heid IM, Löwel H, Ranter B, Koenig W, Kronenberg F. for the KORA Study Group. Association of ankle-brachial index and plaques in the carotid and femoral arteries with cardiovascular events and total mortality in a population-based study with 13 years of follow-up. Eur Heart J 27:2580–2587 First published on September 4, 2006, doi:10.1093/eurheartj/ehl228.
- Diehm C, Lange S, Darius H, Pittrow D, von Stritzky B, Tepohl G, Haberl RL, Allenberg JR, Dasch B, Trampisch HJ. (2006) Association of low ankle brachial index with high mortality in primary care. Eur Heart J 27:1743–1749.
[Abstract/Free Full Text] - Schroder F, Diehm N, Kareem S, Ames M, Pira A, Zwettler U, Lawall H, Diehm C. (2006) A modified calculation of ankle-brachial pressure index is far more sensitive in the detection of peripheral arterial disease. J Vasc Surg 44:531–536.[CrossRef][Web of Science][Medline]
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Related articles in EHJ:
- Association of ankle-brachial index and plaques in the carotid and femoral arteries with cardiovascular events and total mortality in a population-based study with 13 years of follow-up
- Claudia Lamina, Christa Meisinger, Iris M. Heid, Hannelore Löwel, Barbara Rantner, Wolfgang Koenig, Florian Kronenberg, and for the KORA Study Group
EHJ 2006 27: 2580-2587.[Abstract] [FREE Full Text]
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