F. G. R. Fowkes

Ankle brachial index combined with Framingham risk score to predict cardiovascular events and mortality - A meta-analysis

CONTEXTnPrediction models to identify healthy individuals at high risk of cardiovascular disease have limited accuracy. A low ankle brachial index (ABI) is an indicator of atherosclerosis and has the potential to improve prediction.nnnOBJECTIVEnTo determine if the ABI provides information on the risk of cardiovascular events and mortality independently of the Framingham risk score (FRS) and can improve risk prediction.nnnDATA SOURCESnRelevant studies were identified. A search of MEDLINE (1950 to February 2008) and EMBASE (1980 to February 2008) was conducted using common text words for the term ankle brachial index combined with text words and Medical Subject Headings to capture prospective cohort designs. Review of reference lists and conference proceedings, and correspondence with experts was conducted to identify additional published and unpublished studies.nnnSTUDY SELECTIONnStudies were included if participants were derived from a general population, ABI was measured at baseline, and individuals were followed up to detect total and cardiovascular mortality.nnnDATA EXTRACTIONnPrespecified data on individuals in each selected study were extracted into a combined data set and an individual participant data meta-analysis was conducted on individuals who had no previous history of coronary heart disease.nnnRESULTSnSixteen population cohort studies fulfilling the inclusion criteria were included. During 480,325 person-years of follow-up of 24,955 men and 23,339 women, the risk of death by ABI had a reverse J-shaped distribution with a normal (low risk) ABI of 1.11 to 1.40. The 10-year cardiovascular mortality in men with a low ABI (< or = 0.90) was 18.7% (95% confidence interval [CI], 13.3%-24.1%) and with normal ABI (1.11-1.40) was 4.4% (95% CI, 3.2%-5.7%) (hazard ratio [HR], 4.2; 95% CI, 3.3-5.4). Corresponding mortalities in women were 12.6% (95% CI, 6.2%-19.0%) and 4.1% (95% CI, 2.2%-6.1%) (HR, 3.5; 95% CI, 2.4-5.1). The HRs remained elevated after adjusting for FRS (2.9 [95% CI, 2.3-3.7] for men vs 3.0 [95% CI, 2.0-4.4] for women). A low ABI (< or = 0.90) was associated with approximately twice the 10-year total mortality, cardiovascular mortality, and major coronary event rate compared with the overall rate in each FRS category. Inclusion of the ABI in cardiovascular risk stratification using the FRS would result in reclassification of the risk category and modification of treatment recommendations in approximately 19% of men and 36% of women.nnnCONCLUSIONnMeasurement of the ABI may improve the accuracy of cardiovascular risk prediction beyond the FRS.

Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study.

STUDY OBJECTIVE: To determine the prevalence of varicose veins and chronic venous insufficiency (CVI) in the general population. DESIGN: Cross sectional survey. SETTING: City of Edinburgh. PARTICIPANTS: Men and women aged 18-64 years selected randomly from age-sex registers of 12 general practices. MAIN RESULTS: In 1566 subjects examined, the age adjusted prevalence of trunk varices was 40% in men and 32% in women (p < or = 0.01). This sex difference was mostly a result of higher prevalence of mild trunk varices in men. More than 80% of all subjects had mild hyphenweb and reticular varices. The age adjusted prevalence of CVI was 9% in men and 7% in women (p < or = 0.05). The prevalence of all categories of varices and of CVI increased with age (p < or = 0.001). No relation was found with social class. CONCLUSIONS: Approximately one third of men and women aged 18-64 years had trunk varices. In contrast with the findings in most previous studies, mainly conducted in the 1960s and 1970s, chronic venous insufficiency and mild varicose veins were more common in men than women. No evidence of bias in the study was found to account for this sex difference. Changes in lifestyle or other factors might be contributing to an alteration in the epidemiology of venous disease.

Use of ankle brachial pressure index to predict cardiovascular events and death : a cohort study

Abstract Objective: To determine whether a low ankle brachial pressure index is associated with an increased risk of cardiovascular events and death, and whether the prediction of such events could be improved by including this index. Design: Cohort study. Setting: 11 practices in Edinburgh, Scotland. Subjects: 1592 men and women aged 55–74 years selected at random from the age-sex registers of 11 general practices and followed up for 5 years. Main outcome measures: Incidence of fatal and non-fatal cardiovascular events and all cause mortality. Results: At baseline 90 (5.7%) of subjects had an ankle brachial pressure index </=0.7, 288 (18.2%) had an index </=0.9, and 566 (35.6%) </=1.0. After five years subjects with an index </=0.9 at baseline had an increased risk of non-fatal myocardial infarction (relative risk 1.38, 95% confidence interval 0.88 to 2.16), stroke (1.98, 1.05 to 3.77), cardiovascular death (1.85, 1.15 to 2.97), and all cause mortality (1.58, 1.14 to 2.18) after adjustment for age, sex, coronary disease, and diabetes at baseline. The ability to predict subsequent events was greatly increased by combining the index with other risk factors—for example, hypertensive smokers with normal cholesterol concentrations had a positive predictive value of 25.0%, increasing to 43.8% in subjects with a low index and decreasing to 15.6% in those with a normal index. Conclusion: The ankle brachial pressure index is a good predictor of subsequent cardiovascular events, and improves on predictions by conventional risk factors alone. It is simple and accurate and could be included in routine screening of cardiovascular status. Key messages In this study individuals with a low ankle brachial pressure index had an increased risk of fatal and non-fatal cardiovascular events The index was a good predictor of subsequent cardiovascular events, and improved that of conventional risk factors alone The ankle brachial pressure index could be included in routine screening of cardiovascular status Individuals with a low ankle brachial pressure index require additional monitoring, and might benefit from aspirin or other secondary preventive measures

Blood viscosity and risk of cardiovascular events: the Edinburgh Artery Study.

We examined the relationships of whole blood viscosity and its major determinants to incident cardiovascular events (ischaemic heart disease and stroke) in a prospective study of a random population sample of 1592 men and women aged 55–74 years (the Edinburgh Artery Study). 272 fatal and non‐fatal cardiovascular events occurred during 5 years of follow‐up (cumulative incidence 17.1%). Age and sex adjusted mean levels of blood viscosity (3.70 v 3.55u2003mPa.s), haematocrit (46.2 v 45.7%), haematocrit‐corrected blood viscosity (3.57 v 3.48u2003mPa.s), plasma viscosity (1.35 v 1.33u2003mPa.s) and fibrinogen (2.88 v 2.67u2003g/l) were significantly higher in subjects who experienced events than in subjects who did not. The relationships of these rheological variables to cardiovascular events were at least as strong as those of conventional risk factors (smoking habit, diastolic blood pressure, and low‐density lipoprotein cholesterol). After adjustment for these conventional risk factors, the associations of blood viscosity and haematocrit remained significant for stroke, but not for total events; whereas the associations of plasma viscosity and fibrinogen remained significant for total events and for stroke.

Hemostatic Factors as Predictors of Ischemic Heart Disease and Stroke in the Edinburgh Artery Study

Plasma fibrinogen is a consistent predictor of ischemic heart disease (IHD) in prospective studies, but there are fewer data relating other hemostatic variables to IHD and also to stroke. We therefore studied the relationships of plasma fibrinogen, von Willebrand factor antigen, tissue plasminogen activator (TPA) antigen, factor VII, and fibrin D-dimer to incidence of IHD and stroke and determined whether any associations could be explained by conventional risk factors and baseline heart disease. In the Edinburgh Artery study, 1592 men and women aged 55 to 74 years, randomly sampled from the general population, were followed prospectively over 5 years to detect fatal and nonfatal IHD and stroke events. During the 5 years, 268 new vascular events were identified. Baseline plasma fibrinogen was independently related to risk of stroke in multivariate analysis that adjusted for cigarette smoking, LDL-cholesterol, systolic blood pressure, and preexisting IHD (relative risk [RR] 1.52, 95% confidence interval [CI] 1.17, 1.98). TPA antigen, and fibrin D-dimer were also independently associated with risk of stroke (RR 1.69,95% CI 1.22,2.35 and RR 1.96, 95% CI 1.12,3.41, respectively). Significant relationships were found between TPA antigen and myocardial infarction (P < or = .05). In older men and women, increased coagulation activity and disturbed fibrinolysis are predictors of future vascular events (both IHD and stroke).

Epidemiology of chronic venous disease

Abstract Chronic venous disease of the legs occurs commonly in the general population in the Western world. Estimates of the prevalence of varicose veins vary widely from 2–56% in men and from 1–60% in women. These variations reflect differences in variability of study populations including age, race and gender, methods of measurement and disease definition. Definitions of chronic venous disease may rely on reports of varicose veins by study participants, based on self-diagnosis or recall of a diagnosis, or on a standardized physical examination. Venous ulceration is less common, affecting approximately 0.3% of the adult population. Age and pregnancy have been established as risk factors for developing varicose veins. Evidence on other risk factors for venous disease is inconclusive. Prolonged standing has been proposed, but results of studies should be interpreted with caution given the difficulty in measuring levels of posture. Obesity has been suggested as a risk factor in women, but appears to be an aggravating factor rather than a primary cause. Other postulated risk factors include dietary intake and smoking, but evidence is lacking. Longitudinal studies using standardized methods of evaluation are required before the true incidence of chronic venous disease and associated risk factors can be determined.

RANDOMISED CONTROLLED TRIAL OF PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY FOR INTERMITTENT CLAUDICATION

OBJECTIVESnTo determine differences between PTA and conventional medical treatment in treadmill distance until onset of claudication, treadmill maximum walking distance, patient reported maximum walking distance, ankle brachial pressure index (ABPI), quality of life (Nottingham Health Profile, NHP) and Duplex measured extent of occlusive disease.nnnDESIGNnRandomised controlled clinical trial.nnnMETHODSnSix hundred claudicants were screened. Fifty-one men and 11 women with intermittent claudication due to short femoral stenoses or occlusions (n = 47) and iliac stenoses (n = 15) were randomised to either PTA plus medical treatment (PTA group, n = 30) or to medical treatment alone (control group, n = 32). Medical treatment consisted of daily low dose aspirin and advice on smoking and exercise.nnnRESULTSnAt 6 month follow up: In the PTA group more patients reported no claudication (p < or = 0.05) and were asymptomatic on the treadmill (p < or = 0.01) compared to the control group. The ABPI was significantly higher in the PTA group. More of the PTA group reported lower NHP pain scores (p < or = 0.05). In the control group there were more occluded arteries (p < or = 0.001), and the stenosis velocity ratio of patient arteries was significantly higher (p < or = 0.001).nnnCONCLUSIONSnOnly 10% of claudicants had discrete lesions suitable for PTA. Treatment of these patients with PTA produces a greater short-term improvement in walking and quality of life than medical treatment alone and is associated with less progression of disease.

Hostility, cigarette smoking and alcohol consumption in the general population

Hostility has been associated with coronary heart disease, and hostility may affect coronary risk through its influence on risk factors such as cigarette smoking and alcohol consumption. The objective of this study was to determine relationships between hostile personality, cigarette smoking and alcohol consumption in the general population. The Edinburgh Artery Study comprises a cross-sectional survey of 1592 men and women aged 55-74 years sampled from age-sex registers of 10 general practices throughout the city. The Bedford-Foulds Personality Deviance Questionnaire was used to elicit extrapunitiveness (including hostile thoughts), dominance (including hostile acts) and intropunitiveness. Social class, age and deprivation score were controlled for in multivariate analyses. The hostile thoughts scale emerged as a significant independent predictor of alcohol consumption in men and women (P < or = 0.01), and the models accounted for 4-9% of the variance in alcohol consumption. Hostile acts were independently predictive of smoking in men (P < or = 0.001), with the model accounting for 5% of the variance in smoking. Hostile thoughts were independently predictive of smoking in women (P < or = 0.001), and the model accounted for 4% of the variance in their smoking. We conclude that hostility may affect coronary risk through its influence on lifestyle-related coronary risk factors, although in future further elucidation of hostility type and standard measurement of hostility are necessary.

Randomized controlled trial of gamma-linolenic acid and eicosapentaenoic acid in peripheral arterial disease.

BACKGROUND AND AIMSnepidemiological studies suggest polyunsaturated fatty acids protect against the development of atherosclerosis. The aim of this study was to perform a randomized controlled trial of gamma-linolenic and eicosapentaenoic acids in patients with lower limb atherosclerosis. Main outcome measures were: cholesterol and lipoprotein concentrations; haemostatic and rheological variables; the ankle brachial pressure index; walking distance; and cardiovascular events and death.nnnMETHODSn120 men and women with stable intermittent claudication were randomized to 2 years treatment with either a combination of gamma-linolenic and eicosapentaenoic acids, or placebo.nnnRESULTSn39 (65.0 cent) of those taking fatty acids and 36 (60.0 cent) of those taking placebo completed the trial. Lipid concentrations did not differ significantly during the trial. In those taking fatty acids, haematocrit was significantly higher than in the placebo group after 6 months (46.1 cent compared with 44.6 cent, P </= 0.01), and systolic blood pressure was significantly lower after 2 years (150|mmHg compared with 161.8|mmHg, </= 0.05). There was no difference in walking distance, but there was a small reduction in non-fatal coronary events in the fatty acid group (10 cent compared with 15 cent, P > 0.05).nnnCONCLUSIONSna combination of polyunsaturated fatty acids produced a statistically significant reduction in systolic blood pressure, but no other significant benefits on risk factors. The trend towards fewer coronary events in those taking fatty acids warrants further investigation.

Persistent increase in the incidence of abdominal aortic aneurysm in Scotland, 1981–2000

In the 1970s and 1980s, mortality and morbidity rates for abdominal aortic aneurysm (AAA) increased throughout the developed world. As AAAs are associated with similar risk factors to other cardiovascular diseases that have recently decreased in incidence, the incidence of AAA should show a similar declining trend.