Marc Cairols

Relationship between Ankle-Brachial Index and Chronic Kidney Disease in Hypertensive Patients with No Known Cardiovascular Disease

Both decreased GFR and albuminuria are associated with an elevated prevalence of peripheral artery disease. However, the combined effects of these alterations previously were not evaluated. Patients with hypertension and with no known vascular disease (n = 955; mean age 66 yr; 56% male) were selected from internal medicine outpatient clinics throughout Spain. Cardiovascular risk factors, urinary albumin excretion, and the ankle-brachial index (ABI) were assessed in all participants. GFR was estimated according to the Cockroft-Gault equation. Of the study population, 62% had diabetes, 23.8% had a GFR <60 ml/min per 1.73 m2, and 43.8% had albuminuria. The prevalence of ABI <0.9 was greater in patients with a GFR <60 ml/min per 1.73 m2 (37.4 versus 24.3%; P < 0.0001) and in those who had albuminuria (32.2 versus 23.3%; P = 0.001). In patients with both alterations, the prevalence of ABI <0.9 was 45.7%. Multivariate analysis indicated that the factors that were associated independently with low ABI were age (odds ratio [OR] 1.06; 95% confidence interval [CI] 1.03 to 1.08; P < 0.0001), triglyceride concentration (OR 1.003; 95% CI 1.001 to 1.005; P = 0.001), presence of albuminuria (OR 1.61; 95% CI 1.18 to 2.20; P = 0.003), smoking habit (OR 1.72; 95% CI 1.13 to 2.63; P = 0.012), and a GFR <60 ml/min per 1.73 m2 (OR 1.47; 95% CI 1.01 to 2.17; P = 0.049). In patients with hypertension and without known vascular disease, reduced GFR and albuminuria are associated independently with an ABI <0.9. Their combined presence characterizes a subgroup of the population who have an elevated prevalence of peripheral artery disease and could benefit from early diagnosis and treatment.

Sub-clinical vascular disease in type 2 diabetic subjects: relationship with chronic complications of diabetes and the presence of cardiovascular disease risk factors.

BACKGROUND We evaluated the association between a low ankle-brachial index (ABI), chronic complications of diabetes, and the presence of traditional cardiovascular disease risk factors in subjects with type 2 diabetes but without known cardiovascular disease. METHODS We included diabetic subjects (n=923; 52% male; age range 50-85 years) without clinical evidence of coronary, cerebrovascular, or peripheral artery disease (PAD). A history of nephropathy, retinopathy, or neuropathy was collected from the medical records. A 12-lead electrocardiogram and ABI measurements were conducted on all study participants. RESULTS The mean duration of diabetes was 9.6 years. Prevalence of a low ABI (<0.9) was 26.2%. Multivariate analysis indicated that factors significantly associated with a low ABI were age (OR: 1.06; 95%CI: 1.033-1.084; p<0.001), plasma triglyceride concentration (OR: 1.002; 95%CI: 1.001-1.004; p=0.006), duration of diabetes (OR: 1.029; 95%CI: 1.008-1.051; p=0.007), and smoking habit (OR: 1.755; 95%CI: 1.053-2.925; p=0.03). The presence of nephropathy, neuropathy, retinopathy, left ventricular hypertrophy, left bundle branch block, and atrial fibrillation were all associated with a low ABI, but only renal disease remained significant after adjusting for age, duration of diabetes, and cardiovascular risk factors. CONCLUSION A low ABI is highly prevalent in subjects with diabetes and is related to age, duration of diabetes, smoking habit, and hypertriglyceridemia. Although chronic complications are frequently associated with a low ABI, only renal damage is independently associated with peripheral artery disease.

Prevalencia de enfermedad arterial periférica asintomàtica, estimada mediante el índice tobillo-brazo, en pacientes con enfermedad vascular. Estudio MERITO II

Fundamento y objetivo Los pacientes con enfermedad arterial en varios territorios presentan una elevada tasa de complicaciones vasculares y de mortalidad. Su identificacion permitiria definir a un subgrupo de la poblacion de muy alto riesgo, candidatos a recibir medidas preventivas mas energicas. El objetivo del presente estudio ha sido estimar la prevalencia de enfermedad arterial periferica subclinica en personas con antecedentes de enfermedad vascular en otros territorios arteriales. Pacientes y metodo Se incluyo en el estudio a pacientes con historia de enfermedad coronaria y/o cerebrovascular entre los 3 meses y los 5 anos previos, atendidos en consultas de medicina interna repartidas por toda la geografia nacional. Se les realizaron anamnesis, exploracion fisica, analitica sanguinea y urinaria, y se les determino el indice tobillo-brazo (ITB). Resultados Se estudio a 1.203 pacientes (64% varones), con una edad media de 74,3 anos. El 55,4% tenia antecedentes de enfermedad coronaria, un 38% de enfermedad cerebrovascular y un 6,7% de afectacion en ambos territorios. La prevalencia de ITB bajo ( Conclusiones La prevalencia de un ITB bajo es elevada en pacientes asintomaticos con enfermedad coronaria o cerebrovascular, especialmente si presentan afectacion conjunta de ambos territorios.

Índice tobillo-brazo y riesgo vascular

88.450 La eficacia de diferentes medidas terapeuticas para prevenir un primer episodio cardiovascular y/o cerebrovascular ha sido puesta de manifiesto en diversos ensayos de intervencion. Asi, el tratamiento con antiagregantes, hipolipemiantes y antihipertensivos ha demostrado reducciones significativas en la morbimortalidad de origen vascular en prevencion primaria. Este hecho es aun mas llamativo si tenemos en consideracion que el beneficio de los hipolipemiantes ha sido demostrado en sujetos sin hipercolesterolemia y el de los antihipertensivos en personas con cifras tensionales normales. Sin embargo, dada la necesidad de racionalizar los recursos, la utilizacion de estos farmacos requiere la identificacion de aquellas personas cuyo riesgo de complicaciones vasculares sea lo suficientemente alto como para que el beneficio del tratamiento, en terminos de reduccion absoluta de riesgo, supere los inconvenientes derivados del numero potencial de efectos adversos y del coste economico de un tratamiento que, generalmente, debe ser mantenido durante toda la vida. El termino «factor de riesgo cardiovascular» fue introducido por primera vez a partir de las observaciones procedentes del seguimiento de la cohorte de Framingham en la decada de los cincuenta. Actualmente, la estimacion del riesgo cardiovascular global se sustenta en la utilizacion de formulas derivadas de este estudio, las cuales tienen en consideracion tanto el numero como la gravedad de los diferentes factores de riesgo alli identificados. A pesar de tratarse de un instrumento valioso, no identifica a la totalidad de los pacientes que presentan un primer episodio vascular. Ademas, su utilidad en otras poblaciones distintas de aquellas donde se han generado sobrevalora el riesgo cardiovascular si en la zona de aplicacion existe una baja incidencia de enfermedad coronaria, como es el caso de nuestro pais. Estos inconvenientes han conducido a la busqueda activa de nuevos marcadores que mejoren la prediccion del riesgo y, sobre todo, a la busqueda de nuevas tecnicas que permitan un diagnostico incruento de la enfermedad arterial, coronaria o cerebral asintomatica. Algunas de estas tecnicas, como la eco-Doppler de troncos supraaorticos (TSA) tienen un valor predictivo moderado y exigen un instrumental y entrenamiento que no facilitan su utilizacion generalizada. Otras estan actualmente en fase de investigacion. La resonancia magnetica (RM), la tomografia computarizada (TC) con haz de electrones o la TC helicoidal permiten una evaluacion directa del arbol coronario. Si bien el valor predictivo de estas tecnicas todavia no esta establecido, se puede estimar que son procedimientos costosos que permitiran evaluar el riesgo en determinados sujetos pero no serviran para realizar estrategias diagnosticas a grandes grupos de poblacion.

Características clínicas y evolución intrahospitalaria de los pacientes con isquemia crítica de miembros inferiores: estudio ICEBERG

BACKGROUND AND OBJECTIVES Critical leg ischemia (CLI) is a medical emergency with a high morbidity and mortality. Although its prognosis has improved during the last years, there are no data on its clinical characteristics, treatment and in-hospital prognosis in our country. PATIENTS AND METHOD 671 patients (81% males, mean age 71.2 years) with atherosclerotic CLI, attended in 46 departments of vascular surgery were included in the study. RESULTS Participants had a high prevalence of cardiovascular risk factors (72% hypertensive, 27% current smokers, 59% diabetics) and comorbidity (25% coronary heart disease, 18% cerebrovascular disease). 71% had a previous diagnosis of peripheral arterial disease. Upon admission, 71% were referred for revascularization, 5% for direct amputation and 24% for conservative treatment. During hospitalization 22 patients died and 49 were discharged with a major amputation. On multivariate analysis, the only factor associated with the risk of amputation was gangrenous lesions (OR 2.45; IC95% 1.22-4.92). Factors associated with mortality were the presence of chronic renal failure (OR 3.38; IC95% 1.36-8.39) and previous CLI (OR 0.20; IC95% 0.05-0.89). At discharge, 59% received lipid lowering drugs, 70% blood-pressure lowering medications and 85% antiplatelet drugs. CONCLUSION CLI patients attended in Spanish vascular surgery departments have a low amputation rate and a low hospital mortality. However, and due to their high cardiovascular risk, it is necessary to improve the prescription rate of evidence-based cardiovascular prevention therapies at discharge.

Thigh and buttock exertional pain for the diagnosis of peripheral arterial disease

OBJECTIVES To evaluate the prevalence of both non-calf intermittent claudication (IC) and classic IC in patients with no known atherosclerotic disease, and their accuracy to detect peripheral arterial disease (PAD). DESIGN Cross sectional, observational study conducted at 96 internal medicine services. MATERIALS AND METHODS 1487 outpatients with no known atherosclerotic disease, and either diabetes or a SCORE risk estimation of at least 3% were enrolled. IC was assessed using the Edinburgh Claudication Questionnaire and PAD was confirmed by an ankle-brachial index (ABI) <0.9. RESULTS Overall, 7.2% met criteria of classic and 5.8% of non-calf IC. PAD was diagnosed in 393 cases (26.4%). In these PAD patients, 17.8% exhibited classic and 13.2% non-calf IC. Both calf and non-calf IC had similar overall accuracy for detecting PAD. Considering both categories as a whole, the sensitivity of IC to predict a low ABI was 31% and the specificity 93%. CONCLUSIONS Non-calf IC is comparable to classic IC for the diagnosis of PAD in patients with no known arterial disease. The systematic implementation of Edinburgh Claudication Questionnaire could be a valuable call-to-action to improve clinical evaluation of PAD, bearing in mind that PAD detected by either non-calf or classic IC must be confirmed by ABI testing.

Nuevos anticoagulantes orales: una visión multidisciplinaria

Juan Ignacio Arcelus , Marc Cairols , Xavier Granero , David Jiménez , Juan Vicente Llau , Manuel Monreal f, y Vicente Vicente g a Departamento de Cirugı́a, Hospital Virgen de las Nieves, Universidad de Granada, Granada, España b Servicio de Angiologı́a y Cirugı́a Vascular, Hospital Universitari de Bellvitge, Barcelona, España c Servicio de Cirugı́a Ortopédica y Traumatologı́a, Hospital Universitari Germans Trias i Pujol de Badalona, Barcelona, España d Servicio de Neumologı́a, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, España e Servicio de Anestesiologı́a y Reanimación, Hospital Clı́nic Universitari de Valencia, Valencia, España f Servicio de Medicina Interna, Hospital Universitari Germans Trias i Pujol de Badalona, Barcelona, España g Departamento de Hematologı́a y Oncologı́a Clı́nica, Universidad de Murcia, Murcia, España