Markus Schwertfeger

Peripheral Arterial Disease as an Independent Predictor for Excess Stroke Morbidity and Mortality in Primary-Care Patients: 5-Year Results of the getABI Study

Background:There is controversial evidence with regard to the significance of peripheral arterial disease (PAD) as an indicator for future stroke risk. We aimed to quantify the risk increase for mortality and morbidity associated with PAD. Methods:In an open, prospective, noninterventional cohort study in the primary care setting, a total of 6,880 unselected patients ≧65 years were categorized according to the presence or absence of PAD and followed up for vascular events or deaths over 5 years. PAD was defined as ankle-brachial index (ABI) <0.9 or history of previous peripheral revascularization and/or limb amputation and/or intermittent claudication. Associations between known cardiovascular risk factors including PAD and cerebrovascular mortality/events were analyzed in a multivariate Cox regression model. Results:During the 5-year follow-up [29,915 patient-years (PY)], 183 patients had a stroke (incidence per 1,000 PY: 6.1 cases). In patients with PAD (n = 1,429) compared to those without PAD (n = 5,392), the incidence of all stroke types standardized per 1,000 PY, with the exception of hemorrhagic stroke, was about doubled (for fatal stroke tripled). The corresponding adjusted hazard ratios were 1.6 (95% confidence interval, CI, 1.1–2.2) for total stroke, 1.7 (95% CI 1.2–2.5) for ischemic stroke, 0.7 (95% CI 0.2–2.2) for hemorrhagic stroke, 2.5 (95% CI 1.2–5.2) for fatal stroke and 1.4 (95% CI 0.9–2.1) for nonfatal stroke. Lower ABI categories were associated with higher stroke rates. Besides high age, previous stroke and diabetes mellitus, PAD was a significant independent predictor for ischemic stroke. Conclusions:The risk of stroke is substantially increased in PAD patients, and PAD is a strong independent predictor for stroke.

Prognostic value of a low post-exercise ankle brachial index as assessed by primary care physicians

OBJECTIVE We aimed to investigate whether the post-exercise ankle brachial index (ABI) performed by primary care physicians offers useful information for the prediction of death or cardiovascular events, beyond the traditional resting ABI. An additional focus was on patients with intermittent claudication and normal resting ABI. METHODS Using data from the 5-year follow-up of 6468 elderly patients in the primary care setting in Germany (getABI study) we used multivariate Cox regression models adjusted for age, gender and conventional risk factors to determine the association of resting ABI and/or post-exercise ABI and all-cause mortality/morbidity. RESULTS Mean post-exercise ABI in the total cohort was 0.977 and resting ABI was 1.034. For post-exercise ABI, a threshold value of 0.825 had nearly the same sensitivity (28.6%) and specificity (85.7%) as the conventionally used resting ABI with a cut-off value of 0.9 to predict death. Compared to patients with normal post-exercise ABI, a low post-exercise ABI was associated with an almost identical risk increase for mortality (hazard ratio [HR] 1.56, 95% confidence interval [CI] 1.30-1.86) as a low resting ABI (HR 1.65; CI 1.39-1.97) and/or myocardial infarction/stroke. Slight differences were observed for coronary/carotid revascularisation and peripheral revascularisation/amputation. In combined models it could not be shown that post-exercise ABI yielded relevant additional information for the prognosis of mortality and/or myocardial infarction/stroke, not even in the subgroup analysis of patients with intermittent claudication and normal resting ABI. CONCLUSIONS It could not be shown that the post-exercise ABI is a useful tool for the prognosis of mortality and/or myocardial infarction/stroke beyond the resting ABI.

Stellenwert der frühzeitigen Diagnostik und Behandlung der Peripheren Arteriellen Verschlusskrankheit für die Prävention kardiovaskulärer Ereignisse

Zahlreiche epidemiologische Studien konnten den Zusammenhang zwischen einer peripheren arteriellen Verschlusskrankheit (PAVK) und vorzeitigem Tod sowie erhohten koronaren bzw. zerebrovaskularen Ereignisraten belegen. Hieraus lasst sich unmittelbar die Forderung ableiten, dass Risikopatienten fruhzeitig und systematisch auf das Vorliegen einer PAVK gescreent werden sollten, und — bei bestatigtem Verdacht — stringente sekundarpraventive Masnahmen (Risikofaktorenmanagement) eingeleitet werden sollten. Ein solches Vorgehen wird auch von den Fachgesellschaft en empfohlen.

Die Bedeutung der peripheren arteriellen Verschlusskrankheit beim Diabetes mellitus

ZusammenfassungDer Diabetes mellitus wie auch die periphere arterielle Verschlusskrankheit (PAVK) haben substanzielle Bedeutung für die Morbidität, Lebensqualität und Mortalität der betroffenen Patienten. Der vorliegende Artikel beschreibt die Prävalenz beider Erkrankungen sowie die Diagnostik und Prognose der PAVK. Von älteren Personen in der Hausarztpraxis haben jeweils etwa ein Viertel einen Diabetes bzw. eine PAVK und 7,5% beide Erkrankungen gleichzeitig. Für die Diagnose der PAVK sind die Basisuntersuchungen Inspektion, Palpation, Auskultation nicht verlässlich genug und müssen um die Doppler-sonographische Bestimmung des Knöchel-Arm-Index (ABI) in Ruhe und ggf. nach Belastung ergänzt werden. Nach den aktuellen Leitlinien verschiedener wissenschaftlich-medizinischer Gesellschaften ist diese Screening-Untersuchung das Mittel der Wahl. Nur bei einem kleinen Anteil der Diabetespatienten kann der ABI wegen einer Mediasklerose nicht zuverlässig bestimmt werden. Das Risiko eines frühzeitigen Versterbens der Patienten mit PAVK scheint über dem des Diabetes zu liegen, und es ist bei gleichzeitigem Vorliegen beider Erkrankungen dramatisch erhöht. Im Hinblick auf das stark erhöhte Risiko von Patienten mit Diabetes und gleichzeitiger PAVK ist eine intensive Behandlung der Risikofaktoren dieser Hochrisikopatienten von großer Bedeutung.AbstractDiabetes mellitus and peripheral arterial disease (PAD) both have a significant impact on morbidity, quality of life and mortality in affected patients. The present article describes the prevalence of these two diseases, as well as the diagnosis and prognosis of PAD. Approximately a quarter of patients presenting at their general practitioner have diabetes or PAD, respectiveley 7.5% of these have both concomitantly. Basic examinations, palpation and auscultation are insufficiently reliable to establish the diagnosis of PAD and need to be complemented by resting and, where necessary, Doppler sonography measurement of the ankle-brachial index (ABI). According to the current guidelines of several medical societies, this screening examination is the method of choice. Only in a small number of diabetes patients is it not possible to reliably measure ABI due to medial sclerosis. The risk of premature mortality as a result of PAD seems to be higher than that of diabetes, and the risk increases dramatically in the presence of both diseases. In view of the significantly increased risk in diabetes patients with concomitant PAD, intensive treatment of risk factors in these high-risk patients is essential.

Secondary prevention with clopidogrel or acetylsalicylic acid after acute cerebrovascular event. Health services research study of private primary care specialists

BACKGROUND Current guidelines on stroke prevention recommend long-term antiplatelet therapy. Clopidogrel is primarily indicated in patients at higher risk. This investigation documented the current situation of patients who are treated with clopidogrel and/or acetylicsalicylic acid (ASA) following an acute ischemic cerebrovascular event (stroke or transient ischemic attack, TIA) in a primary care setting. PATIENTS AND METHODS Prospective, cross sectional study with 2095 patients in 642 physician offices. RESULTS Patients were 69.0 +/- 10.2 years old (58.2% were men). Ischemic stroke was reported in 57.3% and TIA in 46.0% (several events in one given patient possible). Cardiovascular risk factors were frequent (arterial hypertension 87.6%, hyperlipidaemia 75.3%, diabetes mellitus 42.5%, and smoking in 27.2%) as were atherothrombotic comorbidities (stable coronary artery disease 23.3%, unstable CAD 11.6%, peripheral arterial hypertension 26.6%). A stratification according to the Essen Stroke Risk Score (ESRS) showed that 80.2% of the patients had a high risk of recurrent events. Patients with clopidogrel monotherapy or combination therapy (47.2% and 39.2% of the cohort) compared to ASA monotherapy (16.6%) were more frequently male, had more often a private insurance, a higher number of risk factors and comorbidities as well as a higher ESRS. Long-term antiplatelet therapy was planned by the treating physicians in 6.5% of patients on clopidogrel monotherapy in 33.6% on combination therapy and in 93.4% on ASA monotherapy. CONCLUSION Patients with an acute cerebrovascular event have multiple comorbidities and are therefore relatively frequently treated with clopidogrel. It is striking that in a number of patients no long-term anti-platelet therapy was recommended by the primary care physician.