https://vascular.stanford.edu/content/dam/sm/vascular/documents/endovasc/guidelines/PIIS0741521406022968.pdf

Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II)

https://journal.chestnet.org/article/S0012-3692(12)60129-9/pdf

Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.

Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic) A Collaborative Report from the American Association for Vascular Surgery/Society for Vascular Surgery,* Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation

/pdf/acc-aha-2005-practice-guidelines-for-the-management-of-4ltfid6e9i.pdf

ACC/AHA 2005 Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)

Levels of low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides and total cholesterol are heritable, modifiable risk factors for coronary artery disease. To identify new loci and refine known loci influencing these lipids, we examined 188,577 individuals using genome-wide and custom genotyping arrays. We identify and annotate 157 loci associated with lipid levels at P < 5 × 10(-8), including 62 loci not previously associated with lipid levels in humans. Using dense genotyping in individuals of European, East Asian, South Asian and African ancestry, we narrow association signals in 12 loci. We find that loci associated with blood lipid levels are often associated with cardiovascular and metabolic traits, including coronary artery disease, type 2 diabetes, blood pressure, waist-hip ratio and body mass index. Our results demonstrate the value of using genetic data from individuals of diverse ancestry and provide insights into the biological mechanisms regulating blood lipids to guide future genetic, biological and therapeutic research.

/pdf/discovery-and-refinement-of-loci-associated-with-lipid-17wc78w8iu.pdf

Discovery and refinement of loci associated with lipid levels

ContextPeripheral arterial disease (PAD) is a manifestation of systemic atherosclerosis
that is common and is associated with an increased risk of death and ischemic
events, yet may be underdiagnosed in primary care practice.ObjectiveTo assess the feasibility of detecting PAD in primary care clinics,
patient and physician awareness of PAD, and intensity of risk factor treatment
and use of antiplatelet therapies in primary care clinics.Design and SettingThe PAD Awareness, Risk, and Treatment: New Resources for Survival (PARTNERS)
program, a multicenter, cross-sectional study conducted at 27 sites in 25
cities and 350 primary care practices throughout the United States in June-October
1999.PatientsA total of 6979 patients aged 70 years or older or aged 50 through 69
years with history of cigarette smoking or diabetes were evaluated by history
and by measurement of the ankle-brachial index (ABI). PAD was considered present
if the ABI was 0.90 or less, if it was documented in the medical record, or
if there was a history of limb revascularization. Cardiovascular disease (CVD)
was defined as a history of atherosclerotic coronary, cerebral, or abdominal
aortic aneurysmal disease.Main Outcome MeasuresFrequency of detection of PAD; physician and patient awareness of PAD
diagnosis; treatment intensity in PAD patients compared with treatment of
other forms of CVD and with patients without clinical evidence of atherosclerosis.ResultsPAD was detected in 1865 patients (29%); 825 of these (44%) had PAD
only, without evidence of CVD. Overall, 13% had PAD only, 16% had PAD and
CVD, 24% had CVD only, and 47% had neither PAD nor CVD (the reference group).
There were 457 patients (55%) with newly diagnosed PAD only and 366 (35%)
with PAD and CVD who were newly diagnosed during the survey. Eighty-three
percent of patients with prior PAD were aware of their diagnosis, but only
49% of physicians were aware of this diagnosis. Among patients with PAD, classic
claudication was distinctly uncommon (11%). Patients with PAD had similar
atherosclerosis risk factor profiles compared with those who had CVD. Smoking
behavior was more frequently treated in patients with new (53%) and prior
PAD (51%) only than in those with CVD only (35%; P
<.001). Hypertension was treated less frequently in new (84%) and prior
PAD (88%) only vs CVD only (95%; P <.001) and
hyperlipidemia was treated less frequently in new (44%) and prior PAD (56%)
only vs CVD only (73%, P<.001). Antiplatelet medications
were prescribed less often in patients with new (33%) and prior PAD (54%)
only vs CVD only (71%, P<.001). Treatment intensity
for diabetes and use of hormone replacement therapy in women were similar
across all groups.ConclusionsPrevalence of PAD in primary care practices is high, yet physician awareness
of the PAD diagnosis is relatively low. A simple ABI measurement identified
a large number of patients with previously unrecognized PAD. Atherosclerosis
risk factors were very prevalent in PAD patients, but these patients received
less intensive treatment for lipid disorders and hypertension and were prescribed
antiplatelet therapy less frequently than were patients with CVD. These results
demonstrate that underdiagnosis of PAD in primary care practice may be a barrier
to effective secondary prevention of the high ischemic cardiovascular risk
associated with PAD.

https://jamanetwork.com/journals/jama/articlepdf/194205/joc11056.pdf

Peripheral Arterial Disease Detection, Awareness, and Treatment in Primary Care

Intermittent claudication has been studied in cardiovascular surveys but limited information is available on asymptomatic peripheral arterial disease. The purpose of this paper is to describe the prevalence of both asymptomatic and symptomatic disease and relation to ischaemic heart disease in the Edinburgh Artery Study. A cross-sectional survey was conducted on an age-stratified sample of men and women aged 55 to 74 years selected from age-sex registers in ten general practices in the city. Arterial disease was assessed in 1592 participants by means of the WHO questionnaire on intermittent claudication and measurement of the ankle brachial systolic pressure index (ABPI) and change in ankle systolic pressure during reactive hyperaemia. The prevalence of intermittent claudication was 4.5% (95% confidence interval (CI): 3.5%-5.5%). Major asymptomatic disease causing a significant impairment of blood flow occurred in 8.0% (95% CI: 6.6%-9.4%). A further 16.6% (95% CI: 14.6%-18.5%) had criteria considered abnormal in clinical practice: 9.0% had ABPI less than 0.9 and 7.6% had reactive hyperaemia pressure reduction greater than 20%. Intermittent claudication was equally common in both sexes. The ABPI and reactive hyperaemia results suggested a slight preponderance of asymptomatic disease in males and were consistent with an increasing prevalence with age and lower social class. Mean ABPI was higher in normal men than women, and was lower in the left leg than the right suggesting a unilateral predisposition to disease. Subjects with major asymptomatic disease had more evidence of ischaemic heart disease than in the normal population (relative risk (RR) 1.6; 95% CI: 1.3-1.9).(ABSTRACT TRUNCATED AT 250 WORDS)

Edinburgh Artery Study: Prevalence of Asymptomatic and Symptomatic Peripheral Arterial Disease in the General Population

Background Intermittent claudication is associated with a poor prognosis, but less is known of the risks associated with asymptomatic peripheral arterial disease. The aims of this study were to determine the incidence and natural history of claudication, and the incidence of cardiovascular events in symptomatic and asymptomatic peripheral arterial disease. Methods In 1988, 1592 subjects aged 55-74 years were selected randomly from the age-sex register of 10 general practices in Edinburgh, Scotland. The presence of peripheral arterial disease was determined by the World Health Organization questionnaire on intermittent claudication, the ankle brachial pressure index and a reactive hyperaemia test. This cohort was followed prospectively over 5 years for subsequent cardiovascular events and death. Results One hundred and sixteen new cases of claudication were identified (incidence density 15.5 per 1000 person-years). Of those with claudication at baseline, 28.8% and still had pain after 5 years, 8.2% underwent vascular surgery or amputation, and 1.4% developed leg ulceration. Claudicants had a significantly increased risk of developing angina compared with normals (RR: 2.31, 95% CI: 1.04-5.10), and asymptomatic subjects had a slightly increased risk of myocardial infarction and stroke. Deaths from cardiovascular disease were more likely in both claudicants (RR: 2.67, 95% CI: 1.34-5.29) and subjects with major (RR: 2.08, 95% CI: 1.13-3.83) or minor asymptomatic disease (RR: 1.74, 95% CI: 1.09-2.76). Subjects with major asymptomatic disease also had an increased risk of non-cardiovascular death (RR: 2.19, 95% CI: 1.33-3.59), and therefore had the highest overall risk of death (RR: 2.44, 95% CI: 1.59-3.74). Conclusions Subjects with asymptomatic peripheral arterial disease appear to have the same increased risk of cardiovascular events and death found in claudicants.

/pdf/incidence-natural-history-and-cardiovascular-events-in-3tdnaep805.pdf

Incidence, Natural History and Cardiovascular Events in Symptomatic and Asymptomatic Peripheral Arterial Disease in the General Population

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 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

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

The reproducibility and sources of variation in ankle and brachial systolic pressures were determined for a reactive hyperaemia test used to assess peripheral arterial disease in the lower limbs Thirty-six subjects had repeat measurements taken by four observers on two separate days using a Doppler probe and random zero sphygmomanometer Ankle pressures were measured before and after 4 min of arterial occlusion above the knee The 95 per cent confidence limits for a postocclusion reduction in pressure was approximately +/- 25 mmHg and for the postocclusion ankle-brachial ratio was +/- 20 per cent The corresponding figures for the mean of four measurements taken by two observers on 2 days was approximately +/- 17 mmHg and +/- 13 per cent In patients with vascular disease analysis of variance showed that the greatest sources of variation in the postocclusion ankle-brachial ratio were the 'biological' variations between subjects and between legs But for postocclusion reductions in pressure, variability due to observers and repeat readings was as important as the 'biological' differences between subjects and legs Thus, in respect of variability, the ratio may be a better parameter to detect differences between subjects

E Housley

Papers

Edinburgh Artery Study: Prevalence of Asymptomatic and Symptomatic Peripheral Arterial Disease in the General Population

Incidence, Natural History and Cardiovascular Events in Symptomatic and Asymptomatic Peripheral Arterial Disease in the General Population

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

Reproducibility of reactive hyperaemia test in the measurement of peripheral arterial disease.

Variability ofankle andbrachial systolic pressuresin themeasurementofatherosclerotic peripheral arterial