Skip to main content

Advertisement

SpringerLink
Log in

Self-Reported Peripheral Arterial Disease Predicts Future Vascular Events in a Community-Based Cohort

  • Original Article
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Background

Lower extremity peripheral arterial disease (PAD) is highly prevalent and strongly associated with cardiovascular morbidity and mortality. The ankle-brachial index used to screen for PAD is not routinely performed in primary care settings.

Objective

To determine if self-reported PAD is an independent predictor of combined vascular events (myocardial infarction, ischemic stroke, and vascular death).

Design

Ongoing population-based prospective cohort (the Northern Manhattan Study). Subjects enrolled between July 1993 and June 2001 with a mean follow-up time of 7.1 years.

Patients

Subjects (n = 2,977), aged 40 years or older and free of prior stroke or myocardial infarction, were classified as having self-reported PAD if they answered affirmatively to one of two questions regarding exercise-induced leg pain or a prior diagnosis of PAD.

Main Outcome Measures

Combined vascular outcome defined as incident myocardial infarction, incident ischemic stroke, or vascular death.

Results

The mean age of the cohort was 68.9 ± 10.4 years; 64% were women; 54% Hispanic, 25% African-American, 21% Caucasian; 15% reported having PAD. After a mean follow-up of 7.1 years, self-reported PAD was significantly predictive of combined events (n = 484) in the univariate model (HR 1.5, 95% CI, 1.2–1.9) and after adjustment for traditional cardiovascular risk factors (HR 1.3, 95% CI, 1.0–1.7).

Conclusion

Self-reported PAD is an independent risk factor for future vascular events in this predominantly non-white cohort. The addition of two simple PAD questions to the routine medical history in general medicine settings could identify high-risk patients who would benefit from further vascular evaluation and risk factor modification.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1

Similar content being viewed by others

References

  1. Belch JJ, Topol EJ, Agnelli G, et al. Critical issues in peripheral arterial disease detection and management: a call to action. Arch Intern Med. 2003;163(8):884–92, Apr 28.

    Article  PubMed  Google Scholar 

  2. Criqui MH, Denenberg JO, Langer RD, Fronek A. The epidemiology of peripheral arterial disease: importance of identifying the population at risk. Vasc Med. 1997;2:221–26.

    PubMed  CAS  Google Scholar 

  3. Fowkes FGR, Housley E, Cawood EHH, Macintyre CCA, Ruckley CV, Prescott RJ. Edinburgh Artery Study: prevalence of asymptomatic and symptomatic peripheral arterial disease in the general population. Int J Epidemiol. 1991;20:384–92.

    Article  PubMed  CAS  Google Scholar 

  4. Meijer WT, Hoes AW, Rutgers D, et al. Peripheral arterial disease in the elderly: the Rotterdam Study. Arterioscler Thromb Vasc Biol. 1998;18:185–92.

    PubMed  CAS  Google Scholar 

  5. Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286:1317–24.

    Article  PubMed  CAS  Google Scholar 

  6. Murabito JM, Evans JC, Larson MG, et al. The ankle-brachial index in the elderly and risk of stroke, coronary disease, and death. Arch Intern Med. 2003;163:1939–42.

    Article  PubMed  Google Scholar 

  7. Hertzer NR, Beven EG, Young JR, et al. Coronary artery disease in peripheral vascular patients: a classification of 1000 coronary angiograms and results of surgical management. Ann Surg. 1984;199:223–33.

    Article  PubMed  CAS  Google Scholar 

  8. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet. 1996;348:1329–39.

    Article  Google Scholar 

  9. Ness J, Aronow WS. Prevalence of coexistence of coronary artery disease, ischemic stroke, and peripheral arterial disease in older persons, mean age 80 years, in an academic hospital-based geriatrics practice. J Am Geriatr Soc. 1999;47:1255–56.

    PubMed  CAS  Google Scholar 

  10. Klop RB, Eikelboom BC, Taks AC. Screening of the internal carotid arteries in patients with peripheral vascular disease by colour-flow duplex scanning. Eur J Vasc Surg. 1991;5:41–45.

    Article  PubMed  CAS  Google Scholar 

  11. Criqui MH, Langer RD, Fronek A, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326:381–86.

    PubMed  CAS  Google Scholar 

  12. Newman AB, Shemanski L, Manolio TA, et al. Ankle-arm index as a predictor of cardiovascular disease and mortality in the Cardiovascular Health Study. Arterioscler Thromb Vasc Biol. 1999;19:538–45.

    PubMed  CAS  Google Scholar 

  13. Leng GC, Fowkes FG, Lee AJ, et al. Use of ankle brachial pressure to predict cardiovascular events and death: a cohort study. BMJ. 1996;313:1440–43.

    PubMed  CAS  Google Scholar 

  14. Zheng ZJ, Sharrett AR, Chambless LE, et al. Associations of ankle-brachial index with clinical coronary heart disease, stroke and preclinical carotid and popliteal atherosclerosis: the Atherosclerosis Risk in Communities (ARIC) Study. Atherosclerosis. 1997;131:115–25.

    Article  PubMed  CAS  Google Scholar 

  15. Leng GC, Lee AJ, Fowkes FG, et al. Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. Int J Epidemiol. 1996;25:1172–81.

    Article  PubMed  CAS  Google Scholar 

  16. Abbott RD, Rodriguez BL, Pretrovich H, et al. Ankle-brachial blood pressure in elderly men and the risk of stroke: the Honolulu Heart Program. J Clin Epidemiol. 2001;54:973–78.

    Article  PubMed  CAS  Google Scholar 

  17. McKenna M, Wolfson S, Kuller L. The ratio of ankle and arm arterial pressure as an independent predictor of mortality. Atherosclerosis. 1991;87:119–28.

    Article  PubMed  CAS  Google Scholar 

  18. Vogt MT, Cauley JA, Newman AB, et al. Decreased ankle/arm blood pressure index and mortality in elderly women. JAMA. 1993;270:465–69.

    Article  PubMed  CAS  Google Scholar 

  19. McDermott MM, Feinglass J, Slavensky R, et al. The ankle-brachial index as a predictor of survival in patients with peripheral vascular disease. J Gen Intern Med. 1994;9:445–49.

    Article  PubMed  CAS  Google Scholar 

  20. Ouriel K. Peripheral arterial disease. Lancet. 2001;358:1257–64.

    Article  PubMed  CAS  Google Scholar 

  21. Kannel WB, Skinner JJ, Schwartz MJ, Shurtleff D. Intermittent claudication: Incidence in the Framingham Study. Circulation. 1970;41:875–83.

    PubMed  CAS  Google Scholar 

  22. McDermott MM, Greenland P, Liu K, et al. Leg symptoms in peripheral arterial disease. Associated clinical characteristics and functional impairment. JAMA. 2001;286:1599–1606.

    Article  PubMed  CAS  Google Scholar 

  23. McLafferty RB, Dunnington GL, Mattos MA, et al. Factors affecting the diagnosis of peripheral vascular disease before vascular surgery referral. J Vasc Surg. 2000;31(5):870–79.

    Article  PubMed  CAS  Google Scholar 

  24. Ouriel K, McDonnell AE, Metz CE, Zarins CK. A critical evaluation of stress testing in the diagnosis of peripheral vascular disease. Surgery. 1982;91:686–93.

    PubMed  CAS  Google Scholar 

  25. Yao ST, Hobbs JT, Irvine W. Ankle systolic pressure measurements in arterial disease affecting the lower extremities. B J Surg. 1969;59:676–79.

    Article  Google Scholar 

  26. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary 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. J Am Coll Cardiol. 2006;47:1239–1312.

    Article  PubMed  Google Scholar 

  27. Mohler ER, Jacobson-Treat D, Reilly MP, et al. Utility and barriers to performance of the ankle-brachial index in primary care practice. Vasc Med. 2004;9(4):253–60.

    Article  PubMed  Google Scholar 

  28. Sacco RL, Anand K, Lee HS, et al. Homocysteine and the risk of ischemic stroke in a triethnic cohort. The Northern Manhattan Study. Stroke. 2004;35:2263–69.

    Article  PubMed  CAS  Google Scholar 

  29. White H, Boden-Albala B, Wang C, et al. Ischemic stroke subtype incidence among whites, blacks, and Hispanics: the Northern Manhattan Study. Circulation. 2005;111:1327–31.

    Article  PubMed  Google Scholar 

  30. Gentry EM, Kalsbeek WD, Hegelin GC et al. The Behavioral Risk Factor Surveys, II: design, methods, and estimates from combined state data. Am J Prev Med. 1985;1:9–14.

    PubMed  CAS  Google Scholar 

  31. Sacco RL, Elkind M, Boden-Albala B, et al. The protective effect of moderate alcohol consumption on ischemic stroke. JAMA. 1999;281:53–60.

    Article  PubMed  CAS  Google Scholar 

  32. World Health Organization MONICA Project Principal Investigators. The World Health Organization MONICA Project (monitoring trends and determinants in cardiovascular disease). J Clin Epidemiol. 1988;41:105–14.

    Article  Google Scholar 

  33. Greene HL, Richardson DW, Barker AH, et al. Classification of deaths after myocardial infarction as arrhythmic or nonarrhythmic (the Cardiac Arrhythmia Pilot Study). Am J Cardiol. 1989;63:1–6.

    Article  PubMed  CAS  Google Scholar 

  34. Morris DL, Kritchevsky SB, Davis CE. Serum carotenoids and coronary heart disease. The lipid research clinics coronary primary prevention trial and follow-up study. JAMA. 1994; 272:1439–41.

    Article  PubMed  CAS  Google Scholar 

  35. Wilson PWF, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97:1837–47.

    PubMed  CAS  Google Scholar 

  36. Lee AJ, Price JF, Russell MJ, Smith FB, vanWijk MCW, Fowkes FGR. Improved prediction of fatal myocardial infarction using the ankle-brachial index in addition to conventional risk factors. The Edinburgh Artery Study. Circulation. 2004;110:3075–80.

    Article  PubMed  CAS  Google Scholar 

  37. Rose GA. The diagnosis of ischaemic heart pain and intermittent claudication in field surveys. Bull World Health Organ. 1962;27:645–58.

    PubMed  CAS  Google Scholar 

  38. Leng GC, Fowkes FG. The Edinburgh Claudication Questionnaire: an improved version of the WHO/Rose Questionnaire for use in epidemiological surveys. J Clin Epidemiol. 1992;45:1101–09.

    Article  PubMed  CAS  Google Scholar 

  39. Criqui MH, Fronek A, Barrett-Connor E, et al. The prevalence of peripheral arterial disease in a defined population. Circulation. 1985;71:510–15.

    PubMed  CAS  Google Scholar 

  40. McDermott MM, Mehta S, Ahn H, Greenland P. Atherosclerotic risk factors are less intensively treated in patients with peripheral arterial disease than in patients with coronary artery disease. J Gen Intern Med. 1997;12:209–15.

    Article  PubMed  CAS  Google Scholar 

  41. Collins TC, Petersen NJ, Suarez-Almazor M, Ashton C. The prevalence of peripheral arterial disease in a racially diverse population. Arch Intern Med. 2003;163:1469–74.

    Article  PubMed  Google Scholar 

  42. Criqui MH, Vargas V, Denenberg JO, Ho E, Allison M, Langer RD, et al. Ethnicity and Peripheral Arterial Disease. The San Diego Population Study. Circulation. 2005;112:2703–07.

    Article  PubMed  Google Scholar 

  43. United States Preventive Services Task Force. Recommendation Statement: Screening for Peripheral Arterial Disease. Washington, DC: Agency for Healthcare Research and Quality, 2005:1–8.

  44. Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States. Results from the National Health and Nutrition Examination Survey 1999–2000. Circulation. 2004;110:738–43.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

This work was supported by grants from the National Institute of Neurological Disorders and Stroke (R01 NS 29993, T32 NS 07153) and the General Clinical Research Center (2 M01 RR00645). The data were presented in part in abstract form at the 18th Annual American Heart Association Scientific Sessions in November 2006.

Funding/Support

This work was supported by grants from the National Institute of Neurological Disorders and Stroke (R01 NS 29993, T32 NS 07153) and the General Clinical Research Center (2 M01 RR00645). The funding organizations had no role in the design and conduct of the study, in the collection, analysis, or interpretation of the data, or in the decision to approve publication of the manuscript.

Conflict of Interest

Dr. Tatjana Rundek is a member of the advisory boards for Pfizer and BMS-Sanofi Pharmaceutical Partnership and receives personal compensation from New Health Sciences, Inc., for consulting. Dr. Ralph Sacco discloses receiving personal compensation from Boehringer-Ingelheim, Inc., and BMS-Sanofi Pharmaceutical Partnership for lecturing, and personal compensation from Boehringer-Ingelheim, Inc., Merck, Wyeth, and GlaxoSmithKline for consulting.

Author information

Authors and Affiliations

  1. Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA

    Maya J. Salameh MD, Marco R. Di Tullio MD & Shunichi Homma MD

  2. Department of Neurology, University of Miami, Miller School of Medicine, Miami, FL, USA

    Tatjana Rundek MD, PhD

  3. Department of Neurology, Columbia University College of Physicians and Surgeons and Division of Socio-Medical Science, Columbia University Mailman School of Public Health, New York, NY, USA

    Bernadette Boden-Albala PhD

  4. Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, USA

    Zhezhen Jin PhD

  5. Department of Medicine, Johns Hopkins University Medical Center, Baltimore, MD, USA

    Elizabeth V. Ratchford MD

  6. Department of Neurology, Epidemiology, and Human Genetics, University of Miami, Miller School of Medicine, Miami, FL, USA

    Ralph L. Sacco MD, MS

Authors
  1. Maya J. Salameh MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Tatjana Rundek MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Bernadette Boden-Albala PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Zhezhen Jin PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Elizabeth V. Ratchford MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Marco R. Di Tullio MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Shunichi Homma MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Ralph L. Sacco MD, MS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Maya J. Salameh MD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Salameh, M.J., Rundek, T., Boden-Albala, B. et al. Self-Reported Peripheral Arterial Disease Predicts Future Vascular Events in a Community-Based Cohort. J GEN INTERN MED 23, 1423–1428 (2008). https://doi.org/10.1007/s11606-008-0694-x

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-008-0694-x

KEY WORDS

Search

Navigation