It is time for population-based data on lower extremity edema

Case Presentation: An 80 year old female with medical history of hypertension, diabetes mellitus, chronic atrial fibrillation presented with four weeks of lower extremity edema and dyspnea. Notably, she had also been taking Golimumab for 6 months for Rheumatoid Arthritis (RA). Vital signs on presentations were: Temp:99 F, HR: 140bpm, BP: 105/64, oxygen saturation of 88% on room air. Physical exam revealed crackles at the mid lower lung fields bilaterally and 2+ lower extremity edema. EKG showed new ST inversions in lead 1, avF and V2. Troponin T was elevated to 0.11 ng/ml and proBNP was 21,246 pg/ml. Chest X Ray showed cardiomegaly with diffuse alveolar opacities. Transthoracic echocardiogram (TTE) revealed severely reduced left ventricular systolic function with LVEF of 25-29%, left ventricular regional wall hypokinesis and mildly reduced right ventricular systolic function. All findings were new compared to her last TTE 3 months prior, which showed preserved biventricular systolic function. Coronary angiography revealed no coronary artery disease. The patient was started on intravenous furosemide, and her home beta blocker and ARB were resumed. The patient’s Golimumab was discontinued given prior reports of TNF alpha inhibitor induced cardiomyopathy. Over the ensuing days, she was aggressively diuresed with improvement in oxygenation and ultimately discharged home. Three months after discontinuation of Golimumab, repeat TTE showed normalization of biventricular systolic function. Discussion: TNF alpha inhibitors have revolutionized the treatment of chronic immune mediated inflammatory diseases. Several TNF alpha inhibitors have been associated with cardiomyopathy, however there remains a paucity of evidence regarding cardiotoxicity with Golimumab. We now present, to our knowledge, the first reported case of reversible heart failure due to Golimumab in an 80 year old woman with RA. Golimumab, like other TNF alpha inhibitors, represents a historic advancement in the treatment of immune mediated inflammatory diseases. However, our case implicates this innovative drug in cardiotoxicity similar to other TNF alpha inhibitors. Further prospective studies are needed to establish a stronger correlation between Golimumab and cardiotoxicity.

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Abstract P162: The Baseline Ankle Brachial Index (ABI), but Not Change in the ABI, is Associated With 11-Year Change in the SF-36: The San Diego Population Study (SDPS)

Circulation ◽

10.1161/circ.131.suppl_1.p162 ◽

2015 ◽

Vol 131 (suppl_1) ◽

Author(s):

Christina L Wassel ◽

Matthew A Allison ◽

Joachim H Ix ◽

Julie O Denenberg ◽

Dena E Rifkin ◽

...

Keyword(s):

Quality Of Life ◽

Lower Extremity ◽

Physical Functioning ◽

Ankle Brachial Index ◽

Population Based ◽

Component Score ◽

Lower Baseline ◽

Sf 36

Background: Lower extremity peripheral artery disease (PAD) affects approximately 9 million people in the US. Less well-recognized is that PAD, even when asymptomatic, is associated with decreased functional status and quality of life. Previous studies have largely examined associations of the ankle brachial index (ABI) and quality of life in participants with PAD. To our knowledge no studies have examined the impact of ABI and change in ABI on change in quality of life in a population-based setting. Methods: The SDPS is a population-based prospective study that evaluated non-Hispanic White, African-American, Hispanic and Asian men and women for lower extremity PAD at two examinations approximately 11 years apart. Participants completed the SF-36 questionnaire, and 802 participants had ABI and SF-36 data available at both examinations. Analyses were restricted to these participants who also had a baseline ABI<1.4. Growth curve models were used to assess the associations of baseline ABI and change in the ABI with change in the SF-36 physical component score (PCS) and mental component score (MCS) over time. Change in the ABI was defined as (follow-up ABI - baseline ABI)/baseline ABI. Results: Participants were on average 57±9 years of age at baseline, and 69±9 at follow-up. At baseline, nearly 2 percent had ABI≤0.90, and the mean±SD ABI was 1.12±0.10. After adjustment for age, sex, race/ethnicity, BMI, ever smoking, physical activity, hypertension, diabetes, and dyslipidemia, each SD lower baseline ABI was significantly associated with an average change of -0.63 points (95% CI (-0.10, -1.17), p=0.02) on the PCS. This association was marginally significant for the MCS (-0.54 points (0.14, 1.22), p=0.12). Lower baseline ABI was also associated with negative change in two SF-36 subscales, physical functioning (p=0.02) and vitality (p=0.01). Change in the ABI over 11 years was not associated with change in the MCS (p=0.97) or PCS (p=0.41). Results were similar when excluding participants with ABI≤0.90. Conclusions: A lower ABI at baseline is associated with a significantly worse physical functioning quality of life approximately 11 years later. However change in the ABI was not significantly associated with change in quality of life over this time period. Additional studies are warranted in larger samples, especially to confirm the lack of findings for change in ABI.

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Survival and factors predicting mortality after major and minor lower-extremity amputations among patients with diabetes: a population-based study using health information systems

BMJ Open Diabetes Research & Care ◽

10.1136/bmjdrc-2020-001355 ◽

2020 ◽

Vol 8 (1) ◽

pp. e001355

Author(s):

Silvia Cascini ◽

Nera Agabiti ◽

Marina Davoli ◽

Luigi Uccioli ◽

Marco Meloni ◽

...

Keyword(s):

Risk Factors ◽

Lower Extremity ◽

Renal Disease ◽

High Mortality ◽

Chronic Renal Disease ◽

Mortality Rates ◽

Population Based ◽

Term Survival ◽

Factors Associated ◽

Patients With Diabetes

IntroductionThe aim of the study was to identify the sociodemographic and clinical factors associated with death after the first lower-extremity amputation (LEA), minor and major separately, using data from regional health administrative databases.Research design and methodsWe carried out a population-based cohort study including patients with diabetes residing in the Lazio region and undergoing a primary amputation in the period 2012–2015. Each individual was followed up for at least 2 years. Kaplan-Meier analysis was used to evaluate long-term survival; Cox proportional regression models were applied to identify factors associated with all-cause mortality.ResultsThe cohort included 1053 patients, 72% were male, 63% aged ≥65 years, and 519 (49%) died by the end of follow-up. Mortality rates at 1 and 4 years were, respectively, 33% and 65% for major LEA and 18% and 45% for minor LEA. Significant risk factors for mortality were age ≥65, diabetes-related cardiovascular complications, and chronic renal disease for patients with minor LEA, and age ≥75 years, chronic renal disease and antidepressant drug consumption for subjects with major LEA.ConclusionsThe present study confirms the high mortality rates described in patients with diabetes after non-traumatic LEA. It shows differences between minor and major LEA in terms of mortality rates and related risk factors. The study highlights the role of depression as specific risk factor for death in patients with diabetes after major LEA and suggests including its definition and management in strategies to reduce the high mortality rate observed in this group of patients.

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