Response by Itoga et al to Letter Regarding Article, “Association of Blood Pressure Measurements With Peripheral Arterial Disease Events”

Objectives To date, the ultimate decision to treat iliac artery stenoses in patients suffering from symptomatic peripheral arterial disease is based on the patient’s symptoms and on visual inspection of angiographical images. The primary aim of this study was to investigate the accuracy of geometry-based methods (i.e. visual inspection and quantitative vascular analysis (Viewforum version R7.2v1 Advanced vessel analysis, Philips Healthcare, Best, The Netherlands) of 3D rotational angiography) to identify the severity of equivocal iliac artery stenosis in peripheral arterial disease patients with intra-arterial hyperemic pressure measurements (gold standard) as a reference. Methods Twenty patients with symptomatic iliac artery stenoses were subjected to 3D rotational angiography. Intra-arterial pressure measurements under hyperemic conditions were performed across 24 visually identified iliac artery stenoses. Three experienced interventional-radiologists retrospectively estimated the lumen diameter reduction by visual inspection. Furthermore, quantitative vascular analysis was performed on the 3D rotational angiography data. Geometry-based estimates were classified into two groups: lumen diameter reduction of <50% (non-significant) and diameter reduction [Formula: see text]50% (significant), and compared to the intra-arterial hyperemic pressure gradients. A stenosis causing a pressure gradient (Δp) ≥10 mmHg was considered hemodynamically significant. Results Visual inspection and quantitative vascular analysis correctly identified hemodynamically significant stenoses in, respectively, 83% and 67% of the 24 iliac artery stenoses. Quantitative vascular analysis-based identification of hemodynamic significant stenoses (Δp ≥ 10 mmHg) could be optimized by lowering the threshold to a 42% lumen diameter reduction which improved the accuracy from 67% to 83%. Conclusions Visual inspection of 3D rotational angiography by experienced interventional-radiologists has an 83% accuracy to identify hemodynamic significant iliac artery stenoses (Δ p ≥10 mmHg). The use of quantitative vascular analysis software did not improve accuracy.

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Saving more lives and limbs: applying a cardiac rehabilitation model of structured exercise to symptomatic peripheral arterial disease

British Journal of Cardiac Nursing ◽

10.12968/bjca.2020.0086 ◽

2021 ◽

pp. 1-8

Author(s):

Susan Matthews ◽

Martin Fox ◽

Sarah Coy ◽

Jane Whittaker ◽

Gail Brough ◽

...

Keyword(s):

Quality Of Life ◽

Blood Pressure ◽

Peripheral Arterial Disease ◽

Cardiac Rehabilitation ◽

Intermittent Claudication ◽

Arterial Disease ◽

Morbidity And Mortality ◽

Supervised Exercise ◽

Peripheral Arterial

Background/Aims Peripheral arterial disease is common among those aged 60 years or above and can cause debilitating intermittent claudication. This impacts quality of life and is a marker for increased morbidity and mortality, mainly from cardiovascular disease. Access to recommended exercise programmes for people with symptomatic peripheral arterial disease is poor in most areas of the UK. This study aimed to evaluate the benefits of expanding an established cardiac rehabilitation service to accommodate supervised exercise for people with peripheral arterial disease Methods The study evaluated 11 participants peripheral arterial disease and intermittent claudication who were referred by the Manchester leg circulation service. Participants underwent the programme involving eight weekly 1.5 hour sessions of supervised exercise and cardiovascular education with support, reassurance and motivation. The participants' blood pressure, walking impairment, quality of life, anxiety and depression were monitored and reviewed. Results Overall, the participants' walking distance, intermittent claudication, quality of life and blood pressure had improved. The participants' overall satisfaction with the programme was excellent. The programme also demonstrated clinical and cost-effectiveness. Conclusions A structured, supervised exercise programme can have considerable benefits for people with peripheral arterial disease, improving their symptoms and quality of life. It may also help to reduce the morbidity and mortality risks associated with inactivity in this patient group.

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Heat therapy vs. supervised exercise therapy for peripheral arterial disease: a 12-wk randomized, controlled trial

AJP Heart and Circulatory Physiology ◽

10.1152/ajpheart.00151.2019 ◽

2019 ◽

Vol 316 (6) ◽

pp. H1495-H1506 ◽

Cited By ~ 10

Author(s):

Ashley P. Akerman ◽

Kate N. Thomas ◽

Andre M. van Rij ◽

E. Dianne Body ◽

Mesfer Alfadhel ◽

...

Keyword(s):

Blood Pressure ◽

Peripheral Arterial Disease ◽

Water Immersion ◽

Ankle Brachial Index ◽

Arterial Disease ◽

Hot Water ◽

Walking Distance ◽

Supervised Exercise ◽

Heat Therapy ◽

Peripheral Arterial

Peripheral arterial disease (PAD) is characterized by lower limb atherosclerosis impairing blood supply and causing walking-induced leg pain or claudication. Adherence to traditional exercise training programs is poor due to these symptoms despite exercise being a mainstay of conservative treatment. Heat therapy improves many cardiovascular health outcomes, so this study tested if this was a viable alternative cardiovascular therapy for PAD patients. Volunteers with PAD were randomized to 12 wk of heat ( n = 11; mean age 76 ± 8 yr, BMI 28.7 ± 3.5 kg/m2, 4 females) or exercise ( n = 11; 74 ± 10 yr, 28.5 ± 6.8 kg/m2, 3 females). Heat involved spa bathing at ∼39°C, 3–5 days/wk for ≤30 min, followed by ≤30 min of callisthenics. Exercise involved ≤90 min of supervised walking and gym-based exercise, 1–2 days/wk. Following the interventions, total walking distance during a 6-min walk test increased (from ∼350 m) by 41 m (95% CI: [13, 69], P = 0.006) regardless of group, and pain-free walking distance increased (from ∼170 m) by 43 m ([22, 63], P < 0.001). Systolic blood pressure was reduced more following heat (−7 mmHg, [−4, −10], P < 0.001) than following exercise (−3 mmHg, [0, −6], P = 0.078), and diastolic and mean arterial pressure decreased by 4 mmHg in both groups ( P = 0.002). There were no significant changes in blood volume, ankle-brachial index, or measures of vascular health. There were no differences in the improvement in functional or blood pressure outcomes between heat and exercise in individuals with PAD. NEW & NOTEWORTHY Heat therapy via hot-water immersion and supervised exercise both improved walking distance and resting blood pressure in peripheral arterial disease (PAD) patients over 12 wk. Adherence to heat therapy was excellent, and the heat intervention was well tolerated. The results of the current study indicate that heat therapy can improve functional ability and has potential as an effective cardiovascular conditioning tool for individuals with PAD. Listen to this article's corresponding podcast at https://ajpheart.podbean.com/e/heat-therapy-vs-exercise-in-peripheral-arterial-disease/ .

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Digital Blood Pressure in Normal Subjects and Patients with Peripheral Arterial Disease Effect of Change in Temperature

Scandinavian Journal of Clinical and Laboratory Investigation ◽

10.3109/00365517609081930 ◽

1976 ◽

Vol 36 (8) ◽

pp. 725-730 ◽

Cited By ~ 11

Author(s):

P. E. Nielsen

Keyword(s):

Blood Pressure ◽

Peripheral Arterial Disease ◽

Normal Subjects ◽

Arterial Disease ◽

Disease Effect ◽

Peripheral Arterial

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Ankle Brachial Pressure Index: An update for the vascular specialist and general practitioner

Vascular ◽

10.1177/1708538119842395 ◽

2019 ◽

Vol 27 (5) ◽

pp. 560-570 ◽

Cited By ~ 1

Author(s):

Benjamin Thurston ◽

Joseph Dawson

Keyword(s):

Blood Pressure ◽

Peripheral Arterial Disease ◽

Arterial Disease ◽

Cardiac Risk Factor ◽

Diabetic Patients ◽

Ankle Brachial Pressure Index ◽

Pressure Index ◽

Clinical Scenarios ◽

Invaluable Tool ◽

Peripheral Arterial

Objectives Ankle brachial pressure index (ABPI) is an invaluable tool for assessing the severity of peripheral arterial disease. In addition, it can be used as an independent marker of cardiovascular risk, with a predictive ability similar to the Framingham criteria. Identification of an abnormal ABPI should therefore trigger aggressive cardiac risk factor modulation for a patient. Unfortunately, the significance of abnormal ABPIs is poorly understood within the general medical community. This is compounded by the influence of various comorbidities on accurate measurement of ABPI, potentially leading to a wide variability in readings that need to be considered before interpretation in these patient populations. We aim to address these issues by revealing several common misunderstandings and pitfalls in ABPI measurement, describing accurate methodology, and highlighting patient cohorts in whom additional or alternative approaches may be required. Methods We present a narrative review of the role of ABPI in both the community and hospital setting. We have performed a literature review, exploring the validity and reproducibility of methodology for obtaining ABPI, alongside the utility of ABPI in different clinical scenarios. Results The measurement of ABPI is often performed incorrectly. Common pitfalls include inadequate patient preparation, failure to obtain the blood pressure from the correct lower limb artery in patients with tibial disease, failure to account for differences in brachial blood pressure between the arms, inappropriately chosen equipment and patient factors such as highly calcified arteries. Standardisation of methodology greatly improves reliability of the test. Exercise ABPI can identify significant peripheral arterial disease in patients with normal resting ABPI. In addition to its role in peripheral arterial disease, ABPI measurement has a role in assessing venous ulcers, entrapment syndromes and injured extremities; conversely, it has a more limited utility in the diabetic population. Conclusions A thorough understanding of the correct technique and associated limitations of ABPI measurement is essential in accurately generating and interpreting the data it provides. With this knowledge, the ABPI is an invaluable tool to help manage patients with peripheral arterial disease. Perhaps more importantly, ABPI can be used to identify and risk stratify patients with asymptomatic peripheral arterial disease, itself a major indicator of significant underlying cardiovascular disease. With the emergence of best medical therapy, targeted pharmacotherapy and lifestyle changes can reduce the risk of major cardiovascular events in high-risk patients by approximately 30%, particularly in diabetic patients. Therefore, the utility of ABPI transgresses vascular surgery, with an essential role in general practice and public health.

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