Association of Asymptomatic Peripheral Arterial Disease With Vascular Events in Patients With Stroke or Transient Ischemic Attack

Background and Purpose— Patients with stroke and patients with transient ischemic attack (TIA) are at high risk for vascular events and may not exhibit the signs and symptoms of peripheral arterial disease (PAD). We investigated if asymptomatic PAD detected by ankle brachial index <0.9 is independently associated with recurrent vascular events in patients with stroke or TIA. Methods— In this prospective longitudinal hospital-based cohort study, asymptomatic PAD was detected by ankle brachial index measurement in consecutive patients with stroke and patients with TIA. They were assessed for stroke risk factors, ankle brachial index measurement, and laboratory parameters known to be associated with stroke risk. These patients were followed for composite vascular events, including stroke, TIA, myocardial infarction, and vascular death. Results— In a 1-year period, 102 patients were evaluated, of whom 26% had asymptomatic PAD. All patients were followed for a median period of 2.1 years from the index stroke/TIA (range, 1.0 to 2.7 years) for vascular events. Kaplan–Meier curve showed fewer patients with asymptomatic PAD remained free of composite vascular events (48% compared with 84% in the no-PAD group; log rank, P=0.0001). Asymptomatic PAD was significantly associated with composite vascular events before (hazard ratio, 4.2; 95% CI, 1.9 to 9.3; P=0.0003) and after adjustment for confounders (hazard ratio, from Model 1, 2.8; 95% CI, 1.1 to 7.2; P=0.03 and Model 2, 3.4; 95% CI, 1.4 to 8.2, P=0.006). Asymptomatic PAD was also significantly associated with stroke before (hazard ratio, 6.5; 95% CI, 2.1 to 19.9; P=0.001) and after adjustment for confounders (hazard ratio from Model 1, 4.8; 95% CI, 1.5 to 15.3; P=0.009 and Model 2, 5.2; 95% CI, 1.5 to 17.6; P=0.008). Conclusions— In patients with stroke or TIA, asymptomatic PAD is independently associated with recurrent vascular events and stroke.

[1]  D. Sumner,et al.  Factors affecting the diagnosis of peripheral vascular disease before vascular surgery referral. , 2000, Journal of vascular surgery.

[2]  L. Chambless,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. , 1997, Atherosclerosis.

[3]  Nomenclature and criteria for diagnosis of ischemic heart disease. Report of the Joint International Society and Federation of Cardiology/World Health Organization task force on standardization of clinical nomenclature. , 1979, Circulation.

[4]  Gary L Myers,et al.  Markers of inflammation and cardiovascular disease: application to clinical and public health practice: A statement for healthcare professionals from the Centers for Disease Control and Prevention and the American Heart Association. , 2003, Circulation.

[5]  Rodney A. White,et al.  ACC/AHA 2005 Practice Guidelines for the management of 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 , 2006, Circulation.

[6]  Rodney A. White,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 Ang , 2006, Journal of the American College of Cardiology.

[7]  R. Langer,et al.  Mortality over a period of 10 years in patients with peripheral arterial disease. , 1992, The New England journal of medicine.

[8]  M. Criqui,et al.  Peripheral arterial disease detection, awareness, and treatment in primary care. , 2001, JAMA.

[9]  Eric J Topol,et al.  Critical issues in peripheral arterial disease detection and management: a call to action. , 2003, Archives of internal medicine.

[10]  V. Fuster,et al.  Prevention Conference V: Beyond secondary prevention: identifying the high-risk patient for primary prevention: noninvasive tests of atherosclerotic burden: Writing Group III. , 2000, Circulation.

[11]  P. Ridker,et al.  Relation of levels of hemostatic factors and inflammatory markers to the ankle brachial index. , 2003, The American journal of cardiology.

[12]  Muredach P Reilly,et al.  Utility and barriers to performance of the ankle brachial index in primary care practice , 2004, Vascular medicine.

[13]  B. Horne,et al.  Usefulness of high-sensitivity C-reactive protein in predicting long-term risk of death or acute myocardial infarction in patients with unstable or stable angina pectoris or acute myocardial infarction. , 2002, The American journal of cardiology.

[14]  W. Kannel,et al.  Intermittent Claudication: Incidence in the Framingham Study , 1970, Circulation.

[15]  L. Sharma,et al.  Leg Symptoms in Peripheral Arterial Disease , 2001 .

[16]  E. Larsson,et al.  Peripheral arterial disease. , 2003, Clinical evidence.

[17]  Daniel Levy,et al.  The ankle-brachial index in the elderly and risk of stroke, coronary disease, and death: the Framingham Study. , 2003, Archives of internal medicine.

[18]  R. Prescott,et al.  Edinburgh Artery Study: prevalence of asymptomatic and symptomatic peripheral arterial disease in the general population. , 1991, International journal of epidemiology.

[19]  C. Cimminiello,et al.  Low ankle–brachial index predicts an adverse 1‐year outcome after acute coronary and cerebrovascular events , 2006, Journal of thrombosis and haemostasis : JTH.

[20]  L. Kuller,et al.  The ratio of ankle and arm arterial pressure as an independent predictor of mortality. , 1991, Atherosclerosis.

[21]  G. A. Rose.  The diagnosis of ischaemic heart pain and intermittent claudication in field surveys. , 1962, Bulletin of the World Health Organization.

[22]  R. Langer,et al.  The Epidemiology of Peripheral Arterial Disease: Importance of Identifying the Population at Risk , 1997, Vascular medicine.

[23]  A Hofman,et al.  Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. , 2008, JAMA.

[24]  S. Sen,et al.  Risk Factors for Progression of Aortic Atheroma in Stroke and Transient Ischemic Attack Patients , 2002, Stroke.

[25]  Sidney C. Smith,et al.  MARKERS OF INFLAMMATION AND CARDIOVASCULAR DISEASE: APPLICATION TO CLINICAL AND PUBLIC HEALTH PRACTICE: A STATEMENT FOR HEALTHCARE PROFESSIONALS FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION AND THE AMERICAN HEART ASSOCIATION , 2003 .

[26]  Arno W. Hoes,et al.  Peripheral arterial disease in the elderly: The Rotterdam Study. , 1998, Arteriosclerosis, thrombosis, and vascular biology.

[27]  R. Sacco,et al.  Mortality and causes of death after first ischemic stroke: The Northern Manhattan Stroke Study , 2001 .

[28]  R Eugene Zierler,et al.  Carotid artery stenosis: gray-scale and Doppler US diagnosis--Society of Radiologists in Ultrasound Consensus Conference. , 2003, Radiology.

[29]  L. Sharma,et al.  Leg symptoms in peripheral arterial disease: associated clinical characteristics and functional impairment. , 2001, JAMA.

[30]  H. Diener,et al.  Predictive value of the Essen Stroke Risk Score and Ankle Brachial Index in acute ischaemic stroke patients from 85 German stroke units , 2008, Journal of Neurology, Neurosurgery, and Psychiatry.

[31]  W. Aronow,et al.  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 , 1999, Journal of the American Geriatrics Society.

[32]  R. Poole,et al.  Frequency and severity of asymptomatic coronary disease in patients with different causes of stroke. , 1997, Stroke.

[33]  N. Hertzer,et al.  Coronary Artery Disease in Peripheral Vascular Patients: A Classification of 1000 Coronary Angiograms and Results of Surgical Management , 1984, Annals of surgery.

[34]  Vilmundur Gudnason,et al.  C-reactive protein and other circulating markers of inflammation in the prediction of coronary heart disease. , 2004, The New England journal of medicine.

[35]  A. Sharrett.  The Atherosclerosis Risk in Communities (ARIC) Study. Introduction and objectives of the hemostasis component. , 1992, Annals of epidemiology.