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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 50-54

Unmasking previously unrecognized peripheral arterial disease in patients with coronary artery disease using continuous wave doppler using continuous wave doppler imaging : does the presence of peripheral arterial disease influence the clinicopathological profile of coronary artery disease? An Indian study


1 Department of Medine, Command Hospital Airforce, Bengluru, Karnataka, India
2 Department of Surgery, Command Hospital Airforce, Bengluru, Karnataka, India

Date of Submission02-Oct-2020
Date of Acceptance22-Oct-2020
Date of Web Publication13-Mar-2021

Correspondence Address:
Dr. Rahul Sud
Department of Medicine, Command Hospital Airforce Bangalore, 560 007, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bbrj.bbrj_171_20

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  Abstract 


Background: It is well established that a significant number (30%) of patients suffering from coronary artery disease (CAD) also have underlying peripheral artery disease (PAD) as the only underlying risk factor. They are at increased risk of myocardial infarction as multiple vascular beds beyond the extremities are likely to be affected by atherosclerosis. A large percentage of high-risk patients with the coexistent disease may not be diagnosed with underlying PAD, as they were largely asymptomatic. This study aims to assess the prevalence of previously unrecognized PAD among patients with CAD, the risk association for various risk factors for CAD and PAD and also to determine the relationship between the presence of PAD and severity of CAD. Methods: A 3 years randomized, prospective, cross-sectional study done at Command Hospital Airforce Bangalore, India on patients of CADs, who were planned to undergoing coronary angiogram, were evaluated for the presence of PAD in lower extremities. The interactions between risk factors, Ankle Brachial Index (ABI), and CAD were examined by multiple stepwise regression analysis. Results: A total of 300 patients were studied. PAD has a prevalence of 14% in patients with CAD and it was strongly associated with disease severity. There was statistically significant association in patients with CAD which coexistent PAD with age (P = 0.001), smoking (P = 0.014), hypertension (P = 0.015), diabetes (P = 0.043), obesity (P= 0.004), history of previous cerebrovascular accident (P = 0.0138), number of coronaries involved (P = 0.02) and low-density lipoprotein (P = 0.001) levels as compared to CAD not associated with PAD. Conclusions: The high prevalence of PAD in patients who have CAD confirms the importance of active screening for PAD using ABI and requires aggressive management. We emphasize that clinicians should keep in mind that CAD patients would have other co-morbid vascular manifestations like PAD in order to minimize morbidity and mortality in these patients.

Keywords: Ankle Brachial Index, cerebrovascular accident, coronary artery disease, peripheral arterial disease


How to cite this article:
Nair R, Sud R, Swamy A, Patra V. Unmasking previously unrecognized peripheral arterial disease in patients with coronary artery disease using continuous wave doppler using continuous wave doppler imaging : does the presence of peripheral arterial disease influence the clinicopathological profile of coronary artery disease? An Indian study. Biomed Biotechnol Res J 2021;5:50-4

How to cite this URL:
Nair R, Sud R, Swamy A, Patra V. Unmasking previously unrecognized peripheral arterial disease in patients with coronary artery disease using continuous wave doppler using continuous wave doppler imaging : does the presence of peripheral arterial disease influence the clinicopathological profile of coronary artery disease? An Indian study. Biomed Biotechnol Res J [serial online] 2021 [cited 2021 Aug 5];5:50-4. Available from: https://www.bmbtrj.org/text.asp?2021/5/1/50/311089




  Introduction Top


The prevalence of coronary artery disease (CAD) is on the rise in the developing world. It is well established that both symptomatic and asymptomatic peripheral artery disease (PAD) represents an independent risk for cardiovascular morbidity and mortality.[1] Approximately 30% of patients with CAD may have PAD as the only clinical manifestation of cardiovascular disease.[2] Patients with PAD are at triple the risk of all-cause mortality and at six times, the risk of death from CAD.[3],[4] PAD is systemic atherosclerosis associated with high morbidity and mortality and significantly impair the quality of life, yet it remains underdiagnosed and undertreated condition both under primary and specialty care.[5],[3] PAD history is elicited in only 37% of the cases, peripheral pulses are palpated in <60% of the cases and Ankle Brachial Index (ABI) is performed in <8% of the cases.[6] To the primary care physician, the medical history and physical examination are the major tools for suspecting and establishing the diagnosis of PAD, but both lack sensitivity.[7],[8]


  Methods Top


An Indian study is a bonafide original research work done (after ethical clearance from the by Institute ethical and Scientific committee on 24 Nov 2012) by Dr Rajesh R Nair MD and Dr Rahul Sud MD, DM (Oncology), Department of Medicine Command Hospital, under the guidance of Dr. A J Swamy, MD.DM (Cardiology), Professor Department of medicine & Dr.V Patra, MS, MCH, Professor, Department of Surgery & Vascular surgery, Command Hospital, Air Force, Bangalore.

The prospective, observational study was conducted at the Department of Medicine, Command Hospital (Air Force), Bangalore, India, from October 2012 to May 2015, which is the largest Tertiary care teaching hospital of the armed forces in Southern India. A study was done on the patients of CADs, who were planned to undergo a coronary angiogram for chronic stable angina, unstable angina or myocardial infarction. The IRB clearance was taken for the study from the Institute (CHAFB/23 dated November 3, 2013) (form attached). All patients selected for inclusion in the study were evaluated for the presence of PAD in the lower extremities after obtaining written consent. Patients with pre-existing confirmed diagnosis of peripheral arterial disease, severe renal, hepatic or cardiac impairment, malignancy, severe anemia, tuberculosis ,or any chronic infection or acute infection over the past 2 weeks were excluded from the study. Pre-existing peripheral arterial disease was defined as: documented history of a clinical syndrome consistent with PAD as well as confirmatory imaging (duplex ultrasound, magnetic resonance angiography, computed tomography angiography and/or physiological study (ankle bronchial index)).

All patients with CAD were prospectively screened by a single assessor with a standard clinical assessment, and relevant findings were noted. Patient's age, sex, body mass index (BMI), smoking habits, family history, and comorbidities were documented. Cardiovascular risk factors were documented like diabetes, systemic hypertension, a positive family history of premature CAD, smoking, dyslipidemia, obesity, and the presence of previous cerebrovascular disease. Routine hematological, biochemical investigation, including lipid profile was performed in all patients. All patients were subjected to a clinical examination and signs/symptoms of PAD including intermittent claudication, ischemic rest pain and limbs examination for early skin changes, pallor, bruit, ulceration, pulsation were documented in the patients who succumbed to the disease before assessment were excluded from the study.

CAD is defined as per “The National Institute for Health and Clinical Excellence” clinical guideline. It defines significant CAD as ≥70% diameter narrowing (stenosis) of at least one major epicardial artery segment or ≥50% diameter stenosis in the left main coronary artery. Diagnosis of CAD was based on clinical presentation, the presence of electrocardiographic changes, and elevation of chemical markers and Coronary angiography.

Ankle brachial index

ABI is the ratio between systolic blood pressure (BP) in the ankle and systolic BP in the arm.[9] Measurement of ABI was made in the supine position after 5 min of rest. A pneumatic cuff was placed around the ankle, and the pressure was measured at both the dorsalis pedis and posterior tibial arteries using a hand-held continuous-wave Doppler probe (5–10 MHz). The same technique was also used in both arms for measuring brachial artery pressure. The higher of the two ankle pressures was divided by the brachial artery pressure, as shown in [Table 1].
Table 1: Ankle brachial index and its interpretation

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Statistical methodology

Continuous data are presented as means with standard deviations. Categorical data are presented as the percent frequency occurrence Pearson's Chi-square test was applied to evaluate the association between the various parameters tested as well as the extent of CAD. The interactions between risk factors, ABI, and CAD were examined by multiple stepwise regression analysis. Statistical significance was inferred at P < 0.05.

Declaration of patient consent

The authors certify that we have obtained all appropriate patient consent forms. In the form, the patient(s) have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patient(s) understand that his/her/their name(s) and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


  Results Top


The study was designed to evaluate the prevalence of previously unrecognized peripheral arterial disease in patients with CAD and was carried out with 300 cases with a descriptive study of clinical profile. Out of the total of 300 patients, 191 males and 109 females (male: female ratio 1.75:1). Only six patients were below 55 years, while 54.7% were between the ages 56 and 65 years and 43.3% above 66 years. The majority of the patients except among the studied patients 27% of patients were current smokers and 16% of patients were ex-smokers (reformed smokers) and 57% of patients had never smoked in their life. Of the 300 patients studied, hypertension, a previous episode of cerebrovascular accident (CVA) and obesity was present in 56.7%, 3.3% and 3.7% cases, respectively. Two hundred and nineteen (73%) patients had a BMI above 25 kg/m2. In our study, single-vessel disease was present in 156 (52%) patients, double vessels in 105 (35%), triple vessel disease in 34 (11.3%) patients and triple vessel disease plus left main artery in 5 (1.7%) patients respectively. In our study, most of the patients were in the age group of 56–65 years, comprising of 54.7% followed by those above 66 years age (43.3%) [Table 2].
Table 2: Description of patient's subgroup characteristics, smoking status, comorbidites and coronary involvement

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The lipid profile showed a mean high-density lipoprotein (HDL), low-density lipoprotein (LDL), and Triglyceride of 42.61, 102.80 and 121.81 mg/dl, respectively. The mean ABI in the population was found to be 0.98 [Table 3].
Table 3: Mean and standard deviation of age, body mass index, lipid profile, and ankle-brachial index

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The patients were divided into two groups. Group 1: CAD patients without PAD, and Group 2: CAD with PAD [Table 4]. We did not find any statistical difference in the sex distribution of patients among the two groups. The Group 2 patients (CAD with PAD) had a statistically significant difference in the percentage (P = 0.014) of current (33.3%) and ex-smokers (19%) as compared to Group 1 patients (CAD without PAD), which had the incidence of current (14.3%) and ex-smokers (7.7%). The Group 2 patients (CAD with PAD) had a statistically significant difference in the incidence (P = 0.01) of hypertension (66.6%) as compared to Group 1 patients (CAD without PAD), which had the incidence of hypertension (55%). The Group 2 patients (CAD with PAD) had a statistically significant difference in the incidence (P = 0.043) of diabetes (50%) as compared to Group 1 patients (CAD without PAD), which had the incidence of diabetes (44.9%). The Group 2 patients (CAD with PAD) had a statistically significant difference in the incidence (P = 0.0138) of the previous episode of CVA (7.142%) as compared to Group 1 patients (CAD without PAD), which had the incidence of CVA (2.713%). The Group 2 patients (CAD with PAD) had a statistically significant difference in the incidence (P = 0.004) of obesity (4.7%) as compared to Group 1 patients (CAD without PAD), which had the incidence of obesity (3.4%). The Group 2 patients (CAD with PAD) had statistically significant difference in the incidence (P = 0.002) multiple vessel diseases (83.3%) as compared to Group 1 patients (CAD without PAD), which have the incidence of multiple vessel disease (42.2%) [Table 4].
Table 4: Comparison of Group 1 and 2 patients for smoking, comorbidities, and coronary vessel involve

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In Group 2 patients (CAD with PAD) there was a statistically significant difference in the mean age 65.05 ± 2.8 years (P = 0.001), with 100% of patients were above 56 years as compared to Group 1 patients (CAD without PAD), which had the mean age of 62.66 ± 4.3 years with 82.2% in the similar category. In Group 2 patients (CAD with PAD), there was a statistically significant difference in the mean BMI 22.57 ± 1.2 (P = 0.001), as compared to Group 1 patients (CAD without PAD), which had the mean BMI of 24.53 ± 1.1. In the Group 2 patients (CAD with PAD), there was a statistically significant difference in the mean ABI 0.8602 ± 0.04 (P = 0.000), as compared to Group 1 patients (CAD without PAD), which had the mean ABI of 1.1 ± 0.23. The Group 2 patients (CAD with PAD) had a statistically significant difference in the mean serum LDL level 96.14 ± 10.84 (P = 0.01), as compared to Group 1 patients (CAD without PAD), which had the mean serum LDL level of 103.88 ± 13.7.

There was no statistical difference in the mean values of serum TG and serum HDL among the two groups of patients [Table 5].
Table 5: The mean and standard deviation of age, body mass index, lipid profile, and body mass index among two groups

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  Discussion Top


This prospective interventional study looked at the prevalence of PAD in patients with established CAD. Cohorts of patients with established CAD based on conventional diagnostic criteria, including coronary angiography, were screened for PAD with ABI. There are limited studies on this issue. Most of the studies are retrospective in nature with a larger sample size.

The mean age of the patients in the present study was comparable to the age reported in Indian study by Agarwal et al.,[10] but it is lower than the mean age of patients from developed world.[11] This can be explained by the early occurrence of CAD in Indian population compared to their western cohorts. Among the studied patients, 27% of patients were current smokers and 16% of patients were ex-smokers and 57% patients had never smoked in their life.

Most of the studies with similar methodology and selection criteria have the same prevalence of PAD among CAD patients. Results of other published reports regarding the prevalence of concomitant CAD in patients with PAD are highly variable. Since many of these studies did not use definite imaging data for the diagnosis of CAD and PAD, and others defined CAD as >50% luminal diameter narrowing, not ≥70%, which is considered to be flow-limiting, it is not surprising that together these factors could overestimate of the prevalence of obstructive CAD in this population.

Several studies have demonstrated that the ABI strongly correlates with the presence and severity of atherosclerosis in the coronary arteries. ABI measurement is widely accepted for the identification of asymptomatic PAD and is an important marker of systemic atherosclerosis. PAD severity in each leg was assessed according to the levels of ABI as mild occlusion (0.70–0.90), moderate occlusion (0.40-0.69), and severe occlusion (<0.40).

In the present study, all patients underwent a definitive imaging study that documented the presence and severity of CAD. Peripheral arterial disease was diagnosed based on a validated parameter-ABI. In the present study, the prevalence of CAD patients with PAD was 14% out of total 300 patients studied. The reported prevalence of PAD in patients undergoing PCI with CAD varies from 5% to 40% in some other studies.[12],[13],[14] This is similar to the prevalence reported in other studies from Asia by Kim et al.,[15] South Korea. Compared to the Western population,[16] the prevalence of PAD in of CAD patients was higher. Although the overall prevalence of PAD was 14% in our results, patients with high cardiovascular risk factors such as old age, smoking, and atherosclerotic burden showed significantly higher incidences of PAD and a similar pattern is reported in other studies.[17] In the present study, we observed a statistically significant difference in the prevalence of PAD among the older age group, patients with smoking habits, hypertension, obesity, diabetes and abnormal LDL level. We also found that the incidence of PAD is higher in patients with CAD involving multiple vessels. This shows strong association of PAD with severe multi-vessel coronary artery disease.[18] This is similar to the observations made in the CAD study by Agarwal et al.,[10] and Jeremias et al.[16] [Table 6].
Table 6: Prevalence of peripheral arterial disease in various studies

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Our study has a few limitations. The present study was conducted at single center, which may have led to selection bias. Moreover patients with clinically asymptomatic CAD not admitted were left out of the study pool. So, this study basically reflects the prevalence of PAD in patients with symptomatic CAD and in the entire pool of CAD the prevalence of PAD can be much higher. ABI may have limited value in patients with diabetes, and renal failure as the vessels are calcified in this subgroup. Moreover, the morbidity and mortality in patients with abnormal ABI were not studied as it was a cross-sectional study.


  Conclusions Top


The coexistence of CAD and Peripheral arterial disease is known but not widely studied prospectively. PAD sows the seed in the vessel and this disseminates to the heart and coronary vessels, which paves way to develop CAD, thus it is an important to study their association. PAD has a prevalence of 14% in patients with CAD in our study. Moreover, it was found to be associated directly with the severity of the disease. The CAD patients who had an associated PAD were smokers, had associated comorbidities (hypertension, CVA, obesity, and diabetes mellitus) and multiple vessel involved CAD. Also, there is a direct co-relation with BMI and age. The high prevalence of PAD in patients with CAD confirms the importance of active screening for PAD using ABI and should be performed routinely. The clinicians should keep in mind that CAD patients would have other co-morbid vascular manifestations like PAD and a scoring system, including PAD as a risk factor needs to be developed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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