Atwal, Danish

Background Ankle‐brachial indexes ( ABI ) are a noninvasive diagnostic tool for peripheral arterial disease and a marker of increased cardiovascular risk. ABI is calculated using the highest systolic blood pressure of the 4 ankle arteries (bilateral dorsalis pedis and posterior tibial). Accordingly, patients may be assigned a normal ABI when the result would be abnormal if calculated using one of the other blood pressure readings. Cardiovascular outcomes for patients with discordant ABI s are undescribed. Methods and Results We performed a retrospective study of patients who underwent ABI measurement for any indication between January 1996 and June 2018. Those with normal ABI s (1.00–1.39) were included. We compared patients with all 4 normal ABI s (calculated using all 4 ankle arteries; n=15 577, median age 64.0 years, 54.4% men) to those with discordant ABI s (at least 1 abnormal ABI ≤0.99; n=2095, median age 66.0 years, 47.8% men). The outcomes assessed were ischemic stroke, myocardial infarction, and all‐cause mortality. Compared with patients with concordant normal ABI s, patients with discordant ABI s were older; women; smoked; and had chronic kidney disease, coronary artery disease, diabetes mellitus, chronic obstructive pulmonary disease, hypertension, or prior stroke. Patients with discordant ABI s had a greater risk of myocardial infarction (hazard ratio [HR], 1.31; 95% CI, 1.10–1.56), ischemic stroke ( HR, 1.53; 95% CI, 1.37–1.72), and all‐cause mortality ( HR, 1.27; 95% CI, 1.16–1.39), including after adjustment for baseline comorbidities. Conclusions Discordant ABI results were associated with an increased risk of myocardial infarction, stroke, and all‐cause mortality in the studied population. Clinicians should examine ABI calculations using all 4 ankle arteries to better characterize a patient's cardiovascular risk.

Abstract Introduction Lower extremity physiologic studies are an important non-invasive diagnostic tool in peripheral arterial disease (PAD). PAD and atrial fibrillation (AF) are associated with increased cardiovascular and all-cause mortality. Purpose To evaluate the association between PAD and new-onset AF and the risk of stroke. Methods We performed a study of all patients without AF undergoing ankle-brachial index (ABI) for any indication between January 1996 to June 2018. The ABI cut-off were as follows: abnormal ABI (0–0.99), normal ABI (1.00–1.39) and poor vessel compressibility (PC) (1.40+). Demographic, comorbidity, and outcome variables were extracted using the electronic medical record. Results Overall, 34,441 patients (mean age 66.8±14.3, 57.3% male, 88.2% white) were included in the study with a median follow-up of 7.2 years (interquartile range, 3.0–12.9 years). Multivariate Cox proportional hazard analysis showed increased risk of new-onset AF for male sex, older age, hypertension, coronary artery disease, cerebrovascular disease, chronic kidney disease stage III or greater, congestive heart failure, chronic obstructive pulmonary disease, and cancer (all p<0.0001). After adjustment, ABI results were significantly associated with new-onset AF, particularly poorly-compressible vessels (adjusted HR: 1.42 (1.30–1.55), p<0.0001) compared to abnormal ABI (adjusted HR: 1.12 (1.05–1.20), p=0.0012). Patients with atrial fibrillation were more likely to experience ischemic stroke (39.2% versus 16.1%, p<0.0001). Conclusion Abnormalities in ABI results, particularly poorly-compressible vessels, are independently associated with new-onset atrial fibrillation in a large ambulatory cohort. While the mechanism cannot be assessed, common inflammatory mechanisms and increased vascular stiffness may play an important role. Identification of AF in these at-risk patients may improve cardiovascular outcomes.

Abstract Background Based on previously published data, routine myocardial perfusion imaging in diabetics is not recommended. Selecting patients with diabetes and high risk cardiovascular features could be important to improve the yield of physiologic assessment of the coronary arteries disease and subsequently patient outcome. Purpose We posed the question whether nuclear stress testing has a better yield by selecting diabetic individuals with known vascular disease. Methods We analyzed records for 15,392 diabetics from 1996 to 2009 with and without vascular disease. Vascular disease is defined as carotid vascular disease, abdominal aortic aneurysm, or peripheral arterial disease. There was 2457 myocardial perfusion studies performed within 2 years of the vascular evaluation. We studied the results of these stress testing in each group and evaluated for the presence of myocardial ischemia. Multivariate Cox proportional regression was used to calculate hazard ratios (HR) with 95% confidence intervals after adjusting for age, gender. Results Of those who underwent myocardial perfusion studies 1819 were diabetic with vascular disease group A (mean age 67.8, 70.5% female) and 638 were diabetic without vascular disease group B (mean age 64.5 years, 67.1% female). There was at least one reversible defect suggest myocardial ischemia in 225 and 758 studies in group A and B respectively. Comparing outcome based on the presence of myocardial ischemia in group A without vascular disease, those with vascular disease did have an increased risk of myocardial infarction (adjusted HR: 1.630, 95% CI: 1.281–2.074) and death (adjusted HR: 1.646, 95% CI: 1.413–1.918). Conclusion Myocardial perfusion imaging is a reasonable test in patients with diabetes and vascular disease. The presence of myocardial ischemia is more common and is associated with worse cardiovascular outcome. Acknowledgement/Funding None