Pérez Díaz, JM; Pérez Belmonte, LM; Blanco Díaz, M; Loring Caffarena, M; PlateroSánchez-Escribano, M; Constan Rodríguez, J; Guil García, M; San Román Terán, CM.

Department of Internal Medicine. County Hospital of The Axarquia. Vélez-Málaga, Málaga. Spain

ANKLE-BRACHIAL INDEX AND PERIPHERAL ARTERIAL DISEASE: TWO GREAT NEGLECTED

OBJECTIVESPeripheral arterial disease (PAD) is an important marker of cardiovascular morbidity and one of the main markers to identify, in subclinical stages, patients with atherosclerotic disease. Currently we ignore how many patients are underdiagnosed in our hospital population. Therefore, the objective is to know the underdiagnosis of PAD and the burden of cardiovascular disease. So, we can stratify the risk and influence in our clinic behaviour.

MATERIAL AND METHODSType of study: observational, descriptive and transversal.Field of study: our Internal Medicine wards.Subjects: inpatients on May 15, 2012.Exclusion criteria: hemodynamic instability (hypoperfusion, shock, arrhythmias), severe dehydration, impairedconsciousness (confusion, coma) and severe dementia.Measures and interventions: PAD was defined if the ankle-brachial index (ABI) was <0.9 and underdiagnosis when ABI was <0.9 and they didn’t have PAD diagnosis in the medical record. We determined the intermittent claudication (IC) using the Edinburgh claudication questionnaire. We used the oscilolometric method for measuring the ABI with a validated automatic device (microlife watch BP office ABI). We used statistical program SPSS 15.0 version and nonparametric tests to analyze the data. We divided the patients into two groups: PAD group (PADG) and non-PAD group (NPADG). We analyzed demographic, clinical and semiological data, comorbidities and cardiovascular risk factors.

RESULTS61 patients were analyzed, although 9 were excluded. In both groups the average age was 75 years old and there was a clear male predominance, but not statistically significant. 33.77% has an ABI < 0.9 (16/52), including 4 patients with “index 0” or “mistake” in which the device did not register pulse in the lowers limbs. 7 patients had non-compressible ABI which indicates arterial stillness. 69% of patients were underdiagnosed, despite of 74% had symptomatic IC. Regarding to cardiovascular risk conditions and comobidities was statistically significant in PADG: diabetes mellitus (DM) (34.8 vs. 24%, p=0.03), moderate-severe chronic kidney disease (CKD) (39.1 vs. 17.2%, p=0.001), ischemic cardiomyopathy (IC) (39.1 vs. 24.1%, p=0.001) and stroke (30.4 vs. 6.9%, p=0.0001). There were also more smoking prevalence and dyslipidemia (DLP) in PADG but not statistically significant. High blood pressure (HBP) was the most common risk condition in our patients (more than three-quarters of them). 69% of the PADG had 3 or more cardiovascular risk factors. The triad with HBP, DM and DLP was the most powerful association.

CONCLUSIONSThe underdiagnosis of PAD is really high in our patients, 69%. We have a high percentage of IC in our patients with PAD, in spite of using Edinburgh questionnaires, which is usually not a very sensitive test, what strikes us. However, we don’t surprise the others vascular territories affectation and cardiovascular risk factors in this group. We recommend the ABI to use more widely in patients and evaluate the potential therapeutic impact.

DISCUSSIONABI determination is a simple, noninvasive and validated diagnostic test to detect arterial stenosis of 50% or higher, in lower extremities. The oscillometric method is objective, fast and improves the PAD detection respect to Doppler method if the test is not performed by trained physicians. Many of the elderly patients in our department have many TASC-III guidelines criteria. As a reflection and self-criticism, PAD is easily overlooked by patients and medical internists.

PADG NPADG pDM (%) 34,8 24 <0.03

CKD (%) 39.1 17,2 <0.001

IC (%) 39,1 24,1 <0.001

Stroke 30,4 6,9 <0.0001

33,7%

66,3%

p<0,05