Original article
Asymptomatic peripheral arterial occlusive disease predicted cardiovascular morbidity and mortality in a 7-year follow-up study

https://doi.org/10.1016/j.jclinepi.2003.09.003Get rights and content

Abstract

Objective

Asymptomatic peripheral arterial occlusive disease (PAOD) is a common atherosclerotic disorder among the elderly population. Scarce data are available on the risk of nonfatal and fatal cardiovascular diseases in these subjects. We investigated cardiovascular morbidity and mortality of asymptomatic PAOD subjects.

Study design and setting

A sample of 3649 subjects (40–78 years of age) was selected in collaboration with 18 general practice centers and followed up after the initial screening (mean follow-up time 7.2 years). Asymptomatic PAOD was determined by means of the ankle-brachial pressure index (ABPI). Main outcome measures were nonfatal cardiovascular events and mortality.

Results

Cox proportional hazard models showed that asymptomatic PAOD was significantly associated with cardiovascular morbidity (hazard ratio [HR] 1.6, 95% confidence interval [CI] 1.3–2.1), total mortality (HR 1.4, 95% CI 1.1–1.8), and cardiovascular mortality (HR 1.5, 95% CI 1.1–2.1).

Conclusion

Asymptomatic PAOD is a significant predictor of cardiovascular morbidity and mortality. In high-risk subjects, measurement of the ABPI provides valuable information on future cardiovascular events.

Introduction

Prevention of atherosclerotic diseases associated with high morbidity and mortality, like coronary heart disease and cerebrovascular disease, are main goals of public health policy in industrialized countries. Therefore, identification of high-risk groups is relevant for implementation of preventive measures.

Peripheral arterial occlusive disease (PAOD) is rarely fatal. The majority of PAOD subjects are asymptomatic and of older age [1], [2]. Intermittent claudication (IC), the most common symptomatic manifestation and PAOD, has a relatively benign course as far as the extremities are concerned [3]. Only a small minority develops critical ischemia, justifying specialist intervention [3]. Cross-sectional studies, however, show that almost half of all PAOD subjects seem to have some clinical evidence of coronary heart disease or cerebrovascular disease [3], [4], [5]. Few follow-up studies on PAOD have described subsequent cardiovascular morbidity, especially in asymptomatic subjects [6], [7]. More evidence exists on the increased risk for mortality in claudicants. Symptomatic PAOD is consistently associated with an increased risk for atherosclerotic death [3]. Scarce data are available on mortality of asymptomatic PAOD. The relative risk (RR) of death seems to be higher in asymptomatic subjects compared with the non-PAOD population [3]. Data on gender disparities for adverse outcome are also scanty. Cardiovascular morbidity rates seem higher in women with PAOD, whereas male PAOD subjects seem more at risk for cardiovascular death [3].

The aim of our longitudinal study was to describe the cardiovascular morbidity and mortality of asymptomatic PAOD subjects after 7 years of follow-up. In addition, we investigated possible gender differences in outcome.

Section snippets

Study population

The Limburg PAOD Study started in 1988 in collaboration with 18 general practice centers. The study methods have been extensively described elsewhere [1], [8]. The sampling frame for the study population consisted of 26,620 subjects, aged 40–78 years, registered in the collaborating general practices. Every citizen in the Netherlands is registered in a general practice. Therefore, the practice population of a general practice is a segment of the general population. A postal screening

Population

At baseline, 314 subjects had asymptomatic PAOD (50.6% female), 138 subjects had symptomatic PAOD (34.1% female), and 6 subjects had PAOD of unspecified type. Table 1 shows the baseline characteristics of the asymptomatic, symptomatic, and non-PAOD subjects. Asymptomatic PAOD subjects and claudicants were significantly older, had a worse risk-factor profile, and more often had a history of other cardiovascular diseases compared with non-PAOD subjects.

After a mean follow-up of 7.2 years, 3070

Discussion

Our results show that in the general population, asymptomatic PAOD subjects developed nonfatal and fatal cardiovascular events more often than non-PAOD subjects. Asymptomatic PAOD was not only a significant predictor for nonfatal cardiovascular disease, but also for total and cardiovascular mortality. Asymptomatic and symptomatic PAOD subjects had a comparable prognosis for nonfatal and fatal events. Female asymptomatic PAOD subjects seemed to be at high risk for a nonfatal MI, whereas the risk

Acknowledgements

We thank the participating physicians and the assistants for their contributions to this study. The Limburg PAOD Study was supported by a research grant of the Netherlands Organization for Scientific Research (900-715.154) and the former Dutch “Praeventiefonds” (28-1323). The longitudinal study was supported by a research grant from the Netherlands Heart Foundation (92.170). Doppler devices were donated by Asta Medica BV.

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