PDF icon PDF herunterladen
Exp Clin Endocrinol Diabetes 2004; 112(10): 566-573
DOI: 10.1055/s-2004-830408
Article

J. A. Barth Verlag in Georg Thieme Verlag KG Stuttgart · New York

High Prevalence of Peripheral Arterial Disease and Low Treatment Rates in Elderly Primary Care Patients with Diabetes

S. Lange1 , C. Diehm2 , H. Darius3 , R. Haberl4 , J. R. Allenberg5 , D. Pittrow6 , A. Schuster7 , B. von Stritzky8 , G. Tepohl9 , H. J. Trampisch1
  • 1Department of Medical Informatics, Biometry, and Epidemiology, University of Bochum, Bochum, Germany
  • 2Department of Internal Medicine/Vascular Medicine, Affiliated Teaching Hospital, Ruprecht-Karls University of Heidelberg, Heidelberg, Germany
  • 3Medical Clinic I, Klinikum Berlin-Neukölln, Vivantes Netzwerk für Gesundheit, Berlin, Germany
  • 4Department of Neurology, Municipal Hospital München-Harlaching, Munich, Germany
  • 5Department of Vascular Surgery, Ruprecht-Karls University of Heidelberg, Heidelberg, Germany
  • 6Department of Clinical Pharmacology, Medical Faculty, Technical University of Dresden, Dresden, Germany
  • 73P Consulting, Pöcking, Germany
  • 8Medical Department, Sanofi-Synthelabo GmbH, Berlin, Germany
  • 9Internist/Vascular Medicine, Munich, Germany
Weitere Informationen

Publikationsverlauf

Received: November 20, 2003 First decision: March 3, 2004

Accepted: May 3, 2004

Publikationsdatum:
02. Dezember 2004 (online)

Auch verfügbar aufeRef
   Lizenzen und Reprints
Preview

Abstract

Representative data on peripheral arterial disease (PAD) in community-based office practice are scarce while at the same time of high interest. Thus, we aimed to determine the prevalence of peripheral arterial disease (PAD), comorbidity of atherothrombotic manifestations, and treatment intensity among elderly diabetic patients in primary care.

In this monitored cross-sectional study, 344 general practitioners throughout Germany determined the ankle-brachial index (ABI) of 6880 consecutive, unselected patients aged 65 years or older with bilateral Doppler ultrasound measurements. PAD was defined according to the recent American Heart Association guidelines (using the higher of the 2 systolic ankle pressures: ABI < 0.9) or peripheral revascularisation, or amputation because of PAD. Coronary events (CAD) and cerebrovascular events (CVD) were taken from the patient's history without additional diagnostic measures. Diabetes was defined according to the clinical diagnosis of the physician and/or HbA1c ≥ 6.5 % and/or intake of oral antidiabetic medication and/or application of insulin.

1.743 patients were classified as diabetics: the median disease duration was 6 years (1st; 3rd quartile: 2; 11), median HbA1c 6.6 % (5.9; 7.3), mean age 72.5 ± 5.4 years, and 51.4 % were females. Diabetics had in comparison with non-diabetics a higher prevalence of PAD defined as ABI < 0.9 (26.3 % vs. 15.3 %, univariate odds ratio 2.0 [95 % confidence interval: 1.7; 2.3]), intermittent claudication (5.1 % vs. 2.1 %, OR: 2.5 [1.9; 3.4]), known CAD (16.1 % vs. 10.6 %, OR: 1.6 [1.4; 1.9]), and known CVD (6.8 % vs. 4.8 %; OR: 1.4 [1.2; 1.8]). 57.4 % of the diabetics with previously known PAD (as only atherothrombotic manifestation) received antiplatelet therapy (vs. 75.1 % with CAD and/or CVD only).

The ABI was suitable as screening measure in the primary care setting. In elderly diabetics in comparison to non-diabetics, the prevalence of PAD was very high. Despite the known benefits of antiplatelet therapy, PAD patients were less intensively treated than patients with CAD or CVD.

Key words

Peripheral arterial disease - diabetes - prevalence - atherosclerosis - coronary artery disease - cerebrovascular disease - cross sectional study

References

  • 1 Abbott R, Rodriguez B, Petrovitch H, Yano K, Schatz I, Popper J, Masaki K, Ross G, Curb J. Ankle-brachial blood pressure in elderly men and the risk of stroke: the Honolulu Heart Program.  J Clin Epidemiol. 2001;  54 973-978
    CrossrefPubMedSuche in Google Scholar
  • 2 Adler A I, Stevens R J, Neil A, Stratton I M, Boulton A JM, Holman R R. UKPDS 59: hyperglycemia and other potentially modifiable risk factors for peripheral vascular disease in type 2 diabetes.  Diabetes Care. 2002;  25 894-899
    CrossrefPubMedSuche in Google Scholar
  • 3 Antithrombotic Trialists Collaboration . Collaborative meta-analysis of randomised trials of anti-platelet therapy for prevention of death, myocardial infarction and stroke in high-risk patients.  Brit Med J. 2002;  324 71-86
    CrossrefPubMedSuche in Google Scholar
  • 4 Arbeitsgruppe Epidemiologische Methoden der Deutschen Arbeitsgemeinschaft Epidemiologie (DAE) .Leitlinien und Empfehlungen zur Sicherung von Guter Epidemiologischer Praxis (GEP). DAE 2000
    Suche in Google Scholar
  • 5 Bainton D, Sweetnam P, Baker I, Elwood P. Peripheral vascular disease: consequence for survival and association with risk factors in the Speedwell Prospective Heart Disease Study.  Br Heart J. 1994;  72 128-132
    CrossrefPubMedSuche in Google Scholar
  • 6 Belch J JF, Topol E J, Agnelli G, Bertrand M, Califf R M, Clement D L, Creager M A, Easton J D, Gavin I, James R, Greenland P, Hankey G, Hanrath P, Hirsch A T, Meyer J, Smith S C, Sullivan F, Weber M A. Critical issues in peripheral arterial disease detection and management: A call to action.  Arch Intern Med. 2003;  163 884-892
    CrossrefPubMedSuche in Google Scholar
  • 7 Bowlin S J, Medalie J H, Flocke S A, Zyzanski S J, Goldbourt U. Epidemiology of intermittent claudication in middle-aged men.  Am J Epidemiol. 1994;  140 418-430
    PubMedSuche in Google Scholar
  • 8 Brand F N, Kannel W B, Evans J, Larson M G, Wolf P A. Glucose intolerance, physical signs of peripheral artery disease, and risk of cardiovascular events: the Framingham Study.  Am Heart J. 1998;  136 919-927
    PubMedSuche in Google Scholar
  • 9 Curb J D, Masaki K, Rodriguez B L, Abbott R D, Burchfiel C M, Chen R, Petrovitch H, Sharp D, Yano K. Peripheral artery disease and cardiovascular risk factors in the elderly. The Honolulu Heart Program.  Arterioscler Thromb Vasc Biol. 1996;  16 1495-1500
    PubMedSuche in Google Scholar
  • 10 Deedwania P. Diabetes and vascular disease: common links in the emerging epidemic of coronary artery disease.  Am J Cardiol. 2003;  91 68-71
    CrossrefPubMedSuche in Google Scholar
  • 11 Dolan N C, Liu K, Criqui M H, Greenland P, Guralnik J M, Chan C, Schneider J R, Mandapat A L, Martin G, McDermott M M. Peripheral artery disease, diabetes, and reduced lower extremity functioning.  Diabetes Care. 2002;  25 113-120
    PubMedSuche in Google Scholar
  • 12 Dormandy J, Rutherford R. Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Consensus (TASC).  J Vasc Surg. 2000;  31 S1-S296
    PubMedSuche in Google Scholar
  • 13 Gaede P, Vedel P, Larsen N, Jensen G VH, Parving H-H, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes.  N Engl J Med. 2003;  348 383-393
    Suche in Google Scholar
  • 14 getABI Study Group . The German Epidemiological Trial on Ankle Brachial Index (getABI): rationale, design and methods.  VASA. 2002;  31 241-248
    CrossrefPubMedSuche in Google Scholar
  • 15 Greenland P, Abrams J, Aurigemma G P, Bond M G, Clark L T, Criqui M H, Crouse 3rd J R, Friedman L, Fuster V, Herrington D M, Kuller L H, Ridker P M, Roberts W C, Stanford W, Stone N, Swan H J, Taubert K A, Wexler L. Prevention Conference V. Beyond secondary prevention: Identifying the high-risk patient for primary prevention. Noninvasive tests of atherosclerotic burden.  Circulation. 2000;  101 E16-22
    PubMedSuche in Google Scholar
  • 16 Hirsch A T, Criqui M H, Treat-Jacobson D, Regensteiner J G, Creager M A, Olin J W, Krook S H, Hunninghake D B, Comerota A J, Walsh M E, McDermott M M, Hiatt W R. Peripheral arterial disease detection, awareness, and treatment in primary care.  JAMA. 2001;  286 1317-1324
    CrossrefPubMedSuche in Google Scholar
  • 17 Kallio M, Forsblom C, Groop P-H, Groop L, Lepantalo M. Development of new peripheral arterial occlusive disease in patients with type 2 diabetes during a mean follow-up of 11 years.  Diabetes Care. 2003;  26 1241-1245
    CrossrefPubMedSuche in Google Scholar
  • 18 Laakso M. Hyperglycemia and cardiovascular disease in type 2 diabetes.  Diabetes. 1999;  48 937-942
    CrossrefPubMedSuche in Google Scholar
  • 19 Leng G C, Lee A J, Fowkes F G, Whiteman M, Dunbar J, Housley E, Ruckley C V. Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population.  Int J Epidemiol. 1996;  25 1172-1181
    CrossrefPubMedSuche in Google Scholar
  • 20 MacGregor A S, Price J F, Hau C M, Lee A J, Carson M N, Fowkes F G. Role of systolic blood pressure and plasma triglycerides in diabetic peripheral arterial disease. The Edinburgh Artery Study.  Diabetes Care. 1999;  22 453-458
    CrossrefPubMedSuche in Google Scholar
  • 21 Mackaay A J, Beks P J, Dur A H, Bischoff M, Scholma J, Heine R J, Rauwerda J A. The distribution of peripheral vascular disease in a Dutch Caucasian population: comparison of type II diabetic and non-diabetic subjects.  Eur J Vasc Endovasc Surg. 1995;  9 170-175
    PubMedSuche in Google Scholar
  • 22 McDermott M M, Greenland P, Liu K, Guralnik J M, Celic L, Criqui M H, Chan C, Martin G J, Schneider J, Pearce W H, Taylor L M, Clark E. The ankle brachial index is associated with leg function and physical activity: the Walking and Leg Circulation Study.  Ann Intern Med. 2002;  136 873-883
    CrossrefPubMedSuche in Google Scholar
  • 23 McKenna M, Wolfson S, Kuller L. The ratio of ankle and arm arterial pressure as an independent predictor of mortality.  Atherosclerosis. 1991;  87 119-128
    CrossrefPubMedSuche in Google Scholar
  • 24 Meijer W T, Hoes A W, Rutgers D, Bots M L, Hofman A, Grobbee D E. Peripheral arterial disease in the elderly: The Rotterdam Study.  Arterioscler Thromb Vasc Biol. 1998;  18 185-192
    CrossrefPubMedSuche in Google Scholar
  • 25 Murabito J M, Evans J C, Nieto K, Larson M G, Levy D, Wilson P WF. Prevalence and clinical correlates of peripheral arterial disease in the Framingham Offspring Study.  American Heart Journal. 2002;  143 961-965
    CrossrefPubMedSuche in Google Scholar
  • 26 Ness J, Aronow W S, Ahn C. Risk factors for symptomatic peripheral arterial disease in older persons in an academic hospital-based geriatrics practice.  J Am Geriatr Soc. 2000;  48 312-314
    PubMedSuche in Google Scholar
  • 27 Newman A B, Siscovick D S, Manolio T A, Polak J, Fried L P, Borhani N O, Wolfson S K. Ankle-arm index as a marker of atherosclerosis in the Cardiovascular Health Study. Cardiovascular Heart Study (CHS) Collaborative Research Group.  Circulation. 1993;  88 837-845
    CrossrefPubMedSuche in Google Scholar
  • 28 Newman A B, Shemanski L, Manolio T A, Cushman M, Mittelmark M, Polak J F, Powe N R, Siscovick D. Ankle-arm index as a predictor of cardiovascular disease and mortality in the Cardiovascular Health Study. The Cardiovascular Health Study Group.  Arterioscler Thromb Vasc Biol. 1999;  19 538-545
    CrossrefPubMedSuche in Google Scholar
  • 29 Orchard T J, Strandness Jr D E. Assessment of peripheral vascular disease in diabetes. Report and recommendations of an international workshop sponsored by the American Diabetes Association and the American Heart Association September 18 - 20, 1992 New Orleans, Louisiana.  Circulation. 1993;  88 819-828
    PubMedSuche in Google Scholar
  • 30 Papamichael C M, Lekakis J P, Stamatelopoulos K S, Papaioannou T G, Alevizaki M K, Cimponeriu A T, Kanakakis J E, Papapanagiotou A, Kalofoutis A T, Stamatelopoulos S F. Ankle-brachial index as a predictor of the extent of coronary atherosclerosis and cardiovascular events in patients with coronary artery disease.  Am J Cardiol. 2000;  86 615-618
    CrossrefPubMedSuche in Google Scholar
  • 31 Rose G. The diagnosis of ischaemic heart pain and intermittent claudication in field surveys.  Bull World Health Organ. 1962;  27 645-658
    PubMedSuche in Google Scholar
  • 32 Schmieder F A, Comerota A J. Intermittent claudication: magnitude of the problem, patient evaluation, and therapeutic strategies.  Am J Cardiol. 2001;  87 3D-13D
    PubMedSuche in Google Scholar
  • 33 Tsai A W, Folsom A R, Rosamond W D, Jones D W. Ankle-brachial index and 7-year ischemic stroke incidence: The ARIC study.  Stroke. 2001;  32 1721-1724
    PubMedSuche in Google Scholar
  • 34 Turner R, Cull C, Holman R. United Kingdom Prospective Diabetes Study 17: a 9-year update of a randomized, controlled trial on the effect of improved metabolic control on complications in non-insulin-dependent diabetes mellitus.  Ann Intern Med. 1996;  124 136-145
    PubMedSuche in Google Scholar
  • 35 UK Prospective Diabetes Study Group . Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38.  BMJ. 1998;  317 703-713
    PubMedSuche in Google Scholar
  • 36 Walters D P, Gatling W, Mullee M A, Hill R D. The prevalence, detection, and epidemiological correlates of peripheral vascular disease: a comparison of diabetic and non-diabetic subjects in an English community.  Diabet Med. 1992;  9 710-715
    CrossrefPubMedSuche in Google Scholar
  • 37 Zander E, Heinke P, Reindel J, Kohnert K D, Kairies U, Braun J, Eckel L, Kerner W. Peripheral arterial disease in diabetes mellitus type 1 and type 2: are there different risk factors?.  VASA. 2002;  31 249-254
    PubMedSuche in Google Scholar
  • 38 Zheng Z J, Sharrett A R, Chambless L E, Rosamond W D, Nieto F J, Sheps D S, Dobs A, Evans G W, Heiss G. Associations of ankle-brachial index with clinical coronary heart disease, stroke and preclinical carotid and popliteal atherosclerosis: the Atherosclerosis Risk in Communities (ARIC) Study.  Atherosclerosis. 1997;  131 115-125
    CrossrefPubMedSuche in Google Scholar

PD Dr. Stefan Lange

Abteilung für Medizinische Informatik, Biometrie und Epidemiologie
Ruhr-Universität Bochum

Universitätsstraße 150

44801 Bochum

Germany

Telefon: + 49(0)2343227914

Fax: + 49 (0) 23 43 20 79 14

eMail: stefan.f.lange@ruhr-uni-bochum.de