Association of Ankle-Brachial Indices With Limb Revascularization or Amputation in Patients With Peripheral Artery Disease

Homam Moussa Pacha, Vishnu P. Mallipeddi, Naveed Afzal, Sungrim Moon, Vinod C. Kaggal, Manju Kalra, Gustavo Oderich, Paul W. Wennberg, Thom W Rooke, Christopher G. Scott, Iftikhar Jan Kullo, Robert D McBane, Rick A. Nishimura, Rajeev Chaudhry, Hongfang D Liu, Adelaide M Arruda-Olson

Research output: Contribution to journalArticle

Abstract

Importance: The prevalence and morbidity of peripheral artery disease (PAD) are high, with limb outcomes including revascularization and amputation. In community-dwelling patients with PAD, the role of noninvasive evaluation for risk assessment and rates of limb outcomes have not been established to date. Objective: To evaluate whether ankle-brachial indices are associated with limb outcomes in community-dwelling patients with PAD. Design, Setting, and Participants: A population-based, observational, test-based cohort study of patients was performed from January 1, 1998, to December 31, 2014. Data analysis was conducted from July 15 to December 15, 2017. Participants included a community-based cohort of 1413 patients with PAD from Olmsted County, Minnesota, identified by validated algorithms deployed to electronic health records. Automated algorithms identified limb outcomes used to build Cox proportional hazards regression models. Ankle-brachial indices and presence of poorly compressible arteries were electronically identified from digital data sets. Guideline-recommended management strategies within 6 months of diagnosis were also electronically retrieved, including therapy with statins, antiplatelet agents, angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, and smoking abstention. Main Outcomes and Measures: Ankle-brachial index (index ≤0.9 indicates PAD; <.05, severe PAD; and ≥1.40, poorly compressible arteries) and limb revascularization or amputation. Results: Of 1413 patients, 633 (44.8%) were women; mean (SD) age was 70.8 (13.3) years. A total of 283 patients (20.0%) had severe PAD (ankle-brachial indices <0.5) and 350 (24.8%) had poorly compressible arteries (ankle-brachial indices ≥1.4); 780 (55.2%) individuals with less than severe disease formed the reference group. Only 32 of 283 patients (11.3%) with severe disease and 68 of 350 patients (19.4%) with poorly compressible arteries were receiving 4 guideline-recommended management strategies. In the severe disease subgroup, the 1-year event rate for revascularization was 32.4% (90 events); in individuals with poorly compressible arteries, the 1-year amputation rate was 13.9% (47 events). In models adjusted for age, sex, and critical limb ischemia, poorly compressible arteries were associated with amputation (hazard ratio [HR], 3.12; 95% CI, 2.16-4.50; P < .001) but not revascularization (HR, 0.91; 95% CI, 0.69-1.20; P = .49). In contrast, severe disease was associated with revascularization (HR, 2.69; 95% CI, 2.15-3.37; P < .001) but not amputation (HR, 1.30; 95% CI, 0.82-2.07; P = .27). Conclusions and Relevance: Community-dwelling patients with severe PAD or poorly compressible arteries have high rates of revascularization or limb loss, respectively. Guideline-recommended management strategies for secondary risk prevention are underused in the community.

Original languageEnglish (US)
Pages (from-to)e185547
JournalJAMA Network Open
Volume1
Issue number8
DOIs
StatePublished - Dec 7 2018

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Ankle Brachial Index
Peripheral Arterial Disease
Amputation
Extremities
Arteries
Independent Living
Guidelines
Hydroxymethylglutaryl-CoA Reductase Inhibitors
Electronic Health Records
Angiotensin Receptor Antagonists
Platelet Aggregation Inhibitors
Secondary Prevention
Proportional Hazards Models
Angiotensin-Converting Enzyme Inhibitors
Cohort Studies
Ischemia
Smoking
Outcome Assessment (Health Care)
Morbidity

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Association of Ankle-Brachial Indices With Limb Revascularization or Amputation in Patients With Peripheral Artery Disease. / Moussa Pacha, Homam; Mallipeddi, Vishnu P.; Afzal, Naveed; Moon, Sungrim; Kaggal, Vinod C.; Kalra, Manju; Oderich, Gustavo; Wennberg, Paul W.; Rooke, Thom W; Scott, Christopher G.; Kullo, Iftikhar Jan; McBane, Robert D; Nishimura, Rick A.; Chaudhry, Rajeev; Liu, Hongfang D; Arruda-Olson, Adelaide M.

In: JAMA Network Open, Vol. 1, No. 8, 07.12.2018, p. e185547.

Research output: Contribution to journalArticle

Moussa Pacha, H, Mallipeddi, VP, Afzal, N, Moon, S, Kaggal, VC, Kalra, M, Oderich, G, Wennberg, PW, Rooke, TW, Scott, CG, Kullo, IJ, McBane, RD, Nishimura, RA, Chaudhry, R, Liu, HD & Arruda-Olson, AM 2018, 'Association of Ankle-Brachial Indices With Limb Revascularization or Amputation in Patients With Peripheral Artery Disease', JAMA Network Open, vol. 1, no. 8, pp. e185547. https://doi.org/10.1001/jamanetworkopen.2018.5547
Moussa Pacha, Homam ; Mallipeddi, Vishnu P. ; Afzal, Naveed ; Moon, Sungrim ; Kaggal, Vinod C. ; Kalra, Manju ; Oderich, Gustavo ; Wennberg, Paul W. ; Rooke, Thom W ; Scott, Christopher G. ; Kullo, Iftikhar Jan ; McBane, Robert D ; Nishimura, Rick A. ; Chaudhry, Rajeev ; Liu, Hongfang D ; Arruda-Olson, Adelaide M. / Association of Ankle-Brachial Indices With Limb Revascularization or Amputation in Patients With Peripheral Artery Disease. In: JAMA Network Open. 2018 ; Vol. 1, No. 8. pp. e185547.
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title = "Association of Ankle-Brachial Indices With Limb Revascularization or Amputation in Patients With Peripheral Artery Disease",
abstract = "Importance: The prevalence and morbidity of peripheral artery disease (PAD) are high, with limb outcomes including revascularization and amputation. In community-dwelling patients with PAD, the role of noninvasive evaluation for risk assessment and rates of limb outcomes have not been established to date. Objective: To evaluate whether ankle-brachial indices are associated with limb outcomes in community-dwelling patients with PAD. Design, Setting, and Participants: A population-based, observational, test-based cohort study of patients was performed from January 1, 1998, to December 31, 2014. Data analysis was conducted from July 15 to December 15, 2017. Participants included a community-based cohort of 1413 patients with PAD from Olmsted County, Minnesota, identified by validated algorithms deployed to electronic health records. Automated algorithms identified limb outcomes used to build Cox proportional hazards regression models. Ankle-brachial indices and presence of poorly compressible arteries were electronically identified from digital data sets. Guideline-recommended management strategies within 6 months of diagnosis were also electronically retrieved, including therapy with statins, antiplatelet agents, angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, and smoking abstention. Main Outcomes and Measures: Ankle-brachial index (index ≤0.9 indicates PAD; <.05, severe PAD; and ≥1.40, poorly compressible arteries) and limb revascularization or amputation. Results: Of 1413 patients, 633 (44.8{\%}) were women; mean (SD) age was 70.8 (13.3) years. A total of 283 patients (20.0{\%}) had severe PAD (ankle-brachial indices <0.5) and 350 (24.8{\%}) had poorly compressible arteries (ankle-brachial indices ≥1.4); 780 (55.2{\%}) individuals with less than severe disease formed the reference group. Only 32 of 283 patients (11.3{\%}) with severe disease and 68 of 350 patients (19.4{\%}) with poorly compressible arteries were receiving 4 guideline-recommended management strategies. In the severe disease subgroup, the 1-year event rate for revascularization was 32.4{\%} (90 events); in individuals with poorly compressible arteries, the 1-year amputation rate was 13.9{\%} (47 events). In models adjusted for age, sex, and critical limb ischemia, poorly compressible arteries were associated with amputation (hazard ratio [HR], 3.12; 95{\%} CI, 2.16-4.50; P < .001) but not revascularization (HR, 0.91; 95{\%} CI, 0.69-1.20; P = .49). In contrast, severe disease was associated with revascularization (HR, 2.69; 95{\%} CI, 2.15-3.37; P < .001) but not amputation (HR, 1.30; 95{\%} CI, 0.82-2.07; P = .27). Conclusions and Relevance: Community-dwelling patients with severe PAD or poorly compressible arteries have high rates of revascularization or limb loss, respectively. Guideline-recommended management strategies for secondary risk prevention are underused in the community.",
author = "{Moussa Pacha}, Homam and Mallipeddi, {Vishnu P.} and Naveed Afzal and Sungrim Moon and Kaggal, {Vinod C.} and Manju Kalra and Gustavo Oderich and Wennberg, {Paul W.} and Rooke, {Thom W} and Scott, {Christopher G.} and Kullo, {Iftikhar Jan} and McBane, {Robert D} and Nishimura, {Rick A.} and Rajeev Chaudhry and Liu, {Hongfang D} and Arruda-Olson, {Adelaide M}",
year = "2018",
month = "12",
day = "7",
doi = "10.1001/jamanetworkopen.2018.5547",
language = "English (US)",
volume = "1",
pages = "e185547",
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TY - JOUR

T1 - Association of Ankle-Brachial Indices With Limb Revascularization or Amputation in Patients With Peripheral Artery Disease

AU - Moussa Pacha, Homam

AU - Mallipeddi, Vishnu P.

AU - Afzal, Naveed

AU - Moon, Sungrim

AU - Kaggal, Vinod C.

AU - Kalra, Manju

AU - Oderich, Gustavo

AU - Wennberg, Paul W.

AU - Rooke, Thom W

AU - Scott, Christopher G.

AU - Kullo, Iftikhar Jan

AU - McBane, Robert D

AU - Nishimura, Rick A.

AU - Chaudhry, Rajeev

AU - Liu, Hongfang D

AU - Arruda-Olson, Adelaide M

PY - 2018/12/7

Y1 - 2018/12/7

N2 - Importance: The prevalence and morbidity of peripheral artery disease (PAD) are high, with limb outcomes including revascularization and amputation. In community-dwelling patients with PAD, the role of noninvasive evaluation for risk assessment and rates of limb outcomes have not been established to date. Objective: To evaluate whether ankle-brachial indices are associated with limb outcomes in community-dwelling patients with PAD. Design, Setting, and Participants: A population-based, observational, test-based cohort study of patients was performed from January 1, 1998, to December 31, 2014. Data analysis was conducted from July 15 to December 15, 2017. Participants included a community-based cohort of 1413 patients with PAD from Olmsted County, Minnesota, identified by validated algorithms deployed to electronic health records. Automated algorithms identified limb outcomes used to build Cox proportional hazards regression models. Ankle-brachial indices and presence of poorly compressible arteries were electronically identified from digital data sets. Guideline-recommended management strategies within 6 months of diagnosis were also electronically retrieved, including therapy with statins, antiplatelet agents, angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, and smoking abstention. Main Outcomes and Measures: Ankle-brachial index (index ≤0.9 indicates PAD; <.05, severe PAD; and ≥1.40, poorly compressible arteries) and limb revascularization or amputation. Results: Of 1413 patients, 633 (44.8%) were women; mean (SD) age was 70.8 (13.3) years. A total of 283 patients (20.0%) had severe PAD (ankle-brachial indices <0.5) and 350 (24.8%) had poorly compressible arteries (ankle-brachial indices ≥1.4); 780 (55.2%) individuals with less than severe disease formed the reference group. Only 32 of 283 patients (11.3%) with severe disease and 68 of 350 patients (19.4%) with poorly compressible arteries were receiving 4 guideline-recommended management strategies. In the severe disease subgroup, the 1-year event rate for revascularization was 32.4% (90 events); in individuals with poorly compressible arteries, the 1-year amputation rate was 13.9% (47 events). In models adjusted for age, sex, and critical limb ischemia, poorly compressible arteries were associated with amputation (hazard ratio [HR], 3.12; 95% CI, 2.16-4.50; P < .001) but not revascularization (HR, 0.91; 95% CI, 0.69-1.20; P = .49). In contrast, severe disease was associated with revascularization (HR, 2.69; 95% CI, 2.15-3.37; P < .001) but not amputation (HR, 1.30; 95% CI, 0.82-2.07; P = .27). Conclusions and Relevance: Community-dwelling patients with severe PAD or poorly compressible arteries have high rates of revascularization or limb loss, respectively. Guideline-recommended management strategies for secondary risk prevention are underused in the community.

AB - Importance: The prevalence and morbidity of peripheral artery disease (PAD) are high, with limb outcomes including revascularization and amputation. In community-dwelling patients with PAD, the role of noninvasive evaluation for risk assessment and rates of limb outcomes have not been established to date. Objective: To evaluate whether ankle-brachial indices are associated with limb outcomes in community-dwelling patients with PAD. Design, Setting, and Participants: A population-based, observational, test-based cohort study of patients was performed from January 1, 1998, to December 31, 2014. Data analysis was conducted from July 15 to December 15, 2017. Participants included a community-based cohort of 1413 patients with PAD from Olmsted County, Minnesota, identified by validated algorithms deployed to electronic health records. Automated algorithms identified limb outcomes used to build Cox proportional hazards regression models. Ankle-brachial indices and presence of poorly compressible arteries were electronically identified from digital data sets. Guideline-recommended management strategies within 6 months of diagnosis were also electronically retrieved, including therapy with statins, antiplatelet agents, angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, and smoking abstention. Main Outcomes and Measures: Ankle-brachial index (index ≤0.9 indicates PAD; <.05, severe PAD; and ≥1.40, poorly compressible arteries) and limb revascularization or amputation. Results: Of 1413 patients, 633 (44.8%) were women; mean (SD) age was 70.8 (13.3) years. A total of 283 patients (20.0%) had severe PAD (ankle-brachial indices <0.5) and 350 (24.8%) had poorly compressible arteries (ankle-brachial indices ≥1.4); 780 (55.2%) individuals with less than severe disease formed the reference group. Only 32 of 283 patients (11.3%) with severe disease and 68 of 350 patients (19.4%) with poorly compressible arteries were receiving 4 guideline-recommended management strategies. In the severe disease subgroup, the 1-year event rate for revascularization was 32.4% (90 events); in individuals with poorly compressible arteries, the 1-year amputation rate was 13.9% (47 events). In models adjusted for age, sex, and critical limb ischemia, poorly compressible arteries were associated with amputation (hazard ratio [HR], 3.12; 95% CI, 2.16-4.50; P < .001) but not revascularization (HR, 0.91; 95% CI, 0.69-1.20; P = .49). In contrast, severe disease was associated with revascularization (HR, 2.69; 95% CI, 2.15-3.37; P < .001) but not amputation (HR, 1.30; 95% CI, 0.82-2.07; P = .27). Conclusions and Relevance: Community-dwelling patients with severe PAD or poorly compressible arteries have high rates of revascularization or limb loss, respectively. Guideline-recommended management strategies for secondary risk prevention are underused in the community.

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