Comparison of medical treatment with percutaneous closure of patent foremen ovale for secondary prevention of TIAs and strokes: a case-control study (original) (raw)
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Stroke, 2009
Background and Purpose-Patients with stroke and patients with transient ischemic attack (TIA) are at high risk for vascular events and may not exhibit the signs and symptoms of peripheral arterial disease (PAD). We investigated if asymptomatic PAD detected by ankle brachial index Ͻ0.9 is independently associated with recurrent vascular events in patients with stroke or TIA. Methods-In this prospective longitudinal hospital-based cohort study, asymptomatic PAD was detected by ankle brachial index measurement in consecutive patients with stroke and patients with TIA. They were assessed for stroke risk factors, ankle brachial index measurement, and laboratory parameters known to be associated with stroke risk. These patients were followed for composite vascular events, including stroke, TIA, myocardial infarction, and vascular death. Results-In a 1-year period, 102 patients were evaluated, of whom 26% had asymptomatic PAD. All patients were followed for a median period of 2.1 years from the index stroke/TIA (range, 1.0 to 2.7 years) for vascular events. Kaplan-Meier curve showed fewer patients with asymptomatic PAD remained free of composite vascular events (48% compared with 84% in the no-PAD group; log rank, Pϭ0.0001). Asymptomatic PAD was significantly associated with composite vascular events before (hazard ratio, 4.2; 95% CI, 1.9 to 9.3; Pϭ0.0003) and after adjustment for confounders (hazard ratio, from Model 1, 2.8; 95% CI, 1.1 to 7.2; Pϭ0.03 and Model 2, 3.4; 95% CI, 1.4 to 8.2, Pϭ0.006). Asymptomatic PAD was also significantly associated with stroke before (hazard ratio, 6.5; 95% CI, 2.1 to 19.9; Pϭ0.001) and after adjustment for confounders (hazard ratio from Model 1, 4.8; 95% CI, 1.5 to 15.3; Pϭ0.009 and Model 2, 5.2; 95% CI, 1.5 to 17.6; Pϭ0.008). Conclusions-In patients with stroke or TIA, asymptomatic PAD is independently associated with recurrent vascular events and stroke. (Stroke. 2009;40:3472-3477.)
European Journal of Vascular and Endovascular Surgery, 2008
Objective: A significant proportion of patients with ischemic heart disease have associated peripheral arterial disease (PAD), but many are asymptomatic and this condition remains underdiagnosed. We aimed to study the prevalence of PAD in patients with an acute coronary syndrome (ACS) and to evaluate its influence in hospital clinical outcomes. Methods: The PAMISCA register is a prospective, multicenter study involving patients !40 years old with ACS admitted to selected Spanish hospitals. All patients had their ankle-brachial index (ABI) measured between days 3 and 7 after the ischemic event. Results: 1410 ACS patients (71.4% male) were included. PAD determined by ABI was documented in 561 patients (39.8%). Factors independently related to PAD were age (OR: 1.04; 95% CI: 1.03e1.06; p < 0.001), smoking (OR: 1.88; 95% CI: 1.41e2.49; p < 0.0001), diabetes (OR: 1.30; 95% CI: 1.02e1.65; p < 0.05), previous cardiac disease (OR: 1.54; 95% CI: 1.22e1.95; p < 0.001) and previous cerebrovascular disease (OR: 1.90; 95% CI: 1.28e2.80; p < 0.001). Following the * Corresponding author. Dr. P. Morillas Eur J Vasc Endovasc Surg (2008) 36, 189e196
Intermittent claudication in 8343 men and 21-year specific mortality follow-up
Annals of Epidemiology, 1997
As Western populations live longer, peripheral vascular disease will become a greater individual and public health problem. Therefore, the long-term natural history of intermittent claudication (IC) needs further delineation. The study objective was to describe the 21-year mortality and relative risk for cause-specific mortality for subjects with incident IC. METHODS:
Journal of Public Health, 2010
Peripheral arterial disease (PAD), a marker of elevated vascular risk, is highly prevalent in general practice. We aimed to investigate patient characteristics and outcomes of PAD patients treated according to the guidelines versus those who were not. Methods. PACE-PAD was a multicentre, cluster-randomised prospective, longitudinal cohort study of patients with PAD in primary care, who were followed-up for death or vascular events over 18 months. Guideline-orientation was assumed, if patients received anti¬coagu¬lant/antiplatelet therapy, exercise training, and (if applicable) advice for smoking cessation and therapy of diabetes mellitus, hypertension, or hypercholesterolemia, respectively. Results. The 5099 PAD patients (mean age 68.0 ± 9.0 years, 68.5% males) who were followed-up were in Fontaine stages I, IIa, IIb, III, and IV in 22.5%, 34.6%, 30.1%, 7.8%, and 3.5% (1.5% not specified). Comprehensive guideline orientation was reported in 28.4% only, however, patients in lower Fontaine stages received more often guideline-oriented therapy (I: 30.3%; IIa: 31.6%, IIb: 29.1%, III: 9.8%, IV: 18.0%). During 18 months, 457 patients died (224 due to cerebrovascular or coronary deaths), 319 had instable angina pectoris, 116 myocardial infarction, and 140 an ischemic stroke event. In total, 24% of patients had experienced any vascular event (19.1% a first event). Event rates did not differ between patients treated according to guidelines, and those who were not. Conclusion. The present PAD cohort was a high-risk sample with an unexpectedly high rate of deaths and vascular events. While physicians appear to focus on the treatment of individual risk factors, rates of comprehensive PAD management in line with guideline recommendations are still suboptimal. Factors contributing to the lacking difference between outcomes in the guideline-oriented and nonguideline-oriented groups may comprise low treatment intensity or other reasons for unsatisfactory effect of treatment, misclassification of events, patient's non-compliance with therapy.
Coronary Artery Disease, 2014
Objectives Patients with peripheral artery disease (PAD) less frequently achieve secondary prevention goals compared with patients with coronary artery disease (CAD). We aimed to compare mortality rates in patients with PAD and CAD following first vascular intervention. Patients and methods Patients 18 years of age or older without a history of cardiovascular disease, who underwent first coronary or lower limb vascular intervention between 2002 and 2010, were included in this study. The primary endpoint was all-cause mortality. Results Of the 9950 participants, 8242 (82.8%) underwent first coronary revascularization and 1708 (17.2%) received first peripheral vascular intervention. During a mean followup period of 5.6±2.3 years, 1283 (12.9%) participants died. Compared with CAD patients, patients with PAD had significantly worse long-term prognosis with an increased risk for all-cause mortality (hazard ratio = 2.95, 95% confidence interval 2.6-3.3, P < 0.0001). This association remained statistically significant following a multivariable analysis (hazard ratio = 1.86, 95% confidence interval 1.6-2.1, P < 0.0001). Furthermore, PAD patients were less frequently treated with cardioprotective medications including statins, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, aspirin, and clopidogrel (P < 0.001). Conclusion Patients with PAD have worse outcome compared with patients with CAD, even in the specific group of patients following first vascular intervention. These findings demand more effort to improve secondary prevention guidelines in all patients with cardiovascular diseases, but especially in PAD patients. Coron Artery Dis