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Title: Clinical value of the ankle brachial index and cardiovascular biomarkers in the Polish elderly population
Abstract:
Peripheral artery disease (PAD) is the third most common vascular complication after ischemic heart disease and stroke leading to disability, increased morbidity and mortality in an aging population. It is present in approximately 7-21% of the general population, while clinical symptoms of this disease in the form of intermittent claudication, bruits or lack of peripheral pulses are present in 2.8-6.3% of patients. It worth noting that in almost half the cases symptoms are nonspecific. The ankle brachial index (ABI) is an established method for the detection and monitoring of symptomatic and asymptomatic PAD with a sensitivity of 75%-95% and a specificity of 56%-86%, especially for ABI values <0.9. Aim: The aim of the study was to assess the value of the physical examination of the arterial system in relation to the ABI test, to assess the relationship between the concentration of N-terminal pro-B-type natriuretic peptide (NT-proBNP), inflammatory markers and other biochemical markers with the value of the ankle-brachial index, as well as to present the relationship between ABI and physical examination results with regards to mortality in the elderly. Methods: The results of three subsequent publications were obtained on the basis of analysis of data from the cross-sectional, multicentre PolSenior study conducted from 2007 to 2011 in the older Polish population. The study inv ; olved 5695 people from 16 administrative regions of Poland aged 55-59 years old, representing pre-old age, and 65 years and older. Socio-demographic data concerning complaints and diseases, smoking, ability to walk a distance of 200 m were obtained on the basis of a questionnaire. Participants' assessment included blood pressure measurement, anthropometric measurements, assessment of functional status using the Katz scale, risk of falls using the Tinetti test, and blood sampling for complete blood count, lipid panel, creatinine, NT-proBNP, and inflammatory markers: C-reactive protein (CRP) and interleukin 6 (IL-6). As part of the geriatric assessment, 1018 patients underwent a physical examination of the arterial system (PHEA) consisting of an assessment of the presence of pulses on the carotid, femoral, popliteal, posterior tibial and dorsal pedal arteries and auscultation of the aortic, carotid, femoral and renal arteries in search of bruits. The ABI was measured in accordance with guidelines using a continuous wave Doppler (Doppler Bidop ES-100VH 8 MHz). The normal value of ABI was 0.9 – 1.4, ABI<0.9 (“low ABI”) was interpreted as the presence of peripheral atherosclerosis, while ABI>1.4 (“high ABI”) was related to increased vascular stiffness. Data on deaths 10 years after the end of the study (range 8.4 to 10.5 years; mean 9.4 years) were obtained from the Universal Electr ; onic System for Registration of the Population (PESEL) register. The study was approved by the Bioethical Committee of the Medical University of Silesia in Katowice (Nb: KNW-6501-38/I//08), written informed consent to participate in the study was obtained from all subjects. Statistical analysis was performed using the SAS 9.4 statistical package (SAS Institute Inc., Cary, NC, USA). Records with complete ankle-brachial index data were used for the analyses. Results: As a result of missing data, the study group consisted of 844 people (in the first publication) and 852 people (in the second and third publications); the average age of subjects was 74 (10.6) years old; 53.3% were men. ABI<0.9 was found in 20.3% of participants and >1.4 in 12.1% of participants. Subjects with low ABI values were older, more often male, more often actively smoked, suffered from chronic kidney disease, arterial hypertension, had higher systolic blood pressures and more often had a history of prior myocardial infarction. However, diabetes was more common in the group with ABI >1.4. After dividing the subjects into three subgroups according to the number of PAD symptoms found (0–1, 2–5, 6 and more), we demonstrated a linear trend (P < 0.0001) for decrease in ABI value with an increase in the number of abnormalities found on physical examination of the arterial system. In turn, after distinguishing 3 r ; anges of physical examination of the arterial system into (1) complete examination (upper segment and lower limb arteries), (2) examination of upper segment arteries, and (3) examination of lower limb arteries, based on ROC and area under the curve analysis (AUC), we showed the greatest but modest value of a complete vascular examination and lower limb arterial examination in people with different ABI categories, while the assessment of the upper segment of the arterial system (carotid, renal and aorta) and the ability to walk 200 metres had little diagnostic value for diagnosis of PAD. In another publication, mortality over a 10-year period was assessed based on the age of the subjects and the ABI value. In the analyzed period, 27.3% of people before the age of 80 died and 79.4% aged 80 and over died. However, in the subgroups divided according to ABI value, the highest mortality was found in the ABI<0.9 (67.8%) group while lower, similar mortality rates were found in the groups with normal ABI (41.5%) and high ABI (40.3%), which was confirmed by Kaplan-Meier survival analysis (log-rank test, p<0.001). Similarly, higher mortality in people with ABI<0.9, with no difference in the risk of death in the groups with normal and high ABI, was demonstrated in the subgroup of people <80 years old (log-rank test, p<0.001). In contrast, among participants aged 80 years and over in the an ; alyzed period, mortality was similar in all analysed groups, regardless of the ABI value (p = 0.10). Stepwise regression analysis showed that depending on the age, below and above 80 years, different risk factors are associated with the risk of death. In the subgroup of people under 80, in addition to age, male gender, active smoking and elevated NT-proBNP concentration, the risk of death was increased by ABI values <0.9, in contrast to older people aged ≥ 80 years old, in whom no mortality relationship was observed neither with ABI nor with classical cardiovascular risk factors. In this group, the age (p<0.001), IL-6 levels and increased risk of falls assessed by the Tinetti test played decisive roles. The results of this observation of the oldest people are part of the discussion on the increasing importance of chronic subclinical inflammation known as inflammaging and the usefulness of nonclassical NT-proBNP and IL-6 testing in this age group. A further assessment of the importance of the physical examination of the arterial system (PHEA) confirmed that participants with ABI<0.9 had a higher PHEA score (number of abnormalities 0-17) compared to those with ABI≥0.9; respectively 2.373 (2.7) vs. 0.907 (1.7); p<0.0001. Cox regression analysis showed varying significance of the number of vascular abnormalities depending on the ABI value. In subjects with ABI<0.9, there was no ass ; ociation between 10-year mortality and the number of arterial abnormalities, while such a relationship is found in the group with ABI≥0.9. However, further analysis in this group (ABI ≥ 1.4) showed that patients with 4 or more arterial abnormalities had mortality similar to those with ABI < 0.9. To facilitate the selection of these decisions, a protocol was proposed, which requires confirmation in subsequent studies. Conclusions: 1. ABI values < 0.9 indicative of peripheral arteriosclerosis is present in one fifth of older adults in the community dwelling population. 2. Only a detailed physical examination of the arteries can be useful in detecting peripheral atherosclerosis, however, its value is modest. 3. ABI < 0.9 is associated with higher mortality in older adults, but not among the oldest, i.e. over 80 years old. 4. In the oldest age group, age and moderate inflammation seem to be the strongest risk factors for all-cause mortality. 5. Demonstration of the prognostic value of the Tinetti test to assess gait and balance as well as the risk of falls confirms the need for a comprehensive geriatric assessment in all elderly people. 6. Ankle-brachial index assessment can help identify older adults at increased risk of dying from potentially extensive atherosclerosis. 7. People with ABI values >0.9 and abnormal findings on physical examination of the vascular system may ; benefit from the implementation of a broader work-up of atherosclerosis as per the proposed diagnostic protocol. 8. ABI <0.9 supported by the measurement of NT-proBNP concentrations is a good prognostic indicator for the prediction of all-cause mortality in people up to 80 years old. 9. Cardiovascular markers such as NT-proBNP, CRP, and IL6 positively correlate with mortality during the 10-year observation of the entire population of the PolSenior study, which may be helpful in distinguishing people most at risk of early death.
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Rada Dyscypliny Nauki medyczne
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Jan 9, 2024
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Jan 9, 2024
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http://dl.cm-uj.krakow.pl:8080/publication/5005
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| Edition name | Date |
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| ZB-137692 | Jan 9, 2024 |
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