Lower Extremity Arterial Disease mortality

Lower Extremity Arterial Disease (LEAD) is a common disease entity for men older than 40 and women older than 50 years of age. The prevalence of LEAD continues to increase with age, from less than 3% in the population younger than the age of 60 to more than 20% at age 75 and older. The majority of patients older than 75 with LEAD are asymptomatic. Prevention of arterial disease is key to reducing morbidity and mortality. LEAD is associated with specific risk factors, namely hypertriglyceridemia, homocysteinema, very low HDL cholesterol, physical inactivity, and above all cigaret smoking and diabetes mellitus, alone or in tandem. 

Intensive pharmacologic treatment of diabetes is known to decrease the risk for microvascular events such as nephropathy and retinopathy, but there is less evidence that it decreases macrovascular disease (28,29). DCCT/EDIC trial, however, demonstrated reduction in CVD (nonfatal Ml, stroke, death from CVD, confirmed angina, or the need for coronary-artery revascularization) in patients with type I diabetes assigned to intensive diabetes treatment compared with conventional treatment by 42% (p = 0.02) (30). Patients with lower extremity PAD and both type I and type 2 diabetes should be treated to reduce their glycosylated hemoglobin (Hb AIC) to less than 7%, per the American Diabetes Association recommendation (31). Subanalysis of the UKPDS showed no evidence of a threshold effect of Hb AIC a I % reduction in Hb Al C was associated with a 35% reduction in microvascular endpoints, an 18% reduction in Ml, and a 17% reduction in all-cause mortality. Frequent foot inspection by patients and physicians will enable early identification of foot lesions and ulcerations and facilitate prompt referral for treatment (32). 

Mortality in patients with peripheral vascular disease is most commonly due to cardiovascular disease, and treatment of coronary disease remains the central focus of therapy. Many patients with advanced peripheral arterial disease are more limited by the consequences of peripheral ischemia than by myocardial ischemia. In the cerebral circulation, arterial disease may be manifest as stroke or transient ischemic attacks. The painful symptoms of peripheral arterial disease in the lower extremities (claudication) typically are provoked by exertion, with increases in skeletal muscle O2 demand exceeding blood flow impaired by proximal stenoses. When flow to the extremities becomes critically limiting, peripheral ulcers and rest pain from tissue ischemia can become debilitating. 

Clearly, diabetics who have peripheral arterial disease have higher mortality rates than those who do not have arterial disease. A recent study by Vogt et al. (15) evaluated the relationship between peripheral arterial disease and mortality in a population of close to 2000 individuals over a 13-year period. All patients 50 years of age and older with no history of lower extremity surgery were evaluated for the presence of peripheral arterial disease. Analysis of the data stratified by populations and comorbid conditions showed that a low ankle-brachial index is an independent predictor of all causes of mortality in both men and women with peripheral arterial disease. This increase is a relative risk and is unchanged after exclusions of all patients with a clinical history of cardiovascular disease or diabetes. Thus, a low ankle-brachial index is an important measurement to obtain to assess the risk of mortality among those who smoke and have either angina or diabetes. 

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