Functional status measured by walking impairment questionnaire and cardiovascular risk prediction in peripheral arterial disease: results of the Peripheral Arteriopathy and Cardiovascular Events (PACE) study

Abstract

The prognostic impact of the functional status of patients with intermittent claudication is still obscure. From the lists of seven general practitioners, we identified all subjects aged 40-80 years (n = 4352). Of those reporting leg symptoms while walking on the Rose questionnaire (n = 760), 60 had a qualifying diagnosis of peripheral arterial disease (PAD). All of them received the Walking Impairment Questionnaire (WIQ). For each patient affected by PAD, three sex- and age-matched controls were selected randomly. After a 24-month follow-up, survival curves showed that PAD patients with WIQ scores > median had a higher cardiovascular risk than controls, and patients with WIQ scores < median had an even poorer prognosis (p < 0.001 for all WIQ domains). In PAD, after adjustment for age, sex, ankle-brachial index and comorbidity, two WIQ domains (ie walking speed and stairclimbing) were associated with cardiovascular events. The cardiovascular risk of claudicants who had a score > median for at least three WIQ domains was intermediate versus the risk of controls and PAD patients with a WIQ score < median, also when adjusted for the covariates indicated above (RR = 3.26, p = 0.019). In intermittent claudication, a worse functional status entails a greater risk of ischemic events versus low functional impairment.

Keywords

cardiovascular risk functional status intermittent claudication peripheral arterial disease walking impairment questionnaire

References

Fowkes FG , Housley E , Cawood EH , Macintyre CC , Ruckley CV , Prescott RJ. Edinburgh Artery Study: prevalence of asymptomatic and symptomatic peripheral arterial disease in the general population . Int J Epidemiol 1991; 20: 384-392 .

Meijer WT , Hoes AW , Rutgers D , Bots ML , Hofman A , Grobbee DE. Peripheral arterial disease in the elderly: The Rotterdam Study . Arterioscler Thromb Vasc Biol 1998; 18: 185-192 .

Hiatt WR , Hoag S , Hamman RF. Effect of diagnostic criteria on the prevalence of peripheral arterial disease. The San Luis Valley Diabetes Study . Circulation 1995; 91: 1472-1479 .

Stoffers HE , Rinkens PE , Kester AD , Kaiser V , Knottnerus JA. The prevalence of asymptomatic and unrecognized peripheral arterial occlusive disease . Int J Epidemiol 1996; 25: 282-290 .

Wouter TM , Hoes AW , Rutgers D et al. Peripheral arterial disease in the elderly. The Rotterdam Study . Arterioscler Thromb Vasc Biol 1998; 18: 185-192 .

Barletta G , Perna S , Sabba C , Catalano A , O’Boyle C , Brevetti G. Quality of life in patients with intermittent claudication: relationship with laboratory exercise performance . Vasc Med 1996; 1: 3-7 .

Breek JC , Hamming JF , De Vries J , Aquarius AE , van Berge Henegouwen DP. Quality of life in patients with intermittent claudication using the World Health Organization (WHO) questionnaire . Eur J Vasc Endovasc Surg 2001; 21: 118-122 .

Criqui MH , Langer RD , Fronek A et al. Mortality over a period of 10 years in patients with peripheral arterial disease . N Engl J Med 1992; 326: 381-386 .

Leng GC , Lee AJ , Fowkes FG et al. Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population . Int J Epidemiol 1996; 25: 1172-1181 .

10.

O’Riordain DS , O’Donnell JA. Realistic expectations for the patient with intermittent claudication . Br J Surg 1991; 78: 861-863 .

11.

Newman AB , Shemanski L , Manolio TA et al. 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 .

12.

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 .

13.

Leon AS , Connett J , Jacobs DR Jr , Rauramaa R. Leisure-time physical activity levels and risk of coronary heart disease and death. The Multiple Risk Factor Intervention Trial . JAMA 1987; 258: 2388-2395 .

14.

Pate RR , Pratt M , Blair SN et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine . JAMA 1995; 273: 402-407 .

15.

Paffenbarger RS Jr , Hyde RT , Wing AL , Lee IM , Jung DL , Kampert JB. The association of changes in physical-activity level and other lifestyle characteristics with mortality among men . N Engl J Med 1993; 328: 538-545 .

16.

Brevetti G , Oliva G , Silvestro A , Scopacasa F , Chiariello M. Peripheral Arteriopathy and Cardiovascular Events (PACE) Study Group . Prevalence, risk factors and cardiovascular comorbidity of symptomatic peripheral arterial disease in Italy . Atherosclerosis 2004; 175: 131-138 .

17.

Regensteiner JG , Steiner JF , Panzer RJ , Hiatt WR. Evaluation of walking impairment by questionnaire in patients with peripheral arterial disease . J Vasc Med Biol 1990; 2: 142-152 .

18.

Hiatt WR , Regensteiner JG , Hargarten ME , Wolfel EE , Brass EP. Benefit of exercise conditioning for patients with peripheral arterial disease . Circulation 1990; 81: 602-609 .

19.

Regensteiner JG , Steiner JF , Hiatt WR. Exercise training improves functional status in patients with peripheral arterial disease . J Vasc Surg 1996; 23: 104-115 .

20.

Hiatt WR , Regensteiner JG , Creager MA et al. Propionyl-L-carnitine improves exercise performance and functional status in patients with claudication . Am J Med 2001; 110: 616-622 .

21.

Fronek A , Coel M , Berstein EF. Quantitative ultrasonographic studies of lower extremity flow velocities in health and disease . Circulation 1976; 53: 957-960 .

22.

Hiatt WR , Hirsch AT , Regensteiner JG , Brass EP. Clinical trials for claudication. Assessment of exercise performance, functional status, and clinical end points. Vascular Clinical Trialists . Circulation 1995; 92: 614-621 .

23.

Parmelee PA , Thuras PD , Katz IR , Lawton MP. Validation of the Cumulative Illness Rating Scale in a geriatric residential population . J Am Geriatr Soc 1995; 43: 130-137 .

24.

Cox DR. Regression and life tables . J R Stat Soc Ser B 1972; 34: 187-220 .

25.

Murabito JM , D’Agostino RB , Silbershatz H , Wilson WF. Intermittent claudication. A risk profile from The Framingham Heart Study . Circulation 1997; 96: 44-49 .

26.

Hu G , Eriksson J , Barengo NC et al. Occupational, commuting, and leisure-time physical activity in relation to total and cardiovascular mortality among Finnish subjects with type 2 diabetes . Circulation 2004; 110: 666-673 .

27.

Taylor RS , Brown A , Ebrahim S et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials . Am J Med 2004; 116: 682-692 .

28.

Izquierdo-Porrera AM , Gardner AW , Powell CC , Katzel LI. Effects of exercise rehabilitation on cardiovascular risk factors in older patients with peripheral arterial occlusive disease . J Vasc Surg 2000; 31: 670-677 .

29.

Brendle DC , Joseph LJ , Corretti MC , Gardner AW , Katzel LI. Effects of exercise rehabilitation on endothelial reactivity in older patients with peripheral arterial disease . Am J Cardiol 2001; 87: 324-329 .