Impact of Symptomatic Peripheral Arterial Disease on 1-Year Mortality in Patients Undergoing Percutaneous Coronary Interventions

Abstract

Purpose:

To determine the impact of symptomatic peripheral arterial disease (PAD) on clinical outcomes in patients treated with percutaneous coronary interventions (PCI).

Methods and Results:

Symptomatic PAD was identified in 1969 (18.9%) of 10440 consecutive patients undergoing PCI. Patients with PAD were older, more frequently female, and had smaller body surface area and more atherosclerotic risk factors, chronic renal insufficiency, and heart failure. Patients with PAD had lower rates of procedural success (94.2% versus 96.2%, p<0.0001) and higher rates of in-hospital complications, including all-cause mortality (2.1% versus 1.1%, p=0.0002), cardiac death (1.5% versus 0.7%, p=0.0009), urgent coronary artery bypass grafting (1.9% versus 1.2%, p=0.01), recurrent ischemia (5.6% versus 2.8%, p<0.0001), re-PCI to the target lesion (2.4% versus 1.1%, p<0.0001), stroke (0.6% versus 0.3%, p=0.0344), transient ischemic attack (0.4% versus 0.1%, p=0.01), femoral hematoma (10.3% versus 8.5%, p=0.01), retroperitoneal hematoma (0.8% versus 0.3%, p=0.009), limb ischemia (3.0% versus 0.7%, p<0.0001), gastrointestinal bleeding (1.9% versus 0.9%, p<0.0001), and blood transfusion (10.1% versus 5.2%, p<0.0001). At 1-year follow-up, patients with PAD had a higher mortality rate (13.6% versus 5.2%, p<0.0001), a higher rate of myocardial infarction (8.3% versus 6.5%, p=0.008), and also more target lesion (21.2% versus 19.8%, p=0.02) or target vessel revascularization (24.6% versus 21.2%, p=0.002). By multivariate analysis, PAD was an independent predictor of 1-year mortality (odds ratio 1.71, 95% confidence interval 1.42 to 2.07, p<0.0001).

Conclusions:

Nearly a fifth of patients undergoing PCI have symptomatic PAD. The presence of PAD is associated with lower rates of procedural success, higher rates of in-hospital and 1-year adverse events, and is independently associated with increased 1-year mortality.

Keywords

peripheral vascular disease coronary artery disease angioplasty outcome analysis mortality morbidity

Get full access to this article

View all access options for this article.

References

Fowkes

Housley

Cawood

. Edinburgh Artery Study: Prevalence of asymptomatic and symptomatic peripheral arterial disease in the general population. Int J Epidemiol. 1991; 20: 384–392.

Simonsick

Guralnik

Hennekens

. Intermittent claudication and subsequent cardiovascular disease in the elderly. J Gerontol A Biol Sci Med Sci. 1995; 50A: M17–22.

Verhaeghe

. Epidemiology and prognosis of peripheral obliterative arteriopathy [in French]. Drugs. 1998; 56 Suppl 3: 1–10.

Reeder

Liu

Horlick

. Sociodemographic variation in the prevalence of cardiovascular disease. Can J Cardiol. 1996; 12: 271–277.

Meijer

Hoes

Rutgers

. Peripheral arterial disease in the elderly: The Rotterdam Study. Arterioscler Thromb Vasc Biol. 1998; 18: 185–192.

Atmer

Jogestrand

Laska

. Peripheral artery disease in patients with coronary artery disease. Int Angiol. 1995; 14: 89–93.

Hooi

Stoffers

Knottnerus

. The prognosis of non-critical limb ischaemia: A systematic review of population-based evidence. Br J Gen Pract. 1999; 49: 49–55.

Sikkink

van Asten

van't Hof

. Decreased ankle/brachial indices in relation to morbidity and mortality in patients with peripheral arterial disease. Vasc Med. 1997; 2: 169–173.

Dormandy

Heeck

Vig

. The natural history of claudication: Risk to life and limb. Semin Vasc Surg. 1999; 12: 123–137.

10.

Criqui

Langer

Fronek

. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992; 326: 381–386.

11.

Birkmeyer

O'Connor

Quinton

. The effect of peripheral vascular disease on inhospital mortality rates with coronary artery bypass surgery. Northern New England Cardiovascular Disease Study Group. J Vasc Surg. 1995; 21: 445–452.

12.

Minakata

Konishi

Matsumoto

. Influence of peripheral vascular occlusive disease on the morbidity and mortality of coronary artery bypass grafting. Jpn Circ J. 2000; 64: 905–908.

13.

Rihal

Sutton-Tyrrell

Guo

. Increased incidence of periprocedural complications among patients with peripheral vascular disease undergoing myocardial revascularization in the bypass angioplasty revascularization investigation. Circulation. 1999; 100: 171–177.

14.

Lansky

Popma

. Quantitative angiography. In: Topol

, ed. Textbook of Interventional Cardiology. Philadelphia: WB Saunders; 1999: 725–747.

15.

The Thrombolysis in Myocardial Infarction (TIMI) trial. Phase I findings. TIMI Study Group. N Engl J Med. 1985; 312: 932–936.

16.

Rose

. The diagnosis of ischaemic heart pain and intermittent claudication in field surveys. Bull World Health Organ. 1962; 27: 645–658.

17.

Rubin

. Estimating causal effects from large data sets using propensity scores. Ann Intern Med. 1997; 127: 757–763.

18.

Parsons

. Using SAS software to perform a case-control match on propensity score in an observational study. In: Proceedings on the Twenty-Fifth Annual SAS Users Group International Conference, Cary, NC: SAS Institute Inc.; 2000: 1166–1171.

19.

Anderson

Ohman

Holmes

. Prognostic value of congestive heart failure history in patients undergoing percutaneous coronary interventions. J Am Coll Cardiol. 1998; 32: 936–941.

20.

Harrell

Schunkert

Palacios

. Risk predictors in patients scheduled for percutaneous coronary revascularization. Catheter Cardiovasc Interv. 1999; 48: 253–260.

21.

Peterson

Lansky

Kramer

. Effect of gender on the outcomes of contemporary percutaneous coronary intervention. National Cardiovascular Network Clinical Investigators. Am J Cardiol. 2001; 88: 359–364.

22.

Niles

McGrath

Malenka

. Survival of patients with diabetes and multivessel coronary artery disease after surgical or percutaneous coronary revascularization: Results of a large regional prospective study. Northern New England Cardiovascular Disease Study Group. J Am Coll Cardiol. 2001; 37: 1008–1015.

23.

Gruberg

Mintz

Mehran

. The prognostic implications of further renal function deterioration within 48 h of interventional coronary procedures in patients with pre-existent chronic renal insufficiency. J Am Coll Cardiol. 2000; 36: 1542–1548.

24.

Best

Lennon

Ting

. The impact of renal insufficiency on clinical outcomes in patients undergoing percutaneous coronary interventions. J Am Coll Cardiol. 2002; 39: 1113–1119.

25.

Tan

Sulke

Taub

. Percutaneous transluminal coronary angioplasty of aorta ostial, non-aorta ostial, and branch ostial stenoses: Acute and long-term outcome. Eur Heart J. 1995; 16: 631–639.

26.

Nishida

Colombo

Briguori

. Contemporary percutaneous treatment of saphenous vein graft stenosis: Immediate and late outcomes. J Invasive Cardiol. 2000; 12: 505–512.

27.

Takagi

Stankovic

Finci

. Results and long-term predictors of adverse clinical events after elective percutaneous interventions on unprotected left main coronary artery. Circulation. 2002; 106: 698–702.

28.

Leng

Lee

Fowkes

. Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. Int J Epidemiol. 1996; 25: 1172–1181.

29.

Vickrey

Rector

Wickstrom

. Occurrence of secondary ischemic events among persons with atherosclerotic vascular disease. Stroke. 2002; 33: 901–906.

30.

Lee

Lowe

Woodward

. Fibrinogen in relation to personal history of prevalent hypertension, diabetes, stroke, intermittent claudication, coronary heart disease, and family history: The Scottish Heart Health Study. Br Heart J. 1993; 69: 338–342.

31.

Smith

Lee

Hau

. Plasma fibrinogen, haemostatic factors and prediction of peripheral arterial disease in the Edinburgh Artery Study. Blood Coagul Fibrinolysis. 2000; 11: 43–50.

32.

Banerjee

Pearson

Gilliland

. A six year prospective study of fibrinogen and other risk factors associated with mortality in stable claudicants. Thromb Haemost. 1992; 68: 261–263.

33.

Rossi

Biasucci

Citterio

. Risk of myocardial infarction and angina in patients with severe peripheral vascular disease: Predictive role of C-reactive protein. Circulation. 2002; 105: 800–803.

34.

Ridker

Stampfer

Rifai

. Novel risk factors for systemic atherosclerosis: A comparison of C-reactive protein, fibrinogen, homocysteine, lipoprotein(a), and standard cholesterol screening as predictors of peripheral arterial disease. JAMA. 2001; 285: 2481–2485.

35.

Pradhan

Rifai

Ridker

. Soluble intercellular adhesion molecule-1, soluble vascular adhesion molecule-1, and the development of symptomatic peripheral arterial disease in men. Circulation. 2002; 106: 820–825.

36.

Tisi

Hulse

Chulakadabba

. Exercise training for intermittent claudication: Does it adversely affect biochemical markers of the exercise-induced inflammatory response? Eur J Vasc Endovasc Surg. 1997; 14: 344–350.

37.

Hirsch

Criqui

Treat-Jacobson

. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001; 286: 1317–1324.

38.

McLafferty

Dunnington

Mattos

. Factors affecting the diagnosis of peripheral vascular disease before vascular surgery referral. J Vasc Surg. 2000; 31: 870–879.