Mechanisms of walking limitation in arterial claudication are incompletely elucidated. We aimed to identify new variables associated to walking limitation in patients with claudication.
Methods
We retrospectively analyzed data of 1120 patients referred for transcutaneous exercise oxygen pressure recordings (TcpO2). The outcome measurement was the absolute walking time on treadmill (3.2 km/h, 10% slope). We used both: linear regression analysis and a non-linear analysis, combining support vector machines and genetic explanatory in 800 patients with the following resting variables: age, gender, body mass index, the presence of diabetes, minimal ankle to brachial index at rest, usual walking speed over 10 m (usual-pace), number of comorbid conditions, active smoking, resting heart rate, pre-test glycaemia and hemoglobin, beta-blocker use, and exercise-derived variables: minimal value of pulse oximetry, resting chest-TcpO2, decrease in chest TcpO2 during exercise, presence of buttock ischemia defined as a decrease from rest of oxygen pressure index ≤15 mmHg. We tested the models over 320 other patients.
Results
Independent variables associated to walking time, by decreasing importance in the models, were: age, ankle to brachial index, usual-pace; resting TcpO2, body mass index, smoking, buttock ischemia, heart rate and beta-blockers for the linear regression analysis, and were ankle to brachial index, age, body mass index, usual-pace, decrease in chest TcpO2, smoking, buttock ischemia, glycaemia, heart rate for the non-linear analysis. Testing of models over 320 new patients gave r = 0.509 for linear and 0.575 for non-linear analysis (both p < 0.05).
Conclusion
Buttock ischemia, heart rate and usual-pace are new variables associated to walking time.
ItogaNKMinamiHRChelvakumarMet al.
Cost-effectiveness analysis of asymptomatic peripheral artery disease screening with the ABI test. Vasc Med2018;
23: 97–106.
3.
McDermottMMTianLLiuKet al.
Prognostic value of functional performance for mortality in patients with peripheral artery disease. J Am Coll Cardiol2008;
51: 1482–1489.
4.
SzubaAOkaRKHaradaRet al.
Limb hemodynamics are not predictive of functional capacity in patients with PAD. Vasc Med2006;
11: 155–163.
5.
McDermottMMLiuKGreenlandPet al.
Functional decline in peripheral arterial disease: associations with the ankle brachial index and leg symptoms. JAMA2004;
292: 453–461.
6.
Muller-BuhlUWiesemannAOserBet al.
Correlation of hemodynamic and functional variables with the angiographic extent of peripheral arterial occlusive disease. Vasc Med1999;
4: 247–251.
7.
ParmenterBJRaymondJFiatarone SinghMA.The effect of exercise on haemodynamics in intermittent claudication: a systematic review of randomized controlled trials. Sports Med2010;
40: 433–447.
8.
ParmenterBJRaymondJDinnenPJet al.
Preliminary evidence that low ankle-brachial index is associated with reduced bilateral hip extensor strength and functional mobility in peripheral arterial disease. J Vasc Surg2013;
57: 963–973 e1.
9.
ParrBNoakesTDDermanEW.Factors predicting walking intolerance in patients with peripheral arterial disease and intermittent claudication. S Afr Med J2008;
98: 958–962.
10.
LudygaTKuczmikWBKazibudzkiMet al.
Ankle-brachial pressure index estimated by laser Doppler in patients suffering from peripheral arterial obstructive disease. Ann Vasc Surg2007;
21: 452–457.
11.
Nardi GomesTJMartins de AlbuquerqueIde Moraes CostaPet al.
Association between the ankle-brachial index, intermittent claudication, and physical activity level: what is the influence on the functional capacity of patients with or at high risk of cardiovascular disease?Int J Gen Med2015;
8: 55–62.
12.
McDermottMMFerrucciLGuralnikJMet al.
The ankle-brachial index is associated with the magnitude of impaired walking endurance among men and women with peripheral arterial disease. Vasc Med2010;
15: 251–257.
13.
ResnickHELindsayRSMcDermottMMet al.
Relationship of high and low ankle brachial index to all-cause and cardiovascular disease mortality: the Strong Heart Study. Circulation2004;
109: 733–739.
14.
OuedraogoNFeuilloyMMaheGet al.
Chest TcpO2 changes during constant-load treadmill walking tests in patients with claudication. Physiol Meas2011;
32: 181–194.
15.
GernigonMMarchandJOuedraogoNet al.
Proximal ischemia is a frequent cause of exercise-induced pain in patients with a normal ankle to brachial index at rest. Pain Physician2013;
16: 57–64.
16.
MaheGOuedraogoNMarchandJet al.
Self-reported estimation of usual walking speed improves the performance of questionnaires estimating walking capacity in patients with vascular-type claudication. J Vasc Surg2011;
54: 1360–1365.
17.
AbrahamPPicquetJVielleBet al.
Transcutaneous oxygen pressure measurements on the buttocks during exercise to detect proximal arterial ischemia: comparison with arteriography. Circulation2003;
107: 1896–1900.
18.
HenniSSemporeYWLe MelinerTet al.
Intra-test and test-retest reliability of exercise oximetry in arterial claudication. Microvasc Res2018;
117: 44–49.
19.
VapnikVN.The nature of statistical learning theory.
New York:
Springer-Verlag, 1995.
20.
HollandJH.Adaptation in natural and artificial systems.
Cambridge:
MIT Press, 1992.
21.
AgranoffDFernandez-ReyesDPapadopoulosMCet al.
Identification of diagnostic markers for tuberculosis by proteomic fingerprinting of serum. Lancet2006;
368: 1012–1021.
22.
Shawe-TaylorJCristianiniN.Kernel methods for pattern analysis.
New York:
Cambridge University Press, 2004.
23.
VapnikVN.Statistical learning theory.
New York:
Wiley, 1998.
24.
DruckerHBurgesCJCKaufmanLet al.
Support vector regression machines. Adv Neural Inf Process Syst1997;
9: 155–161.
25.
SuykensJAKVandewalleJ.Least squares support vector machine classifiers. Neural Process Lett1999;
9: 293–300.
26.
WangSWangYDuWet al.
A multi-approaches-guided genetic algorithm with application to operon prediction. Artif Intell Med2007;
41: 151–159.
27.
BrassEPCooperLTHansonPet al.
Association of clinical attributes and treadmill walking performance in patients with claudication due to peripheral artery disease. J Vasc Surg2013;
58: 396–403.
28.
AllisonMAHiattWRHirschATet al.
A high ankle-brachial index is associated with increased cardiovascular disease morbidity and lower quality of life. J Am Coll Cardiol2008;
51: 1292–1298.
29.
DiasRMForjazCLCucatoGGet al.
Obesity decreases time to claudication and delays post-exercise hemodynamic recovery in elderly peripheral arterial disease patients. Gerontology2009;
55: 21–26.
30.
RavalZLiuKTianLet al.
Higher body mass index is associated with more adverse changes in calf muscle characteristics in peripheral arterial disease. J Vasc Surg2012;
55: 1015–1024.
31.
SchererSAHiattWRRegensteinerJG.Lack of relationship between gait parameters and physical function in peripheral arterial disease. J Vasc Surg2006;
44: 782–788.
32.
Ritti-DiasRMLiJHollabaughKMet al.
Kinetics and clinical factors among patients with peripheral artery disease. J Cardiopulm Rehabil Prev2013;
33: 411–418.
33.
McDermottMMFerrucciLLiuKet al.
Women with peripheral arterial disease experience faster functional decline than men with peripheral arterial disease. J Am Coll Cardiol2011;
57: 707–714.
34.
WilligendaelEMTeijinkJABartelinkMLet al.
Influence of smoking on incidence and prevalence of peripheral arterial disease. J Vasc Surg2004;
40: 1158–1165.
35.
FritschiCCollinsEGO'ConnellSet al.
The effects of smoking status on walking ability and health-related quality of life in patients with peripheral arterial disease. J Cardiovasc Nurs2013;
28: 380–386.
JonesWSClareREllisSJet al.
Effect of peripheral arterial disease on functional and clinical outcomes in patients with heart failure (from HF-ACTION). Am J Cardiol2011;
108: 380–384.
38.
ClementsIPMillerWLOlsonLJ.Resting heart rate and cardiac function in dilated cardiomyopathy. Int J Cardiol1999;
72: 27–37.
39.
CoteCZilberbergMDModySHet al.
Haemoglobin level and its clinical impact in a cohort of patients with COPD. Eur Respir J2007;
29: 923–929.
40.
HoffkesHGSaeger-LorenzKEhrlyAM.Optimal hematocrit in patients with intermittent claudication. Exercise-induced muscle tissue oxygen pressure after stepwise hemodilution. Acta Med Austriaca1991;
18: 16–19.
41.
CelsingFErikssonMMarkstromUet al.
Clinical and hemodynamic effects of stepwise lowering of hemoglobin concentration in patients with intermittent claudication. Angiology1994;
45: 43–48.
42.
MaheGOuedraogoNLeftheriotisGet al.
Exercise treadmill testing in patients with claudication, with and without diabetes. Diabet Med2011;
28: 356–362.
43.
HenniSMaheGLamotteCet al.Exercise transcutaneous oximetry significantly modifies the diagnostic hypotheses and impacts scheduled investigations or treatments of patients with exertional limb pain. Eur J Intern Med2018;
52: 28–34.
44.
MaheGKalraMAbrahamPet al.
Application of exercise transcutaneous oxygen pressure measurements for detection of proximal lower extremity arterial disease: a case report. Vasc Med2015;
20: 251–255.
45.
OuedraogoNBarbeauCLegrandMet al.
Routine arterial echo-Doppler is not sufficient to exclude an arterial origin of exercise-induced proximal lower limb pain. Int J Cardiol2013;
167: 1053–1054.
46.
MaheGLeftheriotisGPicquetJet al.
A normal penile pressure cannot rule out the presence of lesions on the arteries supplying the hypogastric circulation in patients with arterial claudication. Vasc Med2009;
14: 331–338.
47.
JonathanMGoldbergMA.Multiple regression analysis and mass assessment: a review of the issues. Appraisal J2001;
1: 89–109.
48.
HaykinS.Neural networks: a comprehensive foundation.
New Jersey:
Prentice Hall, 1999.
49.
ChiangCL.Statistical methods of analysis.
Singapore:
World Scientific, 2003.
50.
MomsenAHJensenMBNoragerCBet al.
Drug therapy for improving walking distance in intermittent claudication: a systematic review and meta-analysis of robust randomised controlled studies. Eur J Vasc Endovasc Surg2009;
38: 463–474.
