Background: Exercise test parameters (exercise ankle brachial index (ABI), walking distance and blood pressure response) separately are associated with long-term outcome in patients with known or suspected peripheral arterial disease (PAD). However, the clinical value of the combination of these parameters together is unknown.
Methods: 2165 patients performed a treadmill exercise test to diagnose or to evaluate their PAD. Resting ABI, exercise ABI, abnormal blood pressure response (hypotensive and hypertensive) and walking distance (impairment <150 m) were measured. The study population was divided into patients with a resting ABI ≥ 0.90 and patients with PAD (resting ABI < 0.90).
Results: The mean follow-up period was 5 years (0.5–14 years). Long-term mortality rate and risks increases when more exercise parameters became abnormal (p-value = 0.001). Patients with a normal resting ABI but with an abnormal exercise test had a higher mortality risk – HR 1.90 (1.32–2.73) – than patients with a normal exercise test. The highest mortality risk and cardiac death was observed in PAD patients with a walking impairment together with an abnormal blood pressure response – HR 3.48 (2.22–5.46).
Conclusion: Exercise tests give multiple parameters, which together provide important prognostic information on long-term outcome in both patients with normal resting ABI and PAD.
MilaniRVLavieCJ. The role of exercise training in peripheral arterial disease. Vasc Med2007; 12: 351–358.
2.
CriquiMHLangerRDFronekAFeigelsonHSKlauberMRMcCannTJ. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med1992; 326: 381–386.
3.
MeruAVMittraSThyagarajanBChughA. Intermittent claudication: an overview. Atherosclerosis2006; 187: 221–237.
4.
NewmanABSiscovickDSManolioTAPolakJFriedLPBorhaniNO. Ankle-arm index as a marker of atherosclerosis in the Cardiovascular Health Study. Cardiovascular Heart Study (CHS) Collaborative Research Group. Circulation1993; 88: 837–845.
5.
MenkeAMuntnerPWildmanRPDreisbachAWRaggiP. Relation of borderline peripheral arterial disease to cardiovascular disease risk. Am J Cardiol2006; 98: 1226–1230.
6.
de LiefdeIIHoeksSEvan GestelYRBaxJJKleinJvan DomburgRT. Usefulness of hypertensive blood pressure response during a single-stage exercise test to predict long-term outcome in patients with peripheral arterial disease. Am J Cardiol2008; 102: 921–926.
7.
de LiefdeIIHoeksSEvan GestelYRKleinJVerhagenHJvan DomburgRT. Prognostic value of hypotensive blood pressure response during single-stage exercise test on long-term outcome in patients with known or suspected peripheral arterial disease. Coron Artery Dis2008; 19: 603–607.
8.
de LiefdeIIHoeksSEvan GestelYRKleinJBaxJJVerhagenHJ. The prognostic value of impaired walking distance on long-term outcome in patients with known or suspected peripheral arterial disease. Eur J Vasc Endovasc Surg2009; 38(4): 482–487.
9.
McDermottMMTianLLiuKGuralnikJMFerrucciLTanJ. Prognostic value of functional performance for mortality in patients with peripheral artery disease. J Am Coll Cardiol2008; 51: 1482–1489.
10.
MyersJPrakashMFroelicherVDoDPartingtonSAtwoodJE. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med2002; 346: 793–801.
11.
FeringaHHBaxJJvan WaningVHBoersmaEElhendyASchoutenO. The long-term prognostic value of the resting and postexercise ankle-brachial index. Arch Intern Med2006; 166: 529–535.
12.
Classification and diagnosis of diabetes mellitus and other categories of glucose intolerance. National Diabetes Data Group. Diabetes1979; 28: 1039–1057.
13.
Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care2003; 26(Suppl 1): S5–S20.
14.
McDermottMM. Ankle brachial index as a predictor of outcomes in peripheral arterial disease. J Lab Clin Med1999; 133: 33–40.
15.
SekhriNFederGSEldridgeSMadhuRHemingwayHTimmisAD. Incremental prognostic value of the exercise electrocardiogram in the initial assessment of patients with suspected angina: cohort study. BMJ2008; 337: 2240–2248.
16.
AijazBBabuinLSquiresRWKopeckySLJohnsonBDThomasRJ. Long-term mortality with multiple treadmill exercise test abnormalities: comparison between patients with and without cardiovascular disease. Am Heart J2008; 156: 783–789.
17.
NicoloffADTaylorLMJrSextonGJSchuffRAEdwardsJMYeagerRA. Relationship between site of initial symptoms and subsequent progression of disease in a prospective study of atherosclerosis progression in patients receiving long-term treatment for symptomatic peripheral arterial disease. J Vasc Surg2002; 35: 38–46. discussion 46–37.
18.
DelpMDO'LearyDS. Integrative control of the skeletal muscle microcirculation in the maintenance of arterial pressure during exercise. J Appl Physiol2004; 97: 1112–1118.
19.
PalatiniP. Exaggerated blood pressure response to exercise: pathophysiologic mechanisms and clinical relevance. J Sports Med Phys Fitness1998; 38: 1–9.
20.
TzemosNLimPOMacDonaldTM. Is exercise blood pressure a marker of vascular endothelial function?. Qjm2002; 95: 423–429.
21.
ComessKAFensterPE. Clinical implications of the blood pressure response to exercise. Cardiology1981; 68: 233–244.
22.
EhsaniAAAustinMBBielloD. Impaired left ventricular function during exercise in coronary artery disease and exertional hypotension. Cardiology1988; 75: 24–31.
23.
GibbonsRJHuDCClementsIPMankinHTZinsmeisterARBrownML. Anatomic and functional significance of a hypotensive response during supine exercise radionuclide ventriculography. Am J Cardiol1987; 60: 1–4.
24.
HakkiAHMunleyBMHadjimiltiadesSMeissnerMDIskandrianAS. Determinants of abnormal blood pressure response to exercise in coronary artery disease. Am J Cardiol1986; 57: 71–75.
25.
MorrisCKMorrowKFroelicherVFHidegAHunterDKawaguchiT. Prediction of cardiovascular death by means of clinical and exercise test variables in patients selected for cardiac catheterization. Am Heart J1993; 125: 1717–1726.
26.
PrakashMMyersJFroelicherVFMarcusRDoDKalisettiD. Clinical and exercise test predictors of all-cause mortality: results from >6,000 consecutive referred male patients. Chest2001; 120: 1003–1013.
27.
de LiefdeIIvan DomburgRTBaxJJKleinJVerhagenHJPoldermansD. A decline in walking distance predicts long-term outcome in patients with known or suspected peripheral artery disease. Eur J Cardiovasc Prev Rehabil2010; 17: 321–328.
