International Journal of Cardiology 151 : 2011

Combination of ankle brachial index and diabetes mellitus to predict cardiovascular events and mortality after an acute coronary syndrome
Juan Quiles, Pedro Morillas, Vicente Bertomeu, Pilar Mazon, Alberto Cordero, Federico Soria, Lorenzo Facila, Jose Ramon Gonzales-Juanatey

Pradana Zaky Romadhon Bambang Herwanto

Department of Cardiology and Vascular Medicine Airlangga University School of Medicine Soetomo Teaching Hospital SURABAYA

Page 1

INTRODUCTION
Diabetes is associated with a marked increase in the risk of coronary heart disease The risk of a diabetic patients without previous myocardial infarction is as high as the risk of a non diabetic patient with a myocardial infarction Peripheral arterial disease (PAD) is also associated with an increase in the risk of fatal and non fatal cardiovascular and cerebrovascular events Epidemiological studies have confirmed an association between diabetes and an increase prevalence of PAD Many patients are asymptomatic and often underdiagnosed
Page 2

...............INTRODUCTION
Combination of diabetes and PAD increases the cardio vascular events rates compared to non-diabetic populations with PAD Data are scarce about the prevalence of PAD in patients with ACS especially in patients with diabetes The objective of this study was to evaluate the prevalence of diabetes and PAD in patient after an ACS and their relationship with all cause and cardiovascular mortality

Page 3

METHODS
This study is an observational, prospective, multicenter study, designed to investigate the prevalence of PAD in patients admitted to Spanish hospital Patients 40 years with an ACS were systemically screened with the ABI previous to hospital discharge 1410 patients were included in the study and 13 patients died before discharge 241 patients decline the invitation of this study Prospective phase of the study included 1156 patients 1054 (91,2%) of them completed the one year follow up and were considered for the analisis
Page 4

.......................METHODS
Calculation of the ABI of both limbs was determined between 3rd and 7th day of the ischemic episode using a pocket Doppler BIDOP ES-100V3 Systolic blood pressure was measured in both arms and legs (posterior tibial) with the patient in supine position The lowest ABI value was selected in each patient All local sites received an identical Doppler and training on the accurate use of the doppler tehnique and calculation of the ABI to guarantee the consistency of the measurements
Page 5

Page 6

.......................METHODS
The presence of PAD was defined by an ABI value 0,9 Patients with a history of peripheral vascular revascularitation and/or ischemic amputation of the leg were also considered as patients with PAD ( 30 px ) The primary endpoint of the study was all-cause mortality The secondary endpoints were cardiovascular mortality, myocardial infarction, need for subsequent revascularitation, hospital admission for heart failure and stroke
Page 7

RESULTS
Total of 1054 patients (91,2%) were followed until a primary events occured or the end of the study After a median follow up of 382 days, 59 patiens died (5,6%), majority of cardiovascular events ( 47 px ) The prevalence of diabetes was 36% and the prevalence of PAD was 39,9% PAD was higher in patients with DM compared to non DM In the overall population, type 2 DM and PAD were associated with older age, a greater prevalence of hypertension, more frequent of prior MI and stroke, lower GFR and more severe coronary artery disease
Page 8

Page 9

.......................RESULTS
In both diabetic and nondiabetic subject, the presence of PAD was significanly associated with an increased of primary event, mainly due to cardiovascular mortality The incidence of death among non DM subjects with PAD was 5,6% and 2,1% in those without PAD In DM subjects with PAD the incidence of death was 15,3% and 4,8% in those without PAD The secondary endpoints ( myocardial infarction, need of revascularitation, hospital admission of heart failure or unstable angina, stroke ) were also higher in PAD and DM

Page 10

Page 11

Page 12

Page 13

DISCUSSION
Diabetic subjects and PAD had much higher mortality from coronary heart disease than without these conditions, confirming previous results This study data indicate a similar incidence of CV events in DM patients without PAD and non-DM with PAD The prevalence of diabetes is high in patients with ACS and its presence is associated with a worse outcome An ABI 0,9 in patients with ACS is also highly prevalent ( 30-40% ) and associated with worse prognosis

Page 14

...................DISCUSSION
ABI provides information of systemic atherosclerosis and represent a simple, non-invasive and inexpensive tool Previous study found that low ABI index in patients with ACS is a predictor of in-hospital CV events and also predictor of an adverse 1-year outcome in ACS patients This study results confirm and expand previous finding and also show that the presense of ABI 0,9 combined with DM is a powerful tool after an ACS to predict adverse events ABI measurement should be promoted, not only to clearly diagnose of PAD, but also to predict mortality in ACS px

Page 15

LIMITATIONS
Like other observational studies, cannot exclude some risk factors especially less well controlled risk factors Definition of PAD in this study considered a pathological ABI if 0,9 but it is known that an ABI of 1,3 suggest noncompressible or partially noncompressible vessels, which are result of medial artery calcification ( often associated with DM and CKD )

Page 16

CONCLUSION
This study shown that a considerable proportion of patients with an ACS have PAD and increased risk for adverse outcome, in a degree similar to diabetic patients Combination of ABI 0,9 and DM identifies a population of even higher risk This study suggest that all patients with ACS should be screened with ABI to detect presence of PAD to better stratify future risk of cardiovascular events

Page 17

THANK YOU

Page 18

Page 19

Page 20