title: Relation of lower-extremity amputation to all-cause and cardiovascular disease mortality in American Indians: the Strong Heart Study.
abstract: OBJECTIVE
  To compare risk of all-cause and cardiovascular disease (CVD) mortality in people with a lower-extremity amputation (LEA) attributable to diabetes and people without an LEA.
  
  
  METHODS
  The Strong Heart Study is a study of CVD and its risk factors in 13 American-Indian communities. LEA was ascertained at baseline by direct examination of the legs and feet. Mortality surveillance is complete through 2000.
  
  
  RESULTS
  Of 2,108 participants with diabetes at baseline, 134 participants (6.4%) had an LEA. Abnormal ankle-brachial index (53%), albuminuria (87%), and long diabetes duration (mean 19.8 years) were common among diabetic subjects with LEA. Mean diabetes duration among diabetic participants without LEA and in those with toe and below-the-knee amputations was 11.9, 18.6, and 21.1 years, respectively. During 8.7 (+/-2.9) years of follow-up, 102 of the participants with LEA (76%) died from all causes and 35 (26%) died from CVD. Of the 1,974 diabetic participants without LEA at baseline, 604 (31%) died from all causes and 206 (10%) died from CVD. The unadjusted hazard ratios (HRs) for all-cause and CVD mortality in diabetic participants with LEA compared with those without were 4.0 and 4.1, respectively. Adjusting for known and suspected confounders, LEA persisted as a predictor of all-cause (HR 2.2, 95% CI 1.7-2.9) and CVD mortality (HR 1.9, 95% CI 1.3-2.9). We observed a significant interaction between baseline LEA and sex on CVD mortality, with female sex conferring added risk of CVD mortality.
  
  
  CONCLUSIONS
  LEA is a potent predictor of all-cause and CVD mortality in diabetic American Indians. The combination of female sex and LEA is associated with greater risk of CVD mortality than either factor alone.
authors.affiliation: Department of Epidemiology and Statistics, MedStar Research Institute, 6495 New Hampshire Ave., Suite 201, Hyattsville, MD 20783. helaine.e.resnick@medstar.net
authors.forename: Helaine E
authors.initials: HE
authors.lastname: Resnick
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Carter
authors.forename: Robert
authors.initials: R
authors.lastname: Lindsay
authors.forename: Susan J
authors.initials: SJ
authors.lastname: Henly
authors.forename: Frederick K
authors.initials: FK
authors.lastname: Ness
authors.forename: Thomas K
authors.initials: TK
authors.lastname: Welty
authors.forename: Elisa T
authors.initials: ET
authors.lastname: Lee
authors.forename: Barbara V
authors.initials: BV
authors.lastname: Howard
mesh_terms: D000671:Amputation, Surgical / Q000401:mortality / Q000706:statistics & numerical data*; D002318:Cardiovascular Diseases / Q000401:mortality*; D002423:Cause of Death; D005260:Female; D006801:Humans; D007198:Indians, North American; D007866:Leg; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000401:mortality; D015995:Prevalence; D016016:Proportional Hazards Models; D012307:Risk Factors; D014481:United States / Q000453:epidemiology