title: Prognostic value of ankle-brachial index and dobutamine stress echocardiography for cardiovascular morbidity and all-cause mortality in patients with peripheral arterial disease.
abstract: BACKGROUND
  Peripheral arterial disease (PAD) is associated with an excessive risk for cardiovascular events and mortality. To determine measures prognostic of adverse events, ankle-brachial index (ABI) was compared with dobutamine stress echocardiography (DSE) in patients referred to our vascular center for the evaluation of PAD.
  
  
  METHODS
  The medical records of consecutive patients referred for the concurrent evaluation of PAD and coronary artery disease (CAD) between 1992 and 1995 were reviewed for subsequent cardiovascular events and death.
  
  
  RESULTS
  Among 395 patients (mean age, 69.7 +/- 9.6 years; 40% women), 341 had abnormal ABI and 268 had abnormal DSE (95 fixed and 173 stress-induced wall motion abnormalities). During a mean follow-up of 4.7 years, 27.3% of patients experienced a cardiovascular event, and 39.4% died. By multivariate analysis, ABI provided the strongest prediction of all-cause mortality (hazard ratio [HR], 2.34; 95% confidence interval [CI], 1.36 to 4.05; P = .002). Conversely, DSE with inducible or fixed wall motion abnormalities showed no association with cardiovascular events or increased mortality in multivariate analysis. The only DSE variable independently predictive of mortality was decreased left ventricular ejection fraction (<50%) at peak stress (HR, 1.70; 95% CI, 1.22 to 2.36; P = .002). Statin and aspirin therapy, but not beta-blockers, were protective. There was no relation between ABI and wall motion index score at rest or after stress.
  
  
  CONCLUSIONS
  In high-risk patients referred to our vascular center for the evaluation of PAD, the assessment of ABI provided a strong independent prediction of all-cause mortality. Therefore, proper interpretation of this simple, affordable, and reproducible measure extends beyond the assessment of PAD severity. Although a poor left ventricular response to dobutamine was also predictive, other echo variables were not.
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
authors.forename: Mallik R
authors.initials: MR
authors.lastname: Thatipelli
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Pellikka
authors.forename: Robert D
authors.initials: RD
authors.lastname: McBane
authors.forename: Thom W
authors.initials: TW
authors.lastname: Rooke
authors.forename: Gabriela A
authors.initials: GA
authors.lastname: Rosales
authors.forename: David
authors.initials: D
authors.lastname: Hodge
authors.forename: Regina M
authors.initials: RM
authors.lastname: Herges
authors.forename: Waldemar E
authors.initials: WE
authors.lastname: Wysokinski
mesh_terms: D000368:Aged; D000842:Ankle / Q000098:blood supply*; D001241:Aspirin / Q000627:therapeutic use; D001794:Blood Pressure; D001916:Brachial Artery / Q000503:physiopathology*; D002318:Cardiovascular Diseases / Q000209:etiology* / Q000401:mortality / Q000503:physiopathology / Q000517:prevention & control; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality / Q000503:physiopathology; D025401:Echocardiography, Stress; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D005500:Follow-Up Studies; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D016491:Peripheral Vascular Diseases / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality / Q000503:physiopathology; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D015203:Reproducibility of Results; D012107:Research Design; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D013318:Stroke Volume; D013997:Time Factors; D016277:Ventricular Function, Left
chemical_list: D005343:Fibrinolytic Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D010975:Platelet Aggregation Inhibitors; D001241:Aspirin