周邊動脈疾病經常未被診斷出來

作者：Laurie Barclay  
出處：WebMD醫學新聞

　　May 7, 2009 — 根據發表在5月號心臟血管介入與導管期刊的周邊動脈疾病介入病患研究（PIPS）結果，即使病患有已知的缺血性心臟疾病且接受專科照護之下，周邊動脈疾病（PAD）經常未被診斷出來。
　　
　　來自紐約市康乃爾大學威爾醫學院威爾康乃爾醫學中心/紐約長老教會醫院的Issam D. Moussa醫師與其同事表示，PAD在初級照護服務下經常未被診斷出來，目前為止，罹患冠狀動脈血管疾病（CAD）患者，PAD未被診斷出來的程度仍然未知。
　　
　　這項研究的目的在於（1）評估疑似罹患缺血性心臟疾病接受冠狀動脈血管攝影以及/或是介入患者過去未被診斷出的PAD盛行率；（2）評估PAD對病患症狀與功能狀態的效應；且（3）確定PAD與CAD嚴重度之間的關聯。
　　
　　在一個三級轉介中心的住院病患服務中，800位沒有被診斷PAD且被轉介接受冠狀動脈血管攝影的病患被收納到這項前瞻性世代研究中，這些病患的年齡都是70歲以上、或50至69歲但有吸菸以及/或是糖尿病病史；評估方面包括醫療史、問卷以決定症狀與功能狀態、測量膝與臂指標（ABI；代表下肢與手臂血壓之間的比值），以該指標低於0.90視為病患罹患PAD。
　　
　　在PIPS世代族群中，有過去未被診斷出PAD的盛行率為15%（95%信賴區間[CI]為12.6-17.7），年齡大於70歲以上的病患（25.2%）與女性病患（23.3%）最高。
　　
　　在CAD病患中，有PAD病患的左主冠狀動脈與多條血管冠狀動脈疾病盛行率較高（87.2%相較於75.5%；P=0.006）。相較於單一血管CAD病患，那些有多條血管冠狀動脈疾病的病患，被診斷有過去未被確認之PAD的風險高出了兩倍（校正後的勝算比[OR]為2.02；95% CI為1.03-3.98）。
　　
　　研究作者寫到，即使是已知有缺血性心臟疾病患者，在專科心臟血管照護服務之下，PAD經常被輕忽；輕忽這個族群病患PAD的頻率會隨著年齡增加、女性、以及有其他傳統心臟血管危險因子而增加；除此之外，這個族群病患罹患PAD連帶確認了罹患較嚴重型式CAD的患者。
　　
　　這項研究的限制包括在初級照護環境下，罹患缺血性心臟疾病患者的高風險臨床病學與臨床病況，這可能影響到研究傾向PAD盛行率較高的結果、以及缺乏有關於CAD病患根據是否有PAD的預後資訊。
　　
　　研究作者們的結論是，我們在這項研究中觀察到，每6位病患就有1位罹患CAD者有PAD，這是在接受專科心臟血管照護下未被發現的結果。所有罹患冠狀動脈血管疾病的患者，都應該接受全身性、以ABI為基礎的PAD篩檢計畫。
　　
　　Sanofi-Synthelabo（美國）贊助這項研究。研究作者們表示沒有相關資金上的往來。

Peripheral Artery Disease Often Underdiagnosed

By Laurie Barclay
Medscape Medical News

May 7, 2009 — Peripheral artery disease (PAD) is often underdiagnosed, even in patients with known ischemic heart disease under specialty care, according to the results of the Peripheral Arterial Disease in Interventional Patients Study (PIPS) reported in the May issue of Catheterization and Cardiovascular Interventions.

"[PAD] is under diagnosed in primary care practices, yet the extent of unrecognized PAD in patients with coronary artery disease (CAD) is unknown," write Issam D. Moussa, MD, from New York Presbyterian Hospital/Weill Cornell Medical Center, Weill Medical College of Cornell University, New York City, and colleagues.

"This study was undertaken to (1) assess the prevalence of previously unrecognized PAD among patients with suspected ischemic heart disease who are undergoing coronary angiography and/or intervention; (2) assess the effects of PAD on patient's symptoms and functional status; and (3) determine the relationship between presence of PAD and severity of CAD."

At an inpatient service of a tertiary referral center, 800 patients without previous diagnosis of PAD who were referred for coronary angiography were enrolled in this prospective cohort study. Patients were aged 70 years or older or aged 50 to 69 years with a history of tobacco use and/or diabetes mellitus. Assessment included medical history, questionnaire to determine symptoms and functional status, and measurement of the ankle-brachial index (ABI; the ratio of blood pressure in the lower legs to blood pressure in the arms), with PAD considered present if ABI was 0.90 or less.

In the PIPS cohort, prevalence of previously unrecognized PAD was 15% (95% confidence interval [CI], 12.6 – 17.7), with highest rates in patients older than 70 years (25.2%) and in women (23.3%).

Among patients with CAD, prevalence of left main and multivessel coronary artery disease was higher in those with PAD (87.2% vs 75.5%; P = .006). Compared with patients with single-vessel CAD, those with multivessel CAD had a 2-fold higher risk of being diagnosed with previously unrecognized PAD (adjusted odds ratio [OR], 2.02; 95% CI, 1.03 – 3.98).

"PAD is often overlooked even in patients with known ischemic heart disease under specialist cardiovascular care," the study authors write. "Overlooked PAD in this population increases in frequency with advanced age, in women, and in the presence of other traditional cardiovascular risk factors. Furthermore, the presence of PAD in this population identifies a subgroup with more severe form of CAD."

Limitations of this study include that the high-risk demographic and clinical profile in patients with ischemic heart disease is associated with a high prevalence of PAD in the primary care setting, which may bias the study results toward higher prevalence of PAD, and a lack of information regarding outcome of patients with CAD according to presence or absence of PAD.

"In this study, we observed that one out of six patients with CAD has PAD, which was not previously detected despite specialist cardiovascular care," the study authors conclude. "Systematic, ABI-based, PAD screening programs should be implemented in all patients with coronary artery disease."

Sanofi-Synthelabo (US) supported this study. The authors have disclosed no relevant financial relationships.

Catheter Cardiovasc Interv. 2009;73:719–724.