© 1998 American Heart Association, Inc.
Original Contributions |
Peripheral Arterial Disease in the Elderly
The Rotterdam Study
From the Department of Epidemiology and Biostatistics (W.T.M., A.W.H., D.R., M.L.B., A.H., D.E.G.) and the Department of General Practice (W.T.M., D.R.), Erasmus University Medical School, Rotterdam; and the Department of General Practice (A.W.H.), and Julius Center for Patient Oriented Research (A.W.H., M.L.B., D.E.G.), Utrecht University, Utrecht, the Netherlands.
Correspondence to Dr Diederick E. Grobbee, Professor of Clinical Epidemiology, Julius Center for Patient Oriented Research, Utrecht University Medical School, Universiteitsweg 100, PO Box 80035, 3508 TA Utrecht, the Netherlands. E-mail d.e.grobbee{at}med.ruu.nl
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Abstract |
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Abstract—To assess the age- and sex-specific prevalence of peripheral arterial disease (PAD) and intermittent claudication (IC) in an elderly population, we performed a population-based study in 7715 subjects (40% men, 60% women) aged 55 years and over. The presence of PAD and IC was determined by measuring the ankle-arm systolic blood pressure index (AAI) and by means of the World Health Organization/Rose questionnaire, respectively. PAD was considered present when the AAI was <0.90 in either leg. The prevalence of PAD was 19.1% (95% confidence interval, 18.1% to 20.0%): 16.9% in men and 20.5% in women. Symptoms of IC were reported by 1.6% (95% confidence interval, 1.3% to 1.9%) of the study population (2.2% in men, 1.2% in women). Of those with PAD, 6.3% reported symptoms of IC (8.7% in men, 4.9% in women), whereas in 68.9% of those with IC an AAI below 0.90 was found. Subjects with an AAI <0.90 were more likely to be smokers, to have hypertension, and to have symptomatic or asymptomatic cardiovascular disease compared with subjects with an AAI of 0.90 or higher. The authors conclude that the prevalence of PAD in the elderly is high whereas the prevalence of IC is rather low, although both prevalences clearly increase with advancing age. The vast majority of PAD patients reports no symptoms of IC.
Key Words: atherosclerosis • elderly • intermittent claudication • peripheral arterial disease • cardiovascular risk
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Introduction |
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Peripheral arterial disease refers to the manifestation of atherosclerosis in the lower limb distal to the aortic bifurcation. When PAD becomes symptomatic, patients often present with complaints of IC: "cramping," "fatigue," or "aching" in the calf of the leg, induced by walking and relieved by standing still. In
25% of patients with IC, there is a progression
to critical ischemia, eg, rest pain and gangrene, that may
eventually necessitate amputation.1 2 Several studies have demonstrated that patients with PAD, both with and without symptoms of IC,3 4 5 are at an increased risk of cardiovascular morbidity and mortality compared with subjects without PAD.4 6 7 8 9 In comparison to the number of reports on other manifestations of atherosclerotic disease, however, relatively few population-based studies on the prevalence of PAD and IC have been performed. We assessed the prevalence of PAD and IC in a large population-based study including 7715 subjects aged 55 years and over.
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Methods |
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This study is part of The Rotterdam Study, a prospective follow-up study designed to investigate determinants of the occurrence and progression of chronic diseases in the elderly. Emphasis is on four areas of research: cardiovascular diseases, neurogeriatric diseases, locomotor diseases, and ophthalmologic diseases. The rationale and design of the study have been described previously.10
All individuals aged 55 years and over living in a suburb of Rotterdam, the Netherlands (a total of 10 275 subjects), were invited to participate in the Rotterdam Study. Baseline measurements were compiled after an extensive interview at the participant's home and two visits to the research center. The overall response rate was 78% (7983 subjects; 3105 men and 4878 women). Of these, 879 subjects lived in nursing homes.
Intermittent claudication was diagnosed according to the criteria of the World Health Organization/Rose questionnaire,11 which was included in the home interview. The prevalence of IC was assessed in 7715 participants in whom the answers to the Rose-questionnaire were available.
Blood pressure was calculated as the mean of two consecutive measurements with a random-zero sphygmomanometer at the right brachial artery while the patient was in a sitting position. The presence of PAD was evaluated by measuring the systolic blood pressure level of the posterior tibial artery at both the left and right leg using an 8-MHz continuous-wave Doppler probe (Huntleigh 500 D, Huntleigh Technology) and a random-zero sphygmomanometer.12 13 14 15 16 For each leg, a single blood pressure reading was taken with the subject in the supine position. The ratio of the systolic blood pressure at the ankle to the systolic blood pressure at the arm (ie, AAI) was calculated for each leg. The lowest AAI in either leg was used in the analysis.4 In agreement with the approach followed by Fowkes et al4 and by Schroll and Munck,17 PAD was considered present when the AAI was <0.90 in at least one leg. The AAI was not determined in 1533 participants: 824 subjects did not visit the research center; 4 subjects died before their visit to the center; and in 705 subjects the systolic arm blood pressure (n=7), the systolic ankle blood pressure (n=559), or both (n=139) were not measured. The characteristics of these 705 individuals did not differ appreciably from the population in which the AAI could be determined. Thus, the AAI was calculated for 6450 participants (2589 men and 3861 women). We excluded 41 participants (0.6%) with an AAI>1.50, because this AAI usually reflects arterial rigidity preventing arterial compression, leading to spuriously high ankle blood pressure values.
Established cardiovascular risk factors and the presence (or absence) of symptomatic cardiovascular diseases were recorded, and several noninvasive measures of atherosclerosis (notably ultrasound measurements of the carotid arteries and abdominal aorta) were performed.10
Hypertension was defined as a systolic blood pressure of 160 mm Hg or higher, a diastolic blood pressure of 95 mm Hg or higher, or current use of antihypertensive drugs for the indication hypertension.18 Diabetes mellitus was defined as current use of antidiabetic drugs or a random or postload serum glucose level >11.0 mmol/L after an oral glucose tolerance test.19 20 Subjects were categorized in as current smokers, former smokers, or those who had never smoked. Serum total cholesterol was determined by an automated enzymatic procedure in a nonfasting blood sample.21 Serum HDL cholesterol was measured after precipitation of the non-HDL fraction with phosphotungstate-magnesium. Height and weight were measured and body mass index (kg/m2) was calculated. A history of myocardial infarction and stroke was obtained through direct questioning and considered positive when confirmed by a physician. A history of angina pectoris was assessed using the World Health Organization/Rose questionnaire.11 LVH was assessed using a 12-lead ECG, recorded with an ESAOTE-ACTA cardiograph with a sampling frequency of 500 Hz and stored digitally. ECG LVH was determined using an automated diagnostic classification system, the modular ECG analysis system (MEANS), based on voltage, shape, and repolarization criteria.22 23 Ultrasonography of both carotid arteries was performed with a 7.5-MHz linear array transducer with a Duplex scanner (ATL UltraMark IV, Advanced Technology Laboratories) to assess intima-media thickness of the distal part of the common carotid artery and the presence of plaques in the common and internal carotid arteries and carotid bifurcation, as detailed elsewhere.24 25 Common carotid intima-media thickness was calculated as the mean of the near and far wall measurements of both left and right carotid arteries. Ultrasound measurements of the diameter of the abdominal aorta were taken by way of B-mode ultrasound recordings using a 3.5-MHz linear-array probe (Toshiba SSH 60A, Toshiba Medical Systems) with the patient in the supine position.26
To compare our prevalence data for PAD and IC with those reported in other population-based screening surveys, adjusted prevalences were calculated by applying the age and gender distributions and definitions of PAD in these other studies to the Rotterdam Study data set. Prevalence rates were calculated with exact 95% confidence limits. One-way ANCOVAs were applied to determine the statistical significance of the differences in cardiovascular risk indicators and noninvasive measures of atherosclerosis between subjects with and without PAD, adjusted for differences in age between these two groups. All analyses were performed using BMDP software (BMDP Statistical Software, Inc).
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Results |
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In Table 1
, selected characteristics
of the study population are given separately for men and women. PAD was
present in 19.1% (95% CI, 18.1% to 20.0%) of all participants.
The prevalence of PAD in women (20.5%; 95% CI, 19.2% to 21.8%) was
higher than that in men (16.9%; 95% CI, 15.4% to 18.3%). The age
difference between men and women accounted for most of this difference
in prevalence, because the prevalences in 5-year age categories for men
and women were similar. In both men and women, a clear increase in the
prevalence of PAD with age was observed, ranging from 6.6% in the age
category 55 to 59 years to 52.0% in the age category 85 years or over
in men, and from 9.5% to 59.6% in the corresponding age categories in
women (Fig 1).
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IC was reported by 1.6% (95% CI, 1.3% to 1.9%) of all
participants, whereas the prevalence of IC in men (2.2%; 95% CI,
1.7% to 2.8%) was higher than in women (1.2%; 95% CI, 0.9% to
1.5%). In both men and women, a clear increase in prevalence of IC
with increasing age was present, ranging from 1.0% in the age
category 55 to 59 years to 6.0% in the age category 85 years or over
in men, and from 0.7% to 2.5% in the corresponding age categories in
women (Fig 2).
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Of the 1166 subjects with PAD, 73 (6.3%) reported symptoms of IC
(Table 2). Interestingly, men with PAD
more often complained of symptoms of intermittent claudication (8.7%)
than women with PAD (4.9%). Of the 106 subjects with symptoms of IC
according to the Rose criteria, 73 (68.9%) had PAD, defined as an
AAI<0.90. This proportion was similar in men and women.
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The mean AAI was 1.05 (standard deviation [SD], 0.23): 1.08
(SD, 0.24) in men and 1.03 (SD, 0.23) in women. The AAI decreased
sharply with advancing age (Fig 3). The
distribution of AAI values (Fig 4) is
skewed to the left. In 41 participants (0.6%), an AAI >1.50 was
measured. These 41 participants were not included in the other tables
or figures.
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In Table 3, subjects with and
without PAD are compared with respect to the presence of
cardiovascular risk factors and disease and noninvasive
measures of atherosclerosis. Subjects with an AAI<0.90
had a more unfavorable cardiovascular risk profile than
did subjects with an AAI
0.90. In both men and women, hypertension,
cigarette smoking, and a history of stroke were significantly more
frequent among subjects with an AAI<0.90. LVH was more frequent in
those with an AAI<0.90, and similarly, these subjects had an increased
common carotid intima-media thickness, a higher frequency of carotid
plaques, and a larger distal abdominal aortic diameter.
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Tables 4 and 5 show a comparison between the results
of previous large screening surveys assessing the prevalence of PAD and
IC and findings from the Rotterdam Study. When the definitions for PAD
and IC and the population characteristics of these other studies were
applied to our own data set, no major differences in the prevalence
estimates were found.
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Discussion |
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In the population-based Rotterdam Study, the prevalence of PAD was 19.1%, varying from 6.6% in women aged 55 to 59 years to 59.6% in men aged 85 years or older. Intermittent claudication was reported by 1.6% of the participants, varying from 0.7% in women aged 55 to 59 years to 6.0% in men aged 85 years or older. Of those with PAD, only 6.3% reported symptoms of IC. Compared with those with an AAI
0.90,
subjects with an AAI<0.90 clearly had an unfavorable
cardiovascular risk profile, also with regard to other
noninvasive measures of atherosclerosis. The response rate in the Rotterdam Study of 78% is within the range of similar surveys, with response rates varying from 59% to 98%.3 4 5 17 27 28 29 30 31 Because of a lower response rate in the very old in the Rotterdam Study, the prevalence of PAD and IC may have been underestimated for this age group, although in a study by Aronow et al32 among 1886 persons with a mean age of 82 years who were living in a nursing home, the prevalence of PAD was 29% among men and 23% among women.
We used the AAI at rest as an indicator of PAD. In a number of surveys, an AAI measurement during exercise or a reactive hyperemia test was used.16 31 33 Hiatt et al31 concluded that these tests are not as useful as the AAI measured at rest. By analogy with other studies, we used a single measurement of the AAI to define PAD. Taking the mean of consecutive measurements, as for example in the Limburg PAOD Study,27 would likely have reduced the prevalence estimates.
There is no consensus regarding the cutoff value for the AAI to
define PAD. Most of the published surveys have used a cutoff value
between 0.80 and 0.95,3 4 5 17 27 28 30 31 whereas
in one, a cutoff value of 0.75 was used.29
Different cutoff values result in different prevalences for PAD between
the individual surveys, as is clearly illustrated by comparing the
crude and adjusted prevalence rates in Table 4
. Other reasons for
reported differences in pre-valence estimates between published
studies are differ-ences in the age and sex distribution of the
screened populations or the restriction to populations with a higher
risk for PAD (such as dyslipidemic,5
hypertensive,30 or
diabetic31 patients).
Only a minority of the participants with PAD in the Rotterdam Study (6.3%) reported symptoms of IC. Other studies reported figures in the range of 5.3% to 18.9%,3 4 5 17 27 28 30 31 with the exception of one study, reporting a prevalence as high as 37.5%.29 This prevalence of 37.5% observed by Coni et al29 should be interpreted with caution because in this study the strict Rose criteria were not used to assess the number of subjects with IC.
The relatively low proportion of PAD patients with complaints of IC can partly be explained by the fact that many elderly people do not walk far enough to experience symptoms of IC, because of either impaired vascularization of the extremities or other typical disorders, such as osteoarthritis. Of interest is that women with PAD less often reported symptoms of IC (4.9%) than men with PAD (8.7%). Possibly, women more frequently present atypical symptoms from ischemic disease than men, by analogy with observations of coronary heart disease.34 35
PAD is often considered an indicator of generalized atherosclerosis and as such is associated with a poor cardiovascular prognosis. This association seems to be true for participants of this study, as illustrated by the relatively unfavorable cardiovascular risk profile of those with an AAI <0.90. From other studies similar findings have been reported,3 4 6 7 8 27 28 especially for the association between PAD and hypertension, diabetes mellitus, and smoking. The finding of an increased common carotid intima-media thickness, a higher frequency of carotid plaques, and a larger diameter of the abdominal aorta (as measures of atherosclerosis) supports the relatively poor prognosis of subjects with an AAI<0.90.
We conclude that the prevalence of PAD in the elderly is high whereas the prevalence of reported IC is relatively low. Both prevalences sharply increase with advancing age. The vast majority of PAD patients reported no symptoms of IC. This, together with the high prevalence of PAD and unfavorable cardiovascular risk profile of patients with PAD, illustrates the need to explore the use of the AAI as a risk indicator in cardiovascular screening and risk profiling in medical practice.
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Selected Abbreviations and Acronyms |
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Acknowledgments |
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This study was supported in part by the NESTOR Stimulation program for geriatric research in The Netherlands (Ministry of Health and Ministry of Education), the Municipality of Rotterdam, The Netherlands Heart Foundation, The Netherlands Organization for Scientific Research (NWO), and the Rotterdam Medical Research Foundation (ROMERES). The authors thank all field workers, computer assistants, and laboratory technicians in the Ommoord research center and the general practitioners in the Ommoord area who supported this study.
Received April 7, 1997; accepted September 23, 1997.
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References |
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 J. W. Knowles, T. L. Assimes, J. Li, T. Quertermous, and J. P. Cooke Genetic Susceptibility to Peripheral Arterial Disease: A Dark Corner in Vascular Biology Arterioscler. Thromb. Vasc. Biol., October 1, 2007; 27(10): 2068 - 2078. [Abstract] [Full Text] [PDF]
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 I. Kardys, R. Vliegenthart, M. Oudkerk, A. Hofman, and J. C. M. Witteman The Female Advantage in Cardiovascular Disease: Do Vascular Beds Contribute Equally? Am. J. Epidemiol., August 15, 2007; 166(4): 403 - 412. [Abstract] [Full Text] [PDF]
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A. Afaq, P. S Montgomery, K. J Scott, S. M Blevins, T. L Whitsett, and A. W Gardner The effect of current cigarette smoking on calf muscle hemoglobin oxygen saturation in patients with intermittent claudication Vascular Medicine, August 1, 2007; 12(3): 167 - 173. [Abstract] [PDF]
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 Z. Pataky, A. Golay, A. Rieker, R. Grandjean, L. Schiesari, and H. Vuagnat A First Evaluation of an Educational Program for Health Care Providers in a Long-Term Care Facility to Prevent Foot Complications International Journal of Lower Extremity Wounds, June 1, 2007; 6(2): 69 - 75. [Abstract] [PDF]
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 Authors/Task Force Members, L. Ryden, E. Standl, M. Bartnik, G. V. d. Berghe, J. Betteridge, M.-J. de Boer, F. Cosentino, B. Jonsson, M. Laakso, et al. Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: full text: The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD) Eur. Heart J. Suppl., June 1, 2007; 9(suppl_C): C3 - C74. [Full Text] [PDF]
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 G. Targher, L. Bertolini, R. Padovani, S. Rodella, R. Tessari, L. Zenari, C. Day, and G. Arcaro Prevalence of Nonalcoholic Fatty Liver Disease and Its Association With Cardiovascular Disease Among Type 2 Diabetic Patients Diabetes Care, May 1, 2007; 30(5): 1212 - 1218. [Abstract] [Full Text] [PDF]
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B. L.W. Bendermacher, J. A.W. Teijink, E. M. Willigendael, M.-L. Bartelink, R. J.G. Peters, R. A. de Bie, H. R. Buller, J. Boiten, M. Langenberg, and M. H. Prins A clinical prediction model for the presence of peripheral arterial disease -- the benefit of screening individuals before initiation of measurement of the ankle--brachial index: an observational study Vascular Medicine, February 1, 2007; 12(1): 5 - 11. [Abstract] [PDF]
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Authors/Task Force Members, L. Ryden, E. Standl, M. Bartnik, G. Van den Berghe, J. Betteridge, M.-J. de Boer, F. Cosentino, B. Jonsson, M. Laakso, et al. Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary: The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD) Eur. Heart J., January 1, 2007; 28(1): 88 - 136. [Full Text] [PDF]
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J. M. Murabito, C.-Y. Guo, C. S. Fox, and R. B. D'Agostino Heritability of the Ankle-Brachial Index: The Framingham Offspring Study Am. J. Epidemiol., November 15, 2006; 164(10): 963 - 968. [Abstract] [Full Text] [PDF]
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 M. A. Ikram, M. Hollander, M. J. Bos, J. A. Kors, P. J. Koudstaal, A. Hofman, J.C.M. Witteman, and M. M.B. Breteler Unrecognized myocardial infarction and the risk of stroke: the Rotterdam Study. Neurology, November 14, 2006; 67(9): 1635 - 1639. [Abstract] [Full Text] [PDF]
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L. C. van Vark, I. Kardys, G. S. Bleumink, A. M. Knetsch, J. W. Deckers, A. Hofman, B. H.Ch. Stricker, and J. C.M. Witteman Lipoprotein-associated phospholipase A2 activity and risk of heart failure: the Rotterdam Study Eur. Heart J., October 1, 2006; 27(19): 2346 - 2352. [Abstract] [Full Text] [PDF]
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 S. de Voogd, R. C. W. Wolfs, N. M. Jansonius, J. C. M. Witteman, A. Hofman, and P. T. V. M. de Jong Atherosclerosis, C-reactive protein, and risk for open-angle glaucoma: the rotterdam study. Invest. Ophthalmol. Vis. Sci., September 1, 2006; 47(9): 3772 - 3776. [Abstract] [Full Text] [PDF]
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V. Schiano, G. Brevetti, G. Sirico, A. Silvestro, G. Giugliano, and M. Chiariello Functional status measured by walking impairment questionnaire and cardiovascular risk prediction in peripheral arterial disease: results of the Peripheral Arteriopathy and Cardiovascular Events (PACE) study Vascular Medicine, August 1, 2006; 11(3): 147 - 154. [Abstract] [PDF]
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 M. de Vries, R. Ouwendijk, K. Flobbe, P. J. Nelemans, A. G. Kessels, G. H. Schurink, J. A. van der Vliet, F. M. J. Heijstraten, P. W. M. Cuypers, L. E. M. Duijm, et al. Peripheral Arterial Disease: Clinical and Cost Comparisons between Duplex US and Contrast-enhanced MR Angiography--A Multicenter Randomized Trial. Radiology, August 1, 2006; 240(2): 401 - 410. [Abstract] [Full Text] [PDF]
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C. Diehm, S. Lange, H. Darius, D. Pittrow, B. von Stritzky, G. Tepohl, R. L. Haberl, J. R. Allenberg, B. Dasch, H. J. Trampisch, et al. Association of low ankle brachial index with high mortality in primary care Eur. Heart J., July 2, 2006; 27(14): 1743 - 1749. [Abstract] [Full Text] [PDF]
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 S. V. Lichtenstein Closed heart surgery: Back to the future J. Thorac. Cardiovasc. Surg., May 1, 2006; 131(5): 941 - 943. [Full Text] [PDF]
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I. Kardys, H.-H. S. Oei, I. M. van der Meer, A. Hofman, M. M.B. Breteler, and J. C.M. Witteman Lipoprotein-Associated Phospholipase A2 and Measures of Extracoronary Atherosclerosis: The Rotterdam Study Arterioscler. Thromb. Vasc. Biol., March 1, 2006; 26(3): 631 - 636. [Abstract] [Full Text] [PDF]
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F. U.S. Mattace-Raso, T. J.M. van der Cammen, A. Hofman, N. M. van Popele, M. L. Bos, M. A.D.H. Schalekamp, R. Asmar, R. S. Reneman, A. P.G. Hoeks, M. M.B. Breteler, et al. Arterial Stiffness and Risk of Coronary Heart Disease and Stroke: The Rotterdam Study Circulation, February 7, 2006; 113(5): 657 - 663. [Abstract] [Full Text] [PDF]
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 N. A. Khan, S. A. Rahim, S. S. Anand, D. L. Simel, and A. Panju Does the Clinical Examination Predict Lower Extremity Peripheral Arterial Disease? JAMA, February 1, 2006; 295(5): 536 - 546. [Abstract] [Full Text] [PDF]
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G. J. Hankey, P. E. Norman, and J. W. Eikelboom Medical Treatment of Peripheral Arterial Disease JAMA, February 1, 2006; 295(5): 547 - 553. [Abstract] [Full Text] [PDF]
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N. Eldrup, H. Sillesen, E. Prescott, and B. G. Nordestgaard Ankle brachial index, C-reactive protein, and central augmentation index to identify individuals with severe atherosclerosis Eur. Heart J., February 1, 2006; 27(3): 316 - 322. [Abstract] [Full Text] [PDF]
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S. M.J.M. Straus, J. A. Kors, M. L. De Bruin, C. S. van der Hooft, A. Hofman, J. Heeringa, J. W. Deckers, J. H. Kingma, M. C.J.M. Sturkenboom, B. H. Ch. Stricker, et al. Prolonged QTc Interval and Risk of Sudden Cardiac Death in a Population of Older Adults J. Am. Coll. Cardiol., January 17, 2006; 47(2): 362 - 367. [Abstract] [Full Text] [PDF]
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J. C. Wang, M. H. Criqui, J. O. Denenberg, M. M. McDermott, B. A. Golomb, and A. Fronek Exertional Leg Pain in Patients With and Without Peripheral Arterial Disease Circulation, November 29, 2005; 112(22): 3501 - 3508. [Abstract] [Full Text] [PDF]
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M. Bo, M. Zanocchi, L. Poli, and M. Molaschi The Ankle-Brachial Index Is Not Related to Mortality in Elderly Subjects Living in Nursing Homes Angiology, November 1, 2005; 56(6): 693 - 697. [Abstract] [PDF]
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M. C. J. M. Kock, M. E. A. P. M. Adriaensen, P. M. T. Pattynama, M. R. H. M. van Sambeek, H. van Urk, T. Stijnen, and M. G. M. Hunink DSA versus Multi-Detector Row CT Angiography in Peripheral Arterial Disease: Randomized Controlled Trial Radiology, November 1, 2005; 237(2): 727 - 737. [Abstract] [Full Text] [PDF]
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R. Ouwendijk, M. C. J. M. Kock, K. Visser, P. M. T. Pattynama, M. W. de Haan, and M. G. M. Hunink Interobserver Agreement for the Interpretation of Contrast-Enhanced 3D MR Angiography and MDCT Angiography in Peripheral Arterial Disease Am. J. Roentgenol., November 1, 2005; 185(5): 1261 - 1267. [Abstract] [Full Text] [PDF]
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M. H. Criqui, V. Vargas, J. O. Denenberg, E. Ho, M. Allison, R. D. Langer, A. Gamst, W. P. Bundens, and A. Fronek Ethnicity and Peripheral Arterial Disease: The San Diego Population Study Circulation, October 25, 2005; 112(17): 2703 - 2707. [Abstract] [Full Text] [PDF]
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 S. L. Eason, N. J. Petersen, M. Suarez-Almazor, B. Davis, and T. C. Collins Diabetes Mellitus, Smoking, and the Risk for Asymptomatic Peripheral Arterial Disease: Whom Should We Screen? J Am Board Fam Med, September 1, 2005; 18(5): 355 - 361. [Abstract] [Full Text] [PDF]
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R. Ouwendijk, M. de Vries, P. M. T. Pattynama, M. R. H. M. van Sambeek, M. W. de Haan, T. Stijnen, J. M. A. van Engelshoven, and M. G. M. Hunink Imaging Peripheral Arterial Disease: A Randomized Controlled Trial Comparing Contrast-enhanced MR Angiography and Multi-Detector Row CT Angiography Radiology, September 1, 2005; 236(3): 1094 - 1103. [Abstract] [Full Text] [PDF]
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J. W Olin Masterclass series in peripheral arterial disease: Hypertension and peripheral arterial disease Vascular Medicine, August 1, 2005; 10(3): 241 - 246. [PDF]
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H.-H. S. Oei, I. M. van der Meer, A. Hofman, P. J. Koudstaal, T. Stijnen, M. M.B. Breteler, and J. C.M. Witteman Lipoprotein-Associated Phospholipase A2 Activity Is Associated With Risk of Coronary Heart Disease and Ischemic Stroke: The Rotterdam Study Circulation, February 8, 2005; 111(5): 570 - 575. [Abstract] [Full Text] [PDF]
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C. L. Leibson, J. E. Ransom, W. Olson, B. R. Zimmerman, W. M. O'Fallon, and P. J. Palumbo Peripheral Arterial Disease, Diabetes, and Mortality Diabetes Care, December 1, 2004; 27(12): 2843 - 2849. [Abstract] [Full Text] [PDF]
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A.J. Lee, J.F. Price, M.J. Russell, F.B. Smith, M.C.W. van Wijk, and F.G.R. Fowkes Improved Prediction of Fatal Myocardial Infarction Using the Ankle Brachial Index in Addition to Conventional Risk Factors: The Edinburgh Artery Study Circulation, November 9, 2004; 110(19): 3075 - 3080. [Abstract] [Full Text] [PDF]
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M. K. Ikram, F. J. de Jong, J. R. Vingerling, J. C. M. Witteman, A. Hofman, M. M. B. Breteler, and P. T. V. M. de Jong Are Retinal Arteriolar or Venular Diameters Associated with Markers for Cardiovascular Disorders? The Rotterdam Study Invest. Ophthalmol. Vis. Sci., July 1, 2004; 45(7): 2129 - 2134. [Abstract] [Full Text] [PDF]
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D. P. Faxon, V. Fuster, P. Libby, J. A. Beckman, W. R. Hiatt, R. W. Thompson, J. N. Topper, B. H. Annex, J. H. Rundback, R. P. Fabunmi, et al. Atherosclerotic Vascular Disease Conference: Writing Group III: Pathophysiology Circulation, June 1, 2004; 109(21): 2617 - 2625. [Full Text] [PDF]
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A. T. Hirsch, P. Gloviczki, A. Drooz, M. Lovell, M. A. Creager, and The Board of Directors of the Vascular Disease Fou Mandate for Creation of a National Peripheral Arterial Disease Public Awareness Program: An Opportunity to Improve Cardiovascular Health Angiology, May 1, 2004; 55(3): 233 - 242. [Abstract] [PDF]
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I. M. van der Meer, M. L. Bots, A. Hofman, A. Iglesias del Sol, D. A.M. van der Kuip, and J. C.M. Witteman Predictive Value of Noninvasive Measures of Atherosclerosis for Incident Myocardial Infarction: The Rotterdam Study Circulation, March 9, 2004; 109(9): 1089 - 1094. [Abstract] [Full Text] [PDF]
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A. Benchimol, V. Bernard, X. Pillois, N. T. Hong, D. Benchimol, and J. Bonnet Validation of a New Method of Detecting Peripheral Artery Disease by Determination of Ankle-Brachial Index Using an Automatic Blood Pressure Device Angiology, March 1, 2004; 55(2): 127 - 134. [Abstract] [PDF]
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K. Kroger Dyslipoproteinemia and Peripheral Arterial Occlusive Disease Angiology, March 1, 2004; 55(2): 135 - 138. [Abstract] [PDF]
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A. T. Hirsch, P. Gloviczki, A. Drooz, M. Lovell, and M. A. Creager Mandate for Creation of a National Peripheral Arterial Disease Public Awareness Program: An Opportunity to Improve Cardiovascular Health Vascular and Endovascular Surgery, March 1, 2004; 38(2): 121 - 130. [Abstract] [PDF]
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A. T Hirsch, P. Gloviczki, A. Drooz, M. Lovell, M. A Creager, and on behalf of The Board of Directors of the Vascula The mandate for creation of a national peripheral arterial disease public awareness program: an opportunity to improve cardiovascular health Vascular Medicine, February 1, 2004; 9(1): 78 - 86. [Abstract] [PDF]
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W. S. Aronow Management of Peripheral Arterial Disease of the Lower Extremities in Elderly Patients J. Gerontol. A Biol. Sci. Med. Sci., February 1, 2004; 59(2): M172 - 177. [Abstract] [Full Text] [PDF]
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 A Theodoridou, L Bento, D P D'Cruz, M A Khamashta, and G R V Hughes Prevalence and associations of an abnormal ankle-brachial index in systemic lupus erythematosus: a pilot study Ann Rheum Dis, December 1, 2003; 62(12): 1199 - 1203. [Abstract] [Full Text] [PDF]
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 J. J Howard, J. Souchek, and T. C Collins Ischaemic outcomes assessment survey: A pilot study in patients with peripheral arterial disease The British Journal of Diabetes & Vascular Disease, November 1, 2003; 3(6): 424 - 430. [Abstract] [PDF]
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 E. R. Mohler III Peripheral Arterial Disease: Identification and Implications Arch Intern Med, October 27, 2003; 163(19): 2306 - 2314. [Abstract] [Full Text] [PDF]
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I. M. van der Meer, A. Iglesias del Sol, A. E. Hak, M. L. Bots, A. Hofman, and J. C.M. Witteman Risk Factors for Progression of Atherosclerosis Measured at Multiple Sites in the Arterial Tree: The Rotterdam Study Stroke, October 1, 2003; 34(10): 2374 - 2379. [Abstract] [Full Text] [PDF]
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T. F. Luscher, M. A. Creager, J. A. Beckman, and F. Cosentino Diabetes and Vascular Disease: Pathophysiology, Clinical Consequences, and Medical Therapy: Part II Circulation, September 30, 2003; 108(13): 1655 - 1661. [Full Text] [PDF]
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 M. W.C.J. Schoofs, M. van der Klift, A. Hofman, C. E.D.H. de Laet, R. M.C. Herings, T. Stijnen, H. A.P. Pols, and B. H.Ch. Stricker Thiazide Diuretics and the Risk for Hip Fracture Ann Intern Med, September 16, 2003; 139(6): 476 - 482. [Abstract] [Full Text] [PDF]
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J. M. Murabito, J. C. Evans, M. G. Larson, K. Nieto, D. Levy, and P. W. F. Wilson The Ankle-Brachial Index in the Elderly and Risk of Stroke, Coronary Disease, and Death: The Framingham Study Arch Intern Med, September 8, 2003; 163(16): 1939 - 1942. [Abstract] [Full Text] [PDF]
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 P. Y. Liu, A. K. Death, and D. J. Handelsman Androgens and Cardiovascular Disease Endocr. Rev., June 1, 2003; 24(3): 313 - 340. [Abstract] [Full Text] [PDF]
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E. Suzuki, K. Egawa, Y. Nishio, H. Maegawa, M. Tsuchiya, M. Haneda, H. Yasuda, S. Morikawa, T. Inubushi, and A. Kashiwagi Prevalence and Major Risk Factors of Reduced Flow Volume in Lower Extremities With Normal Ankle-Brachial Index in Japanese Patients With Type 2 Diabetes Diabetes Care, June 1, 2003; 26(6): 1764 - 1769. [Abstract] [Full Text] [PDF]
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S. Barretto, K. V Ballman, T. W Rooke, and I. J Kullo Early-onset peripheral arterial occlusive disease: clinical features and determinants of disease severity and location Vascular Medicine, May 1, 2003; 8(2): 95 - 100. [Abstract] [PDF]
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J. J. F. Belch, E. J. Topol, G. Agnelli, M. Bertrand, R. M. Califf, D. L. Clement, M. A. Creager, J. D. Easton, J. R. Gavin III, P. Greenland, et al. Critical Issues in Peripheral Arterial Disease Detection and Management: A Call to Action Arch Intern Med, April 28, 2003; 163(8): 884 - 892. [Full Text] [PDF]
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I. M. van der Meer, M. P.M. de Maat, A. E. Hak, A. J. Kiliaan, A. I. del Sol, D. A.M. van der Kuip, R. L.G. Nijhuis, A. Hofman, and J. C.M. Witteman C-Reactive Protein Predicts Progression of Atherosclerosis Measured at Various Sites in the Arterial Tree: The Rotterdam Study Stroke, December 1, 2002; 33(12): 2750 - 2755. [Abstract] [Full Text] [PDF]
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H.-H. S. Oei, R. Vliegenthart, A. E. Hak, A. I. del Sol, A. Hofman, M. Oudkerk, and J. C. M. Witteman The association between coronary calcification assessed by electron beam computed tomography and measures of extracoronary atherosclerosis: The rotterdam coronary calcification study J. Am. Coll. Cardiol., June 5, 2002; 39(11): 1745 - 1751. [Abstract] [Full Text] [PDF]
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J. A. Beckman, M. A. Creager, and P. Libby Diabetes and Atherosclerosis: Epidemiology, Pathophysiology, and Management JAMA, May 15, 2002; 287(19): 2570 - 2581. [Abstract] [Full Text] [PDF]
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I. M. van der Meer, M. P.M. de Maat, M. L. Bots, M. M.B. Breteler, J. Meijer, A. J. Kiliaan, A. Hofman, and J. C.M. Witteman Inflammatory Mediators and Cell Adhesion Molecules as Indicators of Severity of Atherosclerosis: The Rotterdam Study Arterioscler. Thromb. Vasc. Biol., May 1, 2002; 22(5): 838 - 842. [Abstract] [Full Text] [PDF]
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R. Vliegenthart, J. M. Geleijnse, A. Hofman, W. T. Meijer, F. J. A. van Rooij, D. E. Grobbee, and J. C. M. Witteman Alcohol Consumption and Risk of Peripheral Arterial Disease : The Rotterdam Study Am. J. Epidemiol., February 15, 2002; 155(4): 332 - 338. [Abstract] [Full Text] [PDF]
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H. Gaylis, L. S. Geiss, E. Gregg, M. M. Engelgau, R. P. Ram, M. S. Eberhardt, V. L. Burt, J. H. Merenstein, M. Jimbo, R. E. Fried, et al. Diagnosis and Treatment of Peripheral Arterial Disease JAMA, January 16, 2002; 287(3): 313 - 316. [Full Text] [PDF]
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A. T. Hirsch, M. H. Criqui, D. Treat-Jacobson, J. G. Regensteiner, M. A. Creager, J. W. Olin, S. H. Krook, D. B. Hunninghake, A. J. Comerota, M. E. Walsh, et al. Peripheral Arterial Disease Detection, Awareness, and Treatment in Primary Care JAMA, September 19, 2001; 286(11): 1317 - 1324. [Abstract] [Full Text] [PDF]
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 A. E. Hak, H. A. P. Pols, C. D. A. Stehouwer, J. Meijer, A. J. Kiliaan, A. Hofman, M. M. B. Breteler, and J. C. M. Witteman Markers of Inflammation and Cellular Adhesion Molecules in Relation to Insulin Resistance in Nondiabetic Elderly: The Rotterdam Study J. Clin. Endocrinol. Metab., September 1, 2001; 86(9): 4398 - 4405. [Abstract] [Full Text] [PDF]
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 W. R. Hiatt Medical Treatment of Peripheral Arterial Disease and Claudication N. Engl. J. Med., May 24, 2001; 344(21): 1608 - 1621. [Full Text] [PDF]
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A. B. Newman, J. S. Gottdiener, M. A. McBurnie, C. H. Hirsch, W. J. Kop, R. Tracy, J. D. Walston, and L. P. Fried Associations of Subclinical Cardiovascular Disease With Frailty J. Gerontol. A Biol. Sci. Med. Sci., March 1, 2001; 56(3): 158M - 166. [Abstract] [Full Text]
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M. H Criqui Peripheral arterial disease - epidemiological aspects Vascular Medicine, February 1, 2001; 6(1_suppl): 3 - 7. [Abstract] [PDF]
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J. Schweizer, W. Kirch, R. Koch, A. Muller, G. Hellner, and L. Forkmann Short- and Long-Term Results of Abciximab Versus Aspirin in Conjunction with Thrombolysis for Patients with Peripheral Occlusive Arterial Disease and Arterial Thrombosis Angiology, November 1, 2000; 51(11): 913 - 923. [Abstract] [PDF]
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W. T. Meijer, D. E. Grobbee, M. G. M. Hunink, A. Hofman, and A. W. Hoes Determinants of Peripheral Arterial Disease in the Elderly: The Rotterdam Study Arch Intern Med, October 23, 2000; 160(19): 2934 - 2938. [Abstract] [Full Text] [PDF]
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I. C. D. Westendorp, B. A. in't Veld, D. E. Grobbee, H. A. P. Pols, W. T. Meijer, A. Hofman, and J. C. M. Witteman Hormone Replacement Therapy and Peripheral Arterial Disease: The Rotterdam Study Arch Intern Med, September 11, 2000; 160(16): 2498 - 2502. [Abstract] [Full Text]
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L. Papoz, A. Ponton, P. Segond, F. Becker, L. Drouet, J. Levenson, M. Marazanof, Y. Sentou, E. Chollet, J. Etiemble, et al. Feasibility and Reliability of Ankle/Arm Blood Pressure Index in Preventive Medicine Angiology, June 1, 2000; 51(6): 463 - 471. [Abstract] [PDF]
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