The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 60:255-257 (2005)
© 2005 The Gerontological Society of America
Prevalence of Symptomatic Peripheral Arterial Disease, Modifiable Risk Factors, and Appropriate Use of Drugs in the Treatment of Peripheral Arterial Disease in Older Persons Seen in a University General Medicine Clinic
Jose Ness1,
Wilbert S. Aronow2,,
Erin Newkirk1 and
Deanna McDanel1
1 Department of Medicine, University of Iowa School of Medicine, Iowa City.
2 Department of Medicine, Divisions of Cardiology and Geriatrics, New York Medical College, Valhalla.
Address correspondence to Wilbert S. Aronow, MD, FGSA, Cardiology Division, New York Medical College, Macy Pavilion, Room 138, Valhalla, NY 10595. E-mail: wsaronow{at}aol.com
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Abstract
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Background. Persons with peripheral arterial disease (PAD) have a high incidence of cardiovascular morbidity and mortality.
Methods. We investigated the prevalence of symptomatic PAD, modifiable risk factors, and use of drugs in persons 60 years and older seen in a university general medicine clinic. Symptomatic PAD was documented if the person had a documented history of surgery for PAD, if the person had intermittent claudication or other lower extremity symptoms associated with absent or weak arterial pulses or an ankle–brachial index of <0.90, if the person had an abdominal aortic aneurysm, or if the person had symptomatic documented extracranial carotid arterial disease.
Results. There were 620 women and 386 men, mean age 72 ± 9 years (range 60–95 years), and 95% were white. Symptomatic PAD was present in 103 of 386 men (27%) and in 106 of 620 women (17%) (p <.001). The prevalence of current cigarette smoking (31% versus 12% in those without PAD, p <.001) and ex-cigarette smoking (40% versus 26%) in those without PAD, p <. 001) was higher among persons with PAD. Compared with persons without PAD, those with PAD also had a higher prevalence of hypertension (90% versus 76% in persons without PAD, p <.001), diabetes mellitus (45% versus 22%, p <.001), dyslipidemia (88% versus 60%, p <.001), coronary artery disease (63% versus 25%, p <.001), and stroke (36% versus 11%, p <.001). In persons with PAD, antiplatelet drugs were used in 85%, lipid-lowering drugs for dyslipidemia in 67%, beta blockers in 60%, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers in 62%. The average of the last two blood pressures was <140/90 mmHg in 55% of persons with PAD treated for hypertension. The last hemoglobin A1c in diabetics was <7% in 52% of persons with PAD.
Conclusions. Older persons with PAD have a high prevalence of modifiable risk factors, CAD, and stroke. The use of antiplatelet drugs, lipid-lowering drugs for dyslipidemia, beta blockers, and ACE inhibitors or angiotensin-receptor blockers, reduction of blood pressure to <140/90 mmHg in hypertensive persons, and reduction of hemoglobin A1c in diabetics to <7% in older persons with PAD needs to be increased in all clinical settings.
The prevalence of peripheral arterial disease (PAD) increases with age (1–4). PAD also coexists with other atherosclerotic disorders (5,6). Modifiable risk factors that predispose to PAD include cigarette smoking (2,4,7,8), diabetes mellitus (2,4,7–9), hypertension (2,4,7,8,10,11), dyslipidemia (2,4,7–9,12–16), and hypothyroidism (17).
Older persons with PAD should have their modifiable risk factors treated (4). Older persons with PAD should also be treated with antiplatelet drugs (4,18–20), angiotensin-converting enzyme (ACE) inhibitors (20), and with beta blockers (20,21) to reduce cardiovascular morbidity and mortality.
We are reporting data from 1006 persons aged 
60 years seen in a large general medicine clinic at the University of Iowa from September 2002 to February 2003 by practicing geriatricians and internists showing the prevalence of symptomatic PAD in older men and women and the prevalence of modifiable risk factors and of coronary artery disease (CAD) and stroke in older persons with and without PAD. We also report the prevalence of use of antiplatelet drugs, lipid-lowering drugs for dyslipidemia, beta blockers, and ACE inhibitors or angiotensin receptor blockers in older persons with PAD. In addition, we report the prevalence of the average of the last two blood pressures reduced to <140/90 mmHg by antihypertensive drugs in older persons with PAD and the last hemoglobin A1c reduced to <7% in diabetics with PAD.
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METHODS
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The study population included 620 women and 386 men, mean age 72 ± 9 years (range 60–95 years). The 1006 persons included 956 white participants, 21 black, 8 Hispanic, and 21 persons of other races.
The charts of these persons were reviewed by J.N. (a geriatrician) and two pharmacists (D.M. and E.N.), according to a study protocol designed by J.N. and W.S.A. The charts were reviewed for the presence of documented PAD, current cigarette smoking, ex-smoking, hypertension, diabetes mellitus, dyslipidemia, documented CAD, and documented stroke. The charts were also reviewed in all persons for the use of antiplatelet drugs, beta blockers, ACE inhibitors or angiotensin receptor blockers, and lipid-lowering drugs. The antiplatelet drugs used included aspirin, clopidogrel, and ticlodipine in two persons. The blood pressure recorded at the last two clinic visits in persons treated for hypertension was recorded. The last hemoglobin A1c value in diabetics was also recorded.
Symptomatic PAD was documented if the person had a documented history of surgery for PAD, if the person had intermittent claudication or other lower extremity symptoms associated with absent or weak arterial pulses or an ankle–brachial index <0.90, if the person had an abdominal aortic aneurysm, or if the person had symptomatic documented extracranial carotid arterial disease. A systolic blood pressure of 140 mmHg or a diastolic blood pressure of 90 mmHg was considered hypertension (22). Persons with a history of hypertension controlled by therapy were considered to have hypertension. Dyslipidemia was diagnosed as previously described (13–15,23). A serum total cholesterol 200 mg/dl, a serum low-density lipoprotein cholesterol 100 mg/dl, a serum high-density lipoprotein cholesterol <40 mg/dl, or serum triglycerides 190 mg/dl was considered dyslipidemia in persons with PAD. Diabetes mellitus was diagnosed as previously described with a fasting plasma glucose level 126 mg/dl on two occasions. (23).
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RESULTS
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Table 1 shows the prevalence of risk factors and of CAD and stroke in older persons with and without symptomatic PAD and levels of statistical significance. Persons with symptomatic PAD had a similar age and a higher prevalence of male gender, cigarette smoking, ex-smoking, hypertension, diabetes mellitus, dyslipidemia, CAD, and stroke (p <.001) than persons without PAD. The prevalence of symptomatic PAD was similar in whites and nonwhites. There was no significant difference between whites and nonwhites in the variables listed in Table 1.
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Table 1. Prevalence of Risk Factors and Coronary Artery Disease and Stroke in Older Persons With and Without Symptomatic Peripheral Arterial Disease.
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Table 2 shows in persons with PAD the prevalence of use of antiplatelet drugs, lipid-lowering drugs for dyslipidemia, beta blockers, and ACE inhibitors or angiotensin receptor blockers, the prevalence of the average of the last two blood pressures being <140/90 mmHg in persons treated for hypertension, and the prevalence of the last hemoglobin A1c being <7% in diabetics. Among persons with symptomatic PAD, compared with rates of use of antiplatelet and antilipid drugs (85% and 67%, respectively), the rates for control of hypertension and diabetes were low (55% and 52%, respectively). Forty-two of 209 persons (20%) with PAD were treated with two antiplatelet drugs. Eighty of 209 persons (38%) with PAD participated in an exercise program. Fifty-six of 209 persons (27%) with PAD had vascular surgery.
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Table 2. Prevalence of Use of Antiplatelet Drugs, of Lipid-Lowering Drugs for Dyslipidemia, of Beta Blockers, and Angiotensin-Converting Enzyme Inhibitors, Reduction of Blood Pressure to <140/90 mmHg by Antihypertensive Drugs, and Reduction of Hemoglobin Alc to <7% in Diabetics in Older Persons With Peripheral Arterial Disease.
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DISCUSSION
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In the present study, older persons with documented symptomatic PAD had a 2.6 times higher prevalence of current cigarette smoking, a 1.5 times higher prevalence of prior cigarette smoking, a 1.2 times higher prevalence of hypertension, a 2.0 times higher prevalence of diabetes mellitus, and a 1.5 times higher prevalence of dyslipidemia than older persons without PAD (p <.001). The prevalence of coexistent CAD was 2.5 times higher in older persons with PAD (63%) than in older persons without PAD (25%) (p <.001). The prevalence of coexistent stroke was 3.3 times higher in older persons with PAD (36%) than in older persons without PAD (11%) (p <.001).
The appropriate management of older persons with PAD is discussed in detail elsewhere (4). In the present study, antiplatelet drugs were used in 85% of older persons with PAD, lipid-lowering drugs for dyslipidemia in 67% of older persons with PAD, beta blockers in 60% of older persons with PAD, and ACE inhibitors or angiotensin receptor blockers in 62% of older persons with PAD. In persons with treated hypertension, the average of the last two blood pressures was reduced to <140/90 mmHg in 55% of older persons with PAD. The last hemoglobin A1c was reduced to <7% in 52% of older diabetics with PAD.
These data indicate that the highest use of appropriate drugs for the treatment of PAD was with antiplatelet drugs. An educational program on the reduction of modifiable risk factors and the use of appropriate drugs for the treatment of PAD as recommended by the American College of Cardiology/American Heart Association (20) should be considered at the academic medical center where this study was performed. At another academic medical center, an educational program increased the appropriate use of lipid-lowering drugs in older persons with PAD and dyslipidemia from 28% to 79% (15).
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Footnotes
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Decision Editor: John E. Morley, MB, BCh
Received August 29, 2003
Accepted October 8, 2003
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References
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