Vascular Surgery Department, Institute of Biomedical Research, II-B Sant Pau, Barcelona, Spain.
J Vasc Surg. 2012 Nov;56(5):1324-30. doi: 10.1016/j.jvs.2012.04.049. Epub 2012 Jul 12.
Risk prediction is important in medical management, especially to optimize patient management before surgical intervention. No quantitative risk scores or predictors are available for patients with peripheral arterial disease (PAD). Surgical risk and prognosis are usually based on anesthetic scores or clinical evaluation. We suggest that renal function is a better predictor of risk than other cardiovascular parameters. This study used the four-variable Modification of Diet in Renal Disease (MDRD-4)-calculated glomerular filtration rate (GFR) to compare classical cardiovascular risk factors with prognosis and cardiovascular events of hospitalized PAD patients.
The study evaluated 204 patients who were admitted for vascular intervention and diagnosed with grade IIb, III, or IV PAD or with carotid or renal stenosis. Those with carotid or renal stenosis were excluded, leaving 188 patients who were randomized from 2004 to 2005 and monitored until 2010. We performed a life-table analysis with a 6-year follow-up period and one final checkpoint. The following risk factors were evaluated: age, sex, ischemic heart disease, ictus (as a manifestation of cerebrovascular disease related to systemic arterial disease), diabetes, arterial hypertension, dyslipidemia, smoking, chronic obstructive pulmonary disease, type of vascular intervention, and urea and creatinine plasma levels. The GFR was calculated using the MDRD-4 equation. Death, major cardiovascular events, and reintervention for arterial disease were recorded during the follow-up.
Patients (73% men) were a mean age of 71.38 ± 11.43 (standard deviation) years. PAD grade IIb was diagnosed in 41 (20%) and grade III-IV in 147 (72%). Forty-two minor amputations (20.6%), 21 major amputations (10.3%), and 102 revascularizations (50%) were performed. A major cardiovascular event occurred in 60 patients (29.4%), and 71 (34.8%) died. Multivariate logistic regression analysis showed that the MDRD-4 GFR, age, and male sex were independent variables related to death and that the MDRD-4 GFR and chronic obstructive pulmonary disease were related to major cardiovascular events. A statistically significant relationship was also found between serum creatinine levels and reintervention rates.
The MDRD-4 GFR was a better predictor of risk of death or infarction than classical cardiovascular risk factors in patients with PAD. This suggests that its routine use in the initial evaluation in patients with PAD is beneficial.
风险预测在医学管理中非常重要，特别是在手术干预之前优化患者管理。目前尚无外周动脉疾病（PAD）患者的定量风险评分或预测因子。手术风险和预后通常基于麻醉评分或临床评估。我们认为肾功能是比其他心血管参数更好的风险预测指标。本研究使用四变量改良肾脏病膳食研究（MDRD-4）计算的肾小球滤过率（GFR），比较了住院 PAD 患者的经典心血管危险因素与预后和心血管事件。
该研究评估了 204 名因血管介入而住院的患者，这些患者被诊断为 IIb 级、III 级或 IV 级 PAD 或颈动脉或肾狭窄。排除颈动脉或肾狭窄患者后，随机选择了 2004 年至 2005 年期间监测至 2010 年的 188 名患者。我们进行了生存表分析，随访时间为 6 年，并进行了最后一次检查。评估了以下风险因素：年龄、性别、缺血性心脏病、卒（脑血管疾病的表现与全身性动脉疾病有关）、糖尿病、动脉高血压、血脂异常、吸烟、慢性阻塞性肺疾病、血管介入类型以及尿素和肌酐血浆水平。GFR 使用 MDRD-4 方程计算。在随访期间记录了死亡、主要心血管事件和动脉疾病的再介入。
患者（73%为男性）的平均年龄为 71.38 ± 11.43 岁（标准差）。诊断为 IIb 级 PAD 的患者有 41 例（20%），III-IV 级 PAD 的患者有 147 例（72%）。进行了 42 例小截肢（20.6%）、21 例大截肢（10.3%）和 102 例血运重建（50%）。60 例患者发生了主要心血管事件（29.4%），71 例患者死亡（34.8%）。多变量逻辑回归分析显示，MDRD-4 GFR、年龄和男性是与死亡相关的独立变量，而 MDRD-4 GFR 和慢性阻塞性肺疾病与主要心血管事件相关。还发现血清肌酐水平与再介入率之间存在统计学显著关系。
MDRD-4 GFR 是 PAD 患者死亡或梗死风险的预测指标，优于经典心血管危险因素。这表明在 PAD 患者的初始评估中常规使用 MDRD-4 GFR 是有益的。
