Jones W Schuyler, Patel Manesh R, Tsai Thomas T, Go Alan S, Gupta Rajan, Hedayati Nasim, Ho P Michael, Jazaeri Omid, Rehring Thomas F, Rogers R Kevin, Shetterly Susan M, Wagner Nicole M, Magid David J
Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Duke University Medical Center, Durham, NC.
Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Duke University Medical Center, Durham, NC.
Am Heart J. 2015 Aug;170(2):400-8. doi: 10.1016/j.ahj.2015.04.026. Epub 2015 May 2.
Although the presence, extent, and severity of obstruction in patients with lower extremity peripheral artery disease (LE PAD) affect their functional status, quality of life, and treatment, it is not known if these factors are associated with future cardiovascular events. We empirically created an anatomic runoff score (ARS) to approximate the burden of LE PAD and determined its association with clinical outcomes.
We evaluated all patients with LE PAD and bilateral angiography undergoing revascularization in a community-based clinical study. Primary clinical outcomes of interest were (1) a composite of all-cause death, myocardial infarction (MI), and stroke and (2) amputation-free survival. Cox proportional hazards models were created to identify predictors of clinical outcomes.
We evaluated 908 patients undergoing angiography, and a total of 260 (28.0%) patients reached the composite end point (45 MI, 63 stroke, and 152 death) during the study period. Anatomic runoff score ranged from 0 to 15 (mean 4.7; SD 2.5) with higher scores indicating a higher burden of disease, and an optimal cutpoint analysis classified patients into low ARS (<5) and high ARS (≥5). The unadjusted rates of the primary composite end point and amputation-free survival were nearly 2-fold higher in patients with a high ARS when compared with patients with a low ARS. The most significant predictors of the composite end point (death/MI/stroke) were age (δ 10 years; hazard ratio [HR] 1.53; CI 1.32-1.78; P < .001), diabetes mellitus (HR 1.65; CI 1.26-2.18; P < .001), glomerular filtration rate <30 (HR 2.23; CI 1.44-3.44; P < .001), statin use (HR 0.66; CI 0.48-0.88; P < .001), and ARS (δ 2 points; HR 1.21; CI 1.08-1.35; P < .001).
After adjustment for clinical factors, the LE PAD ARS was an independent predictor of future cardiovascular morbidity and mortality in a broadly representative patient population undergoing revascularization for symptomatic PAD. A clinically useful anatomic scoring system, if validated, may assist clinicians in risk stratification during the course of clinical decision making.
虽然下肢外周动脉疾病（LE PAD）患者阻塞的存在、范围及严重程度会影响其功能状态、生活质量及治疗，但尚不清楚这些因素是否与未来心血管事件相关。我们根据经验创建了一个解剖学血流分级评分（ARS）来估算LE PAD的负担，并确定其与临床结局的关联。
在一项基于社区的临床研究中，我们评估了所有接受血运重建且进行双侧血管造影的LE PAD患者。感兴趣的主要临床结局为：（1）全因死亡、心肌梗死（MI）和中风的复合结局；（2）无截肢生存。创建Cox比例风险模型以识别临床结局的预测因素。
我们评估了908例接受血管造影的患者，在研究期间共有260例（28.0%）患者达到复合终点（45例MI、63例中风和152例死亡）。解剖学血流分级评分范围为0至15分（平均4.7分；标准差2.5分），评分越高表明疾病负担越重，通过最佳切点分析将患者分为低ARS（<5分）和高ARS（≥5分）。与低ARS患者相比，高ARS患者的主要复合终点和无截肢生存的未调整发生率高出近2倍。复合终点（死亡/MI/中风）的最显著预测因素为年龄（每增加10岁；风险比[HR] 1.53；95%置信区间[CI] 1.32 - 1.78；P <.001）、糖尿病（HR 1.65；CI 1.26 - 2.18；P <.001）、肾小球滤过率<30（HR 2.23；CI 1.44 - 3.44；P <.001）、他汀类药物使用（HR 0.66；CI 0.48 - 0.88；P <.001）以及ARS（每增加2分；HR 1.21；CI 1.08 - 1.35；P <.001）。
在对临床因素进行调整后，LE PAD的ARS是接受有症状PAD血运重建的广泛代表性患者群体未来心血管发病率和死亡率的独立预测因素。一个临床有用的解剖学评分系统若得到验证，可能有助于临床医生在临床决策过程中进行风险分层。
