Temporal Changes in Characteristics of Patients with Peripheral Artery Disease Relevant to Treating PAD Related Functional Impairment

Pooja Nayak BA, Jack M. Guralnik MD, PhD, Tamar S. Polonsky MD, Melina R Kibbe MD, Lu Tian ScD, Lihui Zhao PhD, Michael H. Criqui MD, MPH, Luigi Ferrucci MD, PhD, Lingyu Li, Mary M. McDermott, MD.

Disclosure•Funded by NHLBI

• I have no actual or potential conflict of interest to this presentation

Background•Peripheral Artery Disease (PAD) is common

•PAD will become more prevalent as the population ages

• Increased prevalence of diabetes and obesity in the United States and Worldwide

Specific AimsTo determine temporal trends in clinical characteristics of people with peripheral artery disease from 1998-2012.

WALCS I Study WALCS II Study

WALCS III Study BRAVO Study

October 1998-September 2000 N=419

October 2002-September 2004 N=242

October 2006-September 2008 N=100

October 2008-September 2010 N=291

October 2010-September 2012 N=172

Methods

N=1224

Inclusion/Exclusion Criteria•Consistent inclusion/exclusion criteria across all studies •Ankle-Brachial Index <0.90 at baseline and age ≥ 55 years •Exclusion Criteria: •Dementia

•Wheelchair-bound

•Foot or leg amputations

•Non-English Speaking

•Major surgery in the past 3 months

•Oxygen with ambulation

•Severe knee osteoarthritis

Identification of Baseline Characteristics•Patient self-report confirmed by PCP questionnaire and medical record review •BMI, diabetes, smoking history, myocardial infarction, angina, heart failure, stroke, cancer, knee arthritis, hip arthritis, leg symptoms, walking exercise, mobility

ResultsTemporal Trends in Age, Sex, ABI from 1998-2012 in People with PAD.

1998 -2000 2002 –2004

2006 –2008

2008 –2010

2010 –2012

Trend P*

Number of participants

419 242 100 291 172 NA

Age (years) 72.9 (7.5) 74.4 (8.1) 72.0 (7.9) 70.9 (7.7) 69.6 (7.4) <.001

Female sex, N (%) 172 (41.1) 117 (48.3) 42 (42.0) 108 (37.1) 65 (37.8) 0.17

Ankle Brachial Index

0.65 (0.15) 0.65 (0.16) 0.64 (0.15) 0.64 (0.15) 0.65 (0.14) 0.71

Trends in the Proportion of African Americans among People with PAD from 1998-2012

Perc

ent

0

12.5

25

37.5

50

1998-2000 2002-2004 2006-2008 2008-2010 2010-2012

p-trend <0.00116.2%

45.3%

Trends in the Proportion of People with PAD with Body Mass Index (BMI) >25 and > 30 from 1998-2012

Perc

ent

0

20

40

60

80

1998-2000 2002-2004 2006-2008 2008-2010 2010-2012

BMI >25 kg/M2: p-trend <0.001

BMI >30 kg/M2: p-trend <0.001

66.1%

78.5%

23.6%

43.0%

Trends in the Proportion of Diabetics among People with PAD from 1998-2012Pe

rcen

t

0

11.5

23

34.5

46

1998-2000 2002-2004 2006-2008 2008-2010 2010-2012

29.8% P-trend <0.001

40.7%

Temporal Trends in Walking Exercise > 3 Times per Week in People with PAD from 1998-2012

Perc

ent

0

9

18

27

36

1998-2000 2002-2004 2006-2008 2008-2010 2010-2012

34.4%

23.3%P-trend=0.025

Temporal Trends in the Number of Blocks Walked by People with PAD in the Last Week from 1998-2012

Num

ber

of B

lock

s W

alke

d

0

8.5

17

25.5

34

1998-2000 2002-2004 2006-2008 2008-2010 2010-2012

32.2

19.1P-trend <0.001

Temporal Trends in Mobility Impairment from 1998-2012 in People with PADPe

rcen

t

0

7.5

15

22.5

30

1998-2000 2002-2004 2006-2008 2008-2010 2010-2012

17.9%

23.3%

P-trend=0.019

Trends in the Proportion of People with PAD Experiencing Intermittent Claudication Versus Other or No Exertional Leg Symptoms from 1998-2012

10/1998 – 09/2000

10/2002 – 09/2004

10/2006 – 09/2008

10/2008 – 09/2010

10/2010 – 09/2012

Trend P*

Number of participants

419 242 100 291 172 NA

Intermittent claudication, N (%)

131 (31.3) 55 (22.8) 30 (30.0) 59 (20.3) 27 (15.7) <.001

Exertional leg symptoms other than classic claudication, N (%)

200 (47.7) 126 (52.3) 49 (49.0) 178 (61.2) 99 (57.6) 0.001

No exertional leg symptoms N (%)

88 (21.0) 60 (24.9) 21 (21.0) 54 (18.6) 46 (26.7) 0.79

Summary of Trends• Increase in proportion of African American participants • Increase in mean BMI and diabetes •Decrease in physical activity with increase in mobility loss •Decline in classic symptoms of intermittent claudication

Sensitivity Analyses•Excluding Veterans Administration participants: results not substantially changed

•Excluding for African American participants •Results not substantially changed

•No significant change over time:

•Proportion reporting exertional symptoms other than claudication

•Proportion reporting walking regularly for exercise

Clinical Significance•Increased prevalence of obesity: • Greater functional impairment and rates of functional decline

•Increased prevalence of diabetes: •Multi-focal and distal atherosclerotic disease

•Less amenable to lower extremity revascularization

•Lower rates of walking exercise and greater mobility impairment •Higher prevalence of atypical leg symptoms: •More difficult to diagnose PAD patients

Limitations•Results may not be generalizable to: •Patients outside Chicago

•Patients with undiagnosed PAD

•Most recent data in 2012 •Findings may be due to differences in patient mix

Conclusions•Proportion of PAD patients with diabetes, obesity, and atypical leg symptoms increased •Mean physical activity decreased •Need interventions that increase activity and weight loss

Thank You!