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Jonathan Golledge - One of the best experts on this subject based on the ideXlab platform.

  • effect of blood pressure lowering medications on leg ischemia in peripheral artery disease patients a meta analysis of randomised controlled trials
    PLOS ONE, 2017
    Co-Authors: Diana Thomas Manapurathe, Joseph V Moxon, Jonathan Golledge, Smriti M Krishna, Brittany Dewdney, Erik Biros
    Abstract:

    Background: It has been suggested that anti-hypertensive medications may worsen leg ischemia in peripheral artery disease (PAD) patients. We undertook a meta-analysis to assess the effect of anti-hypertensive medications on measures of leg ischemia including Maximum Walking Distance (MWD), pain free Walking Distance (PFWD) and ankle brachial pressure index (ABPI). A meta-regression was performed to evaluate whether the effect of the anti-hypertensive medications on mean arterial pressure (MAP) was associated with changes in ABPI, MWD or PFWD. Method: A systematic literature search was performed to identify placebo controlled randomized control trials (RCT) testing anti-hypertensive medications, which reported baseline and follow-up measurements of: MAP and MWD, PFWD or ABPI in patients with intermittent claudication (IC) due to PAD. Result: A meta-analysis was performed on 5 RCTs comprising a total of 180 and 127 patients receiving anti-hypertensive medications and placebo respectively. This analysis suggested that anti-hypertensive medication did not significantly affect MWD, PFWD or ABPI. In contrast, the meta-regression analysis showed that the reduction in MAP due to the anti-hypertensive drugs was positively correlated with increased MWD during follow-up (β = 8.371, p = 0.035). Heterogeneity across studies, as assessed by I2, was high. The follow-up period within the included trials was generally short with 3 out of 5 studies having a follow-up period of ≤ 6 weeks. Conclusion: This study suggests that anti-hypertensive treatment does not worsen but may improve leg ischemia in PAD patients. Larger multicenter trials with longer anti-hypertensive treatment periods are required to clarify the effect of anti-hypertensives on leg ischemia in PAD patients.

  • association of lower extremity performance with cardiovascular and all cause mortality in patients with peripheral artery disease a systematic review and meta analysis
    Journal of the American Heart Association, 2014
    Co-Authors: Dylan R Morris, Alexander J Rodriguez, Joseph V Moxon, Margaret Cunningham, Mary M Mcdermott, Jonathan Myers, Nicholas J Leeper, R E Jones, Jonathan Golledge
    Abstract:

    Background Peripheral artery disease (PAD) is associated with impaired mobility and a high rate of mortality. The aim of this systematic review was to investigate whether reduced lower extremity performance was associated with an increased incidence of cardiovascular and all-cause mortality in people with PAD. Methods and Results A systematic search of the MEDLINE, EMBASE, SCOPUS, Web of Science, and Cochrane Library databases was conducted. Studies assessing the association between measures of lower extremity performance and cardiovascular or all-cause mortality in PAD patients were included. A meta-analysis was conducted combining data from commonly assessed performance tests. The 10 identified studies assessed lower extremity performance by strength tests, treadmill Walking performance, 6-minute walk, Walking velocity, and Walking impairment questionnaire (WIQ). A meta-analysis revealed that shorter Maximum Walking Distance was associated with increased 5-year cardiovascular (unadjusted RR=2.54, 95% CI 1.86 to 3.47, P <10−5, n=1577, fixed effects) and all-cause mortality (unadjusted RR=2.23 95% CI 1.85 to 2.69, P <10−5, n=1710, fixed effects). Slower 4-metre Walking velocity, a lower WIQ stair-climbing score, and poor hip extension, knee flexion, and plantar flexion strength were also associated with increased mortality. No significant associations were found for hip flexion strength, WIQ Distance score, or WIQ speed score with mortality. Conclusions A number of lower extremity performance measures are prognostic markers for mortality in PAD and may be useful clinical tools for identifying patients at higher risk of death. Further studies are needed to determine whether interventions that improve measures of lower extremity performance reduce mortality.

  • a meta analysis of the outcome of endovascular and noninvasive therapies in the treatment of intermittent claudication
    Journal of Vascular Surgery, 2011
    Co-Authors: Anna A Ahimastos, Elise Pappas, Petra Buttner, P J Walker, Bronwyn A Kingwell, Jonathan Golledge
    Abstract:

    Purpose Intermittent claudication is a common symptom of peripheral arterial disease. Currently, there is a lack of consensus on the most effective therapies for this problem. We conducted a meta-analysis of randomized trials assessing the efficacy of endovascular therapy (EVT) compared with noninvasive therapies for the treatment of intermittent claudication. Methods Randomized trials comparing the efficacy of EVT and noninvasive therapies, such as medical therapy (MT) and supervised exercise (SVE) in patients with intermittent claudication were identified by a systematic search. Data were pooled, and combined overall effect sizes (standardized differences of mean values) were calculated for a random effect model in terms of ankle-brachial index (ABI) and treadmill Walking for initial claudication Distance (ICD) and Maximum Walking Distance (MWD). Nine eligible trials (873 participants) were included: two compared EVT and MT alone, four compared EVT and SVE, and three trials compared EVT plus SVE vs SVE alone. Results Heterogeneity between studies was marked. Quantitative data analysis suggested that EVT improved outcomes over MT alone at early follow-up evaluations. Outcomes of EVT plus SVE were better than those of SVE alone in terms of both ABI and treadmill Walking at immediate, early, and intermediate follow-up. No substantial differences in outcomes of EVT alone compared with SVE alone were found. Conclusion In patients with intermittent claudication, current evidence supports improved ABI and treadmill Walking when EVT is added to MT or SVE during early and intermediate follow-up. There is no evidence that EVT alone provides improved outcome over SVE alone. There is low confidence in these findings for a number of reasons, including the small number of trials, the small size of these studies, the heterogeneity in study design, and the limited use of quality of life tools in assessing outcomes. More consistent data from larger, more homogenous studies, including longer follow-up, are required.

  • association of obesity and metabolic syndrome with the severity and outcome of intermittent claudication
    Journal of Vascular Surgery, 2007
    Co-Authors: Jonathan Golledge, Anthony S Leicht, Robert G Crowther, Paula Clancy, Warwick L Spinks, Francis Quigley
    Abstract:

    Background Obesity is recognized as an independent predictor of coronary artery disease; however, its importance in peripheral arterial disease is less clear. The aim of this study was to assess the association between obesity and the severity and outcome of intermittent claudication. Methods This study was a prospective cohort study based at a tertiary referral center. Sixty patients with intermittent claudication selected for conservative treatment were assessed for obesity and metabolic syndrome by using the International Diabetes Federation definition. Other risk factors, including diabetes, hypertension, smoking history, serum lipids, adipocytokines, and C-reactive protein, were measured by clinical and blood assessment. Obesity and metabolic syndrome were related to the severity of peripheral arterial disease, defined by ankle-brachial pressure index and graded treadmill measured Maximum Walking Distance (MWD) and initial claudication Distance, by using multiple linear regression analysis allowing for traditional atherosclerotic risk factors. Patients were followed up for 24 months, and combined outcome was reported in terms of death, cardiovascular events, or requirement for revascularization. The effect of obesity and metabolic syndrome on outcome was investigated by using Kaplan-Meier and Cox proportional hazard analysis. Results Obesity and serum adiponectin were independently associated with the severity of peripheral arterial disease measured by ankle-brachial pressure index (P = .03 and .001), initial claudication Distance (P = .009 and .03), and MWD (P = .001 and .04). Metabolic syndrome was independently associated only with MWD (P = .02). By 24 months, outcome events occurred in 37% ± 7% and 43% ± 9% of patients with metabolic syndrome or obesity, respectively, compared with 0% and 11% ± 6% of those without these diagnoses. Waist circumference independently predicted the likelihood of outcome events (relative risk, 1.16; 95% confidence interval, 1.08-1.26; P < .001). Conclusions These findings, if confirmed in other cohorts, suggest the importance of treating obesity in patients with intermittent claudication. Serum adiponectin concentrations may be an important guide to the efficacy of treatment in patients with intermittent claudication and obesity.

Mehdi H Shishehbor - One of the best experts on this subject based on the ideXlab platform.

  • associations of exercise ankle brachial index pain free Walking Distance and Maximum Walking Distance with the peripheral artery questionnaire finding from the portrait pad registry
    Vascular Medicine, 2019
    Co-Authors: Tarek A Hammad, Kim G Smolderen, John A Spertus, Philip G Jones, Mehdi H Shishehbor
    Abstract:

    An exercise ankle-brachial index (ABI) test can provide further insight into the functional significance of peripheral artery disease (PAD). The variability in its use, associated patient factors and its relation to patients' symptoms are unknown. From the international PORTRAIT registry, we identified 1131 patients with PAD. We fit a hierarchical logistic regression model, adjusting for patient factors, country and site, to examine predictors of and variation in ordering exercise ABI testing. We also examined the associations between test components and health status as quantified by the Peripheral Artery Questionnaire (PAQ) using semi-parametric regression methods. Testing was ordered in 22% in the United States versus 80% in the Netherlands and 90% in Australia. Testing was likely to be performed if the patient was male, younger, had typical symptoms and a higher resting ABI, with substantial variability across sites (median odds ratio=5.9, 95% CI: 3.2-19.5). Adjusting for country and site, the resting ABI and all exercise ABI metrics were associated with the PAQ Physical Limitation score. In addition, important components of the test, namely time to onset of claudication, pain-free Walking Distance (PFWD), and Maximum Walking Distance (MWD), were also associated with PAQ Symptoms and Summary scores. More importantly, even after adjusting for resting ABI, a patient with a post-exercise ABI of 0.29 (25th percentile), compared to 0.61 (75th percentile), achieved 4.4 (95% CI: 0.4-8.4, p=0.031) points less on the PAQ Physical Limitation score. Exercise ABI test use is remarkably variable, and less used in the United States. Its data, specifically PFWD and MWD, might help in objectively assessing the impact of PAD on patients' functioning and quality of life.

  • abstract 19650 associations of exercise ankle brachial index pain free Walking Distance and Maximum Walking Distance with peripheral artery questionnaire finding from portrait registry
    Circulation, 2017
    Co-Authors: Tarek A Hammad, Kim G Smolderen, John A Spertus, Philip G Jones, Mehdi H Shishehbor
    Abstract:

    Objective: Beyond the use of exercise ankle-brachial index (ABI) to diagnose peripheral artery disease (PAD), an exercise ABI can provide further insight into the functional significance of PAD. While ACC/AHA guidelines recommend exercise ABI only when resting measurement is normal and symptoms are suggestive of PAD, the variability in the use of exercise ABI, patient’s factors associated with its use and its relation to patient’s symptoms as quantified by the Peripheral Artery Questionnaire (PAQ), are unknown. Methods: From the multinational PORTRAIT registry, between 06/2011 and 02/2015, we identified 1,132 consecutive patients with PAD (resting ABI ≤ 0.9). We built a hierarchical logistic regression model, including random effects for site and country, to examine predictors and variation, by the calculation of fully-adjusted median odds ratios (MOR), in ordering exercise ABIs. Lastly, association between exercise ABI (absolute and relative change in ABI with exercise, pain-free Walking Distance (PFWD),...

Tarek A Hammad - One of the best experts on this subject based on the ideXlab platform.

  • associations of exercise ankle brachial index pain free Walking Distance and Maximum Walking Distance with the peripheral artery questionnaire finding from the portrait pad registry
    Vascular Medicine, 2019
    Co-Authors: Tarek A Hammad, Kim G Smolderen, John A Spertus, Philip G Jones, Mehdi H Shishehbor
    Abstract:

    An exercise ankle-brachial index (ABI) test can provide further insight into the functional significance of peripheral artery disease (PAD). The variability in its use, associated patient factors and its relation to patients' symptoms are unknown. From the international PORTRAIT registry, we identified 1131 patients with PAD. We fit a hierarchical logistic regression model, adjusting for patient factors, country and site, to examine predictors of and variation in ordering exercise ABI testing. We also examined the associations between test components and health status as quantified by the Peripheral Artery Questionnaire (PAQ) using semi-parametric regression methods. Testing was ordered in 22% in the United States versus 80% in the Netherlands and 90% in Australia. Testing was likely to be performed if the patient was male, younger, had typical symptoms and a higher resting ABI, with substantial variability across sites (median odds ratio=5.9, 95% CI: 3.2-19.5). Adjusting for country and site, the resting ABI and all exercise ABI metrics were associated with the PAQ Physical Limitation score. In addition, important components of the test, namely time to onset of claudication, pain-free Walking Distance (PFWD), and Maximum Walking Distance (MWD), were also associated with PAQ Symptoms and Summary scores. More importantly, even after adjusting for resting ABI, a patient with a post-exercise ABI of 0.29 (25th percentile), compared to 0.61 (75th percentile), achieved 4.4 (95% CI: 0.4-8.4, p=0.031) points less on the PAQ Physical Limitation score. Exercise ABI test use is remarkably variable, and less used in the United States. Its data, specifically PFWD and MWD, might help in objectively assessing the impact of PAD on patients' functioning and quality of life.

  • abstract 19650 associations of exercise ankle brachial index pain free Walking Distance and Maximum Walking Distance with peripheral artery questionnaire finding from portrait registry
    Circulation, 2017
    Co-Authors: Tarek A Hammad, Kim G Smolderen, John A Spertus, Philip G Jones, Mehdi H Shishehbor
    Abstract:

    Objective: Beyond the use of exercise ankle-brachial index (ABI) to diagnose peripheral artery disease (PAD), an exercise ABI can provide further insight into the functional significance of PAD. While ACC/AHA guidelines recommend exercise ABI only when resting measurement is normal and symptoms are suggestive of PAD, the variability in the use of exercise ABI, patient’s factors associated with its use and its relation to patient’s symptoms as quantified by the Peripheral Artery Questionnaire (PAQ), are unknown. Methods: From the multinational PORTRAIT registry, between 06/2011 and 02/2015, we identified 1,132 consecutive patients with PAD (resting ABI ≤ 0.9). We built a hierarchical logistic regression model, including random effects for site and country, to examine predictors and variation, by the calculation of fully-adjusted median odds ratios (MOR), in ordering exercise ABIs. Lastly, association between exercise ABI (absolute and relative change in ABI with exercise, pain-free Walking Distance (PFWD),...

Sandra Spronk - One of the best experts on this subject based on the ideXlab platform.

  • endovascular revascularization and supervised exercise for peripheral artery disease and intermittent claudication a randomized clinical trial
    JAMA, 2015
    Co-Authors: Farzin Fakhry, Sandra Spronk, Lijckle Van Der Laan, Jan J Wever, Joep A W Teijink, Wolter H Hoffmann, Taco M Smits, Jerome P Van Brussel, Guido N M Stultiens, Alex Derom
    Abstract:

    Importance Supervised exercise is recommended as a first-line treatment for intermittent claudication. Combination therapy of endovascular revascularization plus supervised exercise may be more promising but few data comparing the 2 therapies are available. Objective To assess the effectiveness of endovascular revascularization plus supervised exercise for intermittent claudication compared with supervised exercise only. Design, Setting, and Participants Randomized clinical trial of 212 patients allocated to either endovascular revascularization plus supervised exercise or supervised exercise only. Data were collected between May 17, 2010, and February 16, 2013, in the Netherlands at 10 sites. Patients were followed up for 12 months and the data were analyzed according to the intention-to-treat principle. Interventions A combination of endovascular revascularization (selective stenting) plus supervised exercise (n = 106) or supervised exercise only (n = 106). Main Outcomes and Measures The primary end point was the difference in Maximum treadmill Walking Distance at 12 months between the groups. Secondary end points included treadmill pain-free Walking Distance, vascular quality of life (VascuQol) score (1 [worst outcome] to 7 [best outcome]), and 36-item Short-Form Health Survey (SF-36) domain scores for physical functioning, physical role functioning, bodily pain, and general health perceptions (0 [severe limitation] to 100 [no limitation]). Results Endovascular revascularization plus supervised exercise (combination therapy) was associated with significantly greater improvement in Maximum Walking Distance (from 264 m to 1501 m for an improvement of 1237 m) compared with the supervised exercise only group (from 285 m to 1240 m for improvement of 955 m) (mean difference between groups, 282 m; 99% CI, 60-505 m) and in pain-free Walking Distance (from 117 m to 1237 m for an improvement of 1120 m vs from 135 m to 847 m for improvement of 712 m, respectively) (mean difference, 408 m; 99% CI, 195-622 m). Similarly, the combination therapy group demonstrated significantly greater improvement in the disease-specific VascuQol score (1.34 [99% CI, 1.04-1.64] in the combination therapy group vs 0.73 [99% CI, 0.43-1.03] in the exercise group; mean difference, 0.62 [99% CI, 0.20-1.03]) and in the score for the SF-36 physical functioning (22.4 [99% CI, 16.3-28.5] vs 12.6 [99% CI, 6.3-18.9], respectively; mean difference, 9.8 [99% CI, 1.4-18.2]). No significant differences were found for the SF-36 domains of physical role functioning, bodily pain, and general health perceptions. Conclusions and Relevance Among patients with intermittent claudication after 1 year of follow-up, a combination therapy of endovascular revascularization followed by supervised exercise resulted in significantly greater improvement in Walking Distances and health-related quality-of-life scores compared with supervised exercise only. Trial Registration Netherlands Trial Registry Identifier:NTR2249

  • long term clinical effectiveness of supervised exercise therapy versus endovascular revascularization for intermittent claudication from a randomized clinical trial
    British Journal of Surgery, 2013
    Co-Authors: Farzin Fakhry, Ellen V Rouwet, P Den T Hoed, Myriam Hunink, Sandra Spronk
    Abstract:

    Background Long-term comparisons of supervised exercise therapy (SET) and endovascular revascularization (ER) for patients with intermittent claudication are scarce. The long-term clinical effectiveness of SET and ER was assessed in patients from a randomized trial. Methods Consenting patients with intermittent claudication were assigned randomly to either SET or ER. Outcome measures on functional performance (pain-free and Maximum Walking Distance, ankle: brachial pressure index), quality of life (QoL) and number of secondary interventions were measured at baseline and after approximately 7 years of follow-up. Repeated-measurement and Kaplan-Meier methods were used to analyse the data on an intention-to treat-basis. Results A total of 151 patients were randomized initially to either SET or ER. After 7 years, functional performance (P < 0·001) and QoL (P ≤ 0·005) had improved after both SET and ER. Long-term comparison showed no differences between the two treatments, except in the secondary intervention rate, which was significantly higher after SET (P = 0·001). Nevertheless, the total number of endovascular and surgical interventions (primary and secondary) remained higher after ER (P < 0·001). Conclusion In the longer term, SET-first or ER-first treatment strategies were equally effective in improving functional performance and QoL in patients with intermittent claudication. The substantially higher number of invasive interventions in the ER-first group supports a SET-first treatment strategy for intermittent claudication. Registration number: NTR199 (http://www.trialregister.nl). Exercise better option

  • supervised Walking therapy in patients with intermittent claudication
    Journal of Vascular Surgery, 2012
    Co-Authors: Farzin Fakhry, Ellen V Rouwet, Koen M Van De Luijtgaarden, Ted Den P Hoed, M Myriam G Hunink, Sandra Spronk
    Abstract:

    Objective Exercise therapy is a common intervention for the management of intermittent claudication (IC). However, considerable uncertainty remains about the effect of different exercise components such as intensity, duration, or content of the exercise programs. The aim of this study was to assess the effectiveness of supervised Walking therapy (SWT) as treatment in patients with IC and to update and identify the most important exercise components resulting in an optimal training protocol for patients with IC. Methods A systematic literature search using MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases was performed. Randomized controlled trials (RCTs) published between January 1966 and February 2012 were included if they evaluated the effectiveness of SWT. Predefined exercise components were extracted, including treadmill use during training, claudication pain end point used during Walking, length of the SWT program, and total training volume. A meta-analysis and meta-regression was performed to evaluate the weighted mean difference in Maximum Walking Distance (MWD) and pain-free Walking Distance (PFWD) between SWT and noninterventional observation. Results Twenty-five RCTs (1054 patients) comparing SWT vs noninterventional observation showed a weighted mean difference of 180 meters (95% confidence interval, 130-230 meters) in MWD and 128 meters (95% confidence interval, 92-165 meters) in PFWD, both in favor of the SWT group. In multivariable meta-regression analysis, none of the predefined exercise components were independently associated with significant improvements in MWD or PFWD. Conclusions SWT is effective in improving MWD and PFWD in patients with IC. However, pooled results from the RCTs did not identify any of the exercise components including intensity, duration, or content of the program as being independently associated with improvements in MWD or PFWD.

Gerard Stansby - One of the best experts on this subject based on the ideXlab platform.

  • cost effectiveness of cilostazol naftidrofuryl oxalate and pentoxifylline for the treatment of intermittent claudication in people with peripheral arterial disease
    Angiology, 2014
    Co-Authors: Yang Meng, Hazel Squires, Emma Simpson, S Harnan, John Stevens, S Thomas, Gerard Stansby, Jonathan A Michaels, Mark E Odonnell
    Abstract:

    We assessed the cost-effectiveness of cilostazol, naftidrofuryl oxalate, and pentoxifylline for intermittent claudication due to peripheral arterial disease (PAD) in adults whose symptoms continue despite a period of conventional management. A Markov decision model was developed to assess the lifetime costs and benefits of each vasoactive drug compared to no vasoactive drug and with each other. Regression analysis was undertaken to model the relationship between Maximum Walking Distance and utility. Resource use data were sourced from the literature and sensitivity analyses were undertaken. Naftidrofuryl oxalate is more effective and less costly than cilostazol and pentoxifylline and has an estimated cost per quality-adjusted life year gained of around £6070 compared to no vasoactive drug. The analysis uses effectiveness evidence from a network meta-analysis. In contrast to previous guidelines recommending cilostazol, the analysis suggests that naftidrofuryl oxalate is the only vasoactive drug for PAD which is likely to be cost-effective.

  • systematic review of the efficacy of cilostazol naftidrofuryl oxalate and pentoxifylline for the treatment of intermittent claudication
    British Journal of Surgery, 2012
    Co-Authors: John Stevens, Hazel Squires, Emma Simpson, Yang Meng, S Harnan, Jonathan A Michaels, Steven M Thomas, Gerard Stansby
    Abstract:

    Background: A systematic review and network meta-analysis was undertaken to consider the evidence for the efficacy and tolerability of placebo, cilostazol, naftidrofuryl oxalate and pentoxifylline in patients with intermittent claudication due to peripheral arterial disease (PAD). Methods: MEDLINE, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Conference Proceedings, BIOSIS, National Research Register and MetaRegister databases were searched. Eligible studies were randomized controlled trials (RCTs) and published systematic reviews of patients with intermittent claudication due to PAD and whose symptoms persisted despite a period of conservative management. Study selection was conducted by one reviewer with involvement from a clinician. Data were extracted by one reviewer with no blinding to authors or journal, and checked by a second reviewer. Outcome measures were Maximum Walking Distance (MWD) and pain-free Walking Distance (PFWD). Results: The review identified 1876 citations; 26 RCTs met the inclusion criteria for the systematic review. Eleven trials provided data relevant for the meta-analysis. Naftidrofuryl oxalate was ranked first for both MWD and PFWD (probability of 0·947 and 0·987, respectively, of being the best treatment) followed by cilostazol and pentoxifylline. For naftidrofuryl oxalate, cilostazol and pentoxifylline, MWD increased by 60 (95 per cent credible interval 20 to 114) per cent, 25 (11 to 40) per cent and 11 (−1 to 24) per cent respectively relative to placebo, and PFWD increased by 49, 13 and 9 per cent. Conclusion: Naftidrofuryl oxalate and cilostazol are both effective treatments for claudication; naftidrofuryl oxalate is likely to be the most effective, with minimal serious adverse events. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.