LDL cholesterol levels, peripheral vascular disease, type 2 diabetes, ankle-brachial index, Int J Epidemiol, Clinical Diabetes, pressure index, Journal, Indian Academy of Clinical Medicine Vol., J. Prevalence, Ann Acad Med Singapore, diabetes, prevalence, duration, HbA1c levels, Kownator S. Prevalence, Primary Healthcare Study, diabetes mellitus, arterial disease, heart disease, cerebrovascular accident, ABI, Doppler ultrasound, systolic blood pressure, peripheral arterial disease, Doppler signal, brachial arteries, risk factors, blood pressure cuff, type 2 diabetes mellitus, fasting blood sugar, dorsalis pedis, Doppler probe, peripheral arterial occlusive disease
JIACM 2013; 14(2): 111-4
Peripheral vascular disease a silent assassin: Its rising trend in Punjab Ashok Khurana*, Preeti Dhoat**, TS Marwaha***
Abstract Objective: To determine the prevalence of Peripheral Arterial Disease
in type 2 diabetes
mellitus using the ankle-brachial pressure index and to educate the patients regarding risk factor modification and importance of early intervention
to prevent future progression. Research Design
and methods: A 12 MHz Doppler probe was used in the arms and legs to assess the ankle brachial index (ABI) in 200 type 2 diabetes mellitus
patients aged more than 40 years. A thorough history of patients including age, smoking history, history of symptoms of peripheral arterial disease, complete physical examination
, and routine investigations were collected at the time of enrolment for all subjects. A ratio of the highest blood pressure
from the posterior tibial or pedal arteries of each leg to the highest blood pressure from the brachial arteries < 0.9 was considered abnormal. Results: Abnormal ABIs were found in 33% (66/200) patients with type 2 diabetes mellitus. 45.5% patients had ABI 0.80 - 0.89, 33.3% patients had ABI 0.50 - 0.79, and 21.2% patients had ABI < 0.5. Conclusions: Prevalence of peripheral vascular disease in type 2 diabetes mellitus is on rise in northern India. Key words: Type 2 diabetes mellitus, peripheral vascular disease.
Introduction Peripheral vascular disease is a major macrovascular complication of diabetes mellitus1.Because of the unique involvement of distal pattern of vessels and invariable association with neuropathy, peripheral arterial disease in diabetics presents late, having already developed limbthreating ischaemia2. Ankle-brachial pressure index is a noninvasive testing method which greatly increases the accuracy of clinical diagnosis
for the presence of arterial disease and serves as an objective index to follow the Natural History
of the disease3. Ankle-brachial pressure index is the most efficient, objective, and practical means of documenting presence and severity of peripheral arterial disease4. In the present study, 200 patients with type 2 diabetes mellitus were enrolled to find out prevalence of peripheral vascular disease using anklebrachial pressure index. The data thus obtained was analysed statistically. Material and methods Study Group
: 200 patients aged more than 40 years, who were admitted in various units of the Department of Medicine of Sri Guru Ram Das Hospital, Amritsar, Punjab with type 2 diabetes mellitus were enrolled. Patients of type 1 diabetes mellitus, smokers, those having ischaemic heart disease
, those with history of hypertension before diagnosis of type 2 diabetes mellitus, and those with previous history of
cerebrovascular accident or heart disease were excluded from the study. Study protocol The ABI was measured with a blood pressure cuff and a Doppler ultrasound sensor. The cuff was applied to both arms and ankles. The Doppler probe was used to determine systolic blood pressure
in both brachial arteries in the antecubital fossa, and in the right and left posterior tibial arteries,and the right and left dorsalis pedis arteries. With an 12 MHz Doppler probe we obtained the systolic arterial pressure when the first Doppler signal was heard. The ABI for each leg was calculated as the ratio of the higher of the two systolic pressures (posterior tibial or dorsalis pedis) in the leg and the higher systolic pressure of either the left or right arm. The method used was in accordance with a recent consensus statement on measuring the ABI. An ABI < 0.9 in either leg was considered abnormal, suggesting peripheral arterial disease; progressively lower ABI values indicate more severe obstruction. A thorough history of patients including age, smoking history, history of symptoms of peripheral arterial disease,complete physical examination and routine investigations including haemoglobin, total leucocyte count, differencial leucocyte count, fasting blood sugar, HbA1C level, blood urea, serum creatinine, sodium,potassium,lipid profile,urine (complete),and ECG were done.
* Professor,** assistant professor
,*** Junior Resident,Department of Medicine,Sri Guru Ram Das Institute of medical science
s and Research, Mehta Road, Vallah, Amritsar - 143 501, Punjab.statistical analysis
Statistical analysis was with chi-square test and univariate regression analysis
. Results Abnormal ABIs were found in 33% (66/200) patients with type 2 diabetes mellitus enrolled in the present study.Out of this, 45.5% patients had ABI 0.80 - 0.89, 33.3% patients had ABI 0.50 - 0.79, and 21.2% patients had ABI < 0.5. Among these 66 patients having peripheral vascular disease, females had higher percentage of peripheral arterial disease as compared to males 62.1% vs 37.9% (p < 0.05). 13.6% (9) patients belonged to the age group of 40 - 49 years. 34.8% (23) patients belonged to the age group of 50 - 59 years. 51.6% (34) patients belonged to the age group 60 years and above. With increasing age, the prevalence of peripheral arterial disease in type 2
Fig. 3: Correlation of peripheral vascular disease with clinical approach.
Fig. 4: Correlation of peripheral vascular disease with foot ulcer. Fig. 1: Gender-specific prevalence of peripheral vascular disease.
Fig. 2: Age-wise distribution of peripheral vascular disease.
Fig. 5: Correlation of peripheral vascular disease with HbA1c levels. diabetes showed an increasing trend (p < 0.05).39.4% (26) patients were asymptomatic, while 60.6% (40) were symptomatic with symptoms of claudication, rest pain, Leriche syndrome (p < 0.001).18.2% (12) patients had foot ulcer, while 81.8% (54) patients had no such abnormality (p < 0.001). 36.4% (24) patients had HbA1C levels > 7, while 63.6% (42) had HbA1C levels < 7. Overall, patients with
Journal, Indian Academy of clinical medicine
Vol. 14, No. 2 April-June, 2013
Fig. 6: Correlation of peripheral vascular disease with duration of diabetes in years. Fig. 7: Correlation of peripheral vascular disease with LDL Cholestrol levels. Fig. 8: Ankle-branchial index stratification in patients having peripheral vascular disease with foot ulcer. peripheral arterial disease had correlation with HbA1C levels as compared to patients without peripheral arterial disease (p < 0.05). 10.6% (7) patients had duration of diabetes less or equivalent to one year.18.2% (12) patients had duration of diabetes between 2 to 5 years. 25.8% (17) patients had duration of diabetes between 6 to 10 years
while 45.4% (30) patients had duration of diabetes >10 years (p <0.001). 62.1% (41) patients had serum LDL cholesterol levels
>190 mg/dl. Out of 134 patients of type 2 diabetes who had no evidence of peripheral arterial disease, 22.4% (30) patients had serum cholesterol levels > 190 mg/dl (p < 0.001). Discussion Correlation of peripheral vascular disease with gender distribution, age distribution, clinical symptoms, glycosylated haemoglobin, duration of diabetes, LDL cholesterol levels was done. This study showed that females had higher prevalence of peripheral arterial disease as compared to males.While assessing prevalence and risk factors
for peripheral arterial disease in an Asian population with diabetes mellitus,Tavintharan et al found that prevalence of PAD was more in the female gender5. This study showed that with increasing age the prevalence of peripheral arterial disease in type 2 diabetes increased. Lekshmi et al while studying the peripheral arterial disease in community-basED patients
with diabetes in Singapore reported that, prevalence of peripheral arterial disease was positively associated with increasing age6. This study showed that high prevalence of symptoms pertaining to lower limbs was found in patients with peripheral arterial disease. This is in concordance with the study done by Buitrуn et al which showed that the presence of either signs or symptoms was more frequent in subjects with peripheral arterial disease7. This study showed that all patients with peripheral arterial disease had higher levels of HbA1C as compared to patients without peripheral arterial disease. Adler et at studied potential risk factors for the development of peripheral arterial disease and reported that hyperglycaemia was associated with an increased risk for peripheral arterial disease, independent of other risk factors8. Our study also showed positive correlation of duration of diabetes with peripheral vessel disease.Papanas et al proved in their study that peripheral arterial occlusive disease in patients was associated with duration of diabetes mellitus9. This study also found that peripheral arterial disease was positively correlated with LDL cholesterol levels. This is in concordance with the study done by Cacoub et al which showed that LDL cholesterol levels and peripheral arterial disease are positively correlated10. The prevalence of peripheral arterial disease using ankle-brachial pressure index in this study was 66 (out of 200 patients), that is 33%. Hirsch et al conducted a multicentre, cross-sectional study
and detected a prevalence of 29%11. Mourad et al in a prospective, observational, real-life, epidemiologic study (ELLIPSE) calculated the prevalence of peripheral arterial disease to be 41.1%12.
Journal, Indian Academy of Clinical Medicine Vol. 14, No. 2 April-June, 2013
Conclusion The prevalence of peripheral vascular disease in type 2 diabetes mellitus as measured by ankle-brachial pressure index was 33% (66 out of total 200 patients). Hence this increasing trend of peripheral vascular disease requires patient education for risk factor modification and early intervention to prevent future progression. References 1. Stratton IM, Adler AI, Neil HA. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes prospective observational study. BMJ 2000; 321 (7258): 405-12. 2. Sheehan P. Peripheral Arterial Disease in People with Diabetes: Consensus Statement Recommends Screening. Clinical Diabetes 2004; 22(4): 179-80. 3. Fowkes FGR. The measurement of atherosclerotic peripheral arterial disease in epidemiological surveys. Int J Epidemiol 1988; 17: 248-54. 4. Yao JST,Hobbs JT,Irvine WT. Ankle systolic pressure measurements in arterial diseases affecting the lower extremeties. Br J Surg 1969; 56: 676-9. 5. Tavintharan S, Ning Cheung, Su Chi Lim.Prevalence and risk factors for peripheral artery disease in an Asian population with diabetes
mellitus. Diab Vasc Dis Res 2009; 6(2): 80-6. 6. Lekshmi Narayanan RM, KohWP,Phang J.Peripheral arterial disease in community-based patients with diabetes in Singapore: Results from a Primary Health
care Study. Ann Acad Med Singapore 2010; 39(7): 525-7. 7. Buitrуn-Granados LV, Martнnez-Lуpez C, Escobedo-de la Peсa J. Prevalence of peripheral arterial disease and related risk factors in an urban Mexican population. Angiology 2004; 55(1): 43-51. 8. Adler AI, Stevens RJ, Neil A. UKPDS 59: hyperglycaemia and other potentially modifiable risk factors for peripheral vascular disease in type 2 diabetes. 9. Papanas N, Tziakas D, Maltezos E. Risk factors for concomitant peripheral arterial occlusive disease in patients with coronary artery disease: is there a difference between diabetic and nondiabetic patients? Acta Clin Belg 2005; 60(3): 122-8. 10. Cacoub P, Cambou J, Kownator S. Prevalence of peripheral arterial disease in high-risk patients
using ankle-brachial index in general practice: a cross-sectional study. Int J ClinPract 2009; 63(1): 63-70. 11. Hirsch AT, Criqui MH, Treat-Jacobson D. Peripheral arterial disease detection, awareness, and treatment in Primary Care
. JAMA 2001; 286(11): 1317-24. 12. Mourad JJ, Cacoub P, Collet JP. Screening of unrecognized peripheral arterial disease (PAD) using ankle-brachial index in high cardiovascular risk patients free from symptomatic PAD.J Vasc Surg 2009;50(3): 572-80.
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Journal, Indian Academy of Clinical Medicine Vol. 14, No. 2 April-June, 2013
A Khurana, P Dhoat, TS Marwaha