prevalence, correlates, and prognosis of peripheral artery

Washington University School of Medicine Washington University School of Medicine

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Open Access Publications

2014

Prevalence correlates and prognosis of peripheral artery disease Prevalence correlates and prognosis of peripheral artery disease

in rural ecuador-rationale protocol and phase I results of a in rural ecuador-rationale protocol and phase I results of a

population-based survey an atahualpa project-ancillary study population-based survey an atahualpa project-ancillary study

Oscar H Del Brutto Universidad Espiritu Santo-Ecuador

Mark J Sedler Stony Brook University

Robertino M Mera Vanderbilt University

Pablo R Castillo Mayo Clinic College of Medicine

Elizabeth H Cusick Stony Brook University

See next page for additional authors Follow this and additional works at httpsdigitalcommonswustleduopen_access_pubs

Recommended Citation Recommended Citation Del Brutto Oscar H Sedler Mark J Mera Robertino M Castillo Pablo R Cusick Elizabeth H Gruen Jadry A Phelan Kelsie J Del Brutto Victor J Zambrano Mauricio and Brown David L Prevalence correlates and prognosis of peripheral artery disease in rural ecuador-rationale protocol and phase I results of a population-based survey an atahualpa project-ancillary study International Journal of Vascular Medicine 1-9 (2014) httpsdigitalcommonswustleduopen_access_pubs3486

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Authors Authors Oscar H Del Brutto Mark J Sedler Robertino M Mera Pablo R Castillo Elizabeth H Cusick Jadry A Gruen Kelsie J Phelan Victor J Del Brutto Mauricio Zambrano and David L Brown

This open access publication is available at Digital CommonsBecker httpsdigitalcommonswustleduopen_access_pubs3486

Research ArticlePrevalence Correlates and Prognosis of Peripheral ArteryDisease in Rural EcuadormdashRationale Protocol and Phase IResults of a Population-Based Survey An AtahualpaProject-Ancillary Study

Oscar H Del Brutto12 Mark J Sedler3 Robertino M Mera4

Pablo R Castillo5 Elizabeth H Cusick3 Jadry A Gruen3 Kelsie J Phelan3

Victor J Del Brutto6 Mauricio Zambrano6 and David L Brown7

1 School of Medicine Universidad Espıritu Santo-Ecuador Guayaquil Ecuador2 Air Center 3542 PO Box 522970 Miami Fl 33152-2970 USA3 School of Medicine Stony Brook University Health Sciences Center L-4 Room 158 Stony Brook NY 11794 USA4Gastroenterology Department Vanderbilt University Nashville TN USA5 Sleep Disorders Center Mayo Clinic College of Medicine 4500 San Pablo Road Jacksonville FL 32224 USA6Community Center Villa Club Etapa Cosmos Mz 15 Villa 42 Atahualpa Daule Guayas Ecuador7 Cardiovascular Division Washington University School of Medicine 660 S Euclid Avenue Campus Box 8086St Louis MO 63110 USA

Correspondence should be addressed to Oscar H Del Brutto oscardelbruttohotmailcom

Received 23 May 2014 Accepted 28 July 2014 Published 21 September 2014

Academic Editor Robert M Schainfeld

Copyright copy 2014 Oscar H Del Brutto et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

Background Little is known on the prevalence of peripheral artery disease (PAD) in developing countries Study design Population-based study in Atahualpa In Phase I the Edinburgh claudication questionnaire (ECQ) was used for detection of suspectedsymptomatic PAD persons with a negative ECQ but a pulse pressure ge65mmHg were suspected of asymptomatic PAD In PhaseII the ankle-brachial index will be used to test reliability of screening instruments and to determine PAD prevalence In PhaseIII participants will be followed up to estimate the relevance of PAD as a predictor of vascular outcomes Results During PhaseI 665 Atahualpa residents aged ge40 years were enrolled (mean age 595 plusmn 126 years 58 women) A poor cardiovascular healthstatus was noticed in 464 (70) persons of which 27 (4) had a stroke and 14 (2) had ischemic heart disease Forty-four subjects(7) had suspected symptomatic PAD and 170 (26) had suspected asymptomatic PAD Individuals with suspected PAD wereolder more often women and had a worse cardiovascular profile than those with nonsuspected PAD Conclusions Prevalence ofsuspected PAD in this underserved population is high Subsequent phases of this study will determine whether prompt detectionof PAD is useful to reduce the incidence of catastrophic vascular diseases in the region

1 Introduction

Underserved populations of LatinAmerica are going througha process of epidemiologic transition due to increases inlife expectancy and changes in dietary habits and lifestyles[1] As a consequence the incidence and prevalence rates ofcardiovascular diseases are increasing to the point that these

conditions are considered to be the next health epidemicsof the region [2] Epidemiologic surveys assessing specificrisk factors are mandatory to define and to respond to thepotential burden of ischemic heart disease and stroke inthese regions Such surveys may prove to be cost-effective fordeveloping strategies directed to improve the cardiovascularhealth of other populations or ethnic groups [3]

Hindawi Publishing CorporationInternational Journal of Vascular MedicineVolume 2014 Article ID 643589 8 pageshttpdxdoiorg1011552014643589

2 International Journal of Vascular Medicine

Peripheral artery disease (PAD) is the third most com-mon vascular disease affecting more than 10 of individualsgreater than 70 years of age worldwide [4] This conditionis an important marker of systemic atherosclerosis and hasbeen independently associated with an increased risk ofischemic heart disease and stroke [5ndash7] Despite this thereis controversy regarding the role of routine screening andprompt detection of PAD [8] Prior conflicting results havebeen at least in part due to a lack of standardization ofdiagnostic methods used for PAD diagnosis in population-based surveys the fact that only either asymptomatic orsymptomatic individuals have been screened and differencesin the age raceethnicity and cardiovascular risk statusacross studied populations [9ndash11] Most cohort studies havebeen conducted in the developed world little longitudinalinformation is available from the few cross-sectional sur-veys assessing PAD prevalence in low- and middle-incomecountries [12ndash15] Thus we performed a population-basedcohort study to determine the prevalence clinical correlatesevolution and outcome of PAD in a rural Ecuadoriancommunity which may be used as a template for othercommunity-based studies attempting to reduce the burden ofnoncommunicable diseases in rural areas of low- andmiddle-income countries

2 Methods

21 Population Studied Atahualpa is located in rural coastalEcuador (2∘181015840S 80∘461015840W) and was selected for the studyas a village representative of the region More than 95 ofthe population belongs to the NativeMestizo ethnic group(Amerindians) All inhabitants speak Spanish and most menbelong to the blue-collar class (artisan carpenters) and mostwomen are homemakers with a rather homogeneous familyincome rate that fluctuates from US$ 5000 to $ 12000 peryear Atahualpa is relatively isolated and closed inhabitantsdo not migrate and many of them have never visited largeurban centers People mobilize within the village mainlyby walking or bicycle riding as very few own a motorvehicleThere are no fast-food restaurants most people eat athome The diet is rich in fish and carbohydrates but poor inpolyunsaturated fats and dairy products The village has onlyone health center of the Minister of Health staffed by generalphysicians nurses dentists and obstetricians

22 The Atahualpa Project The methodology and opera-tional definitions of the Atahualpa Project have been detailedelsewhere [16ndash18] In brief this multistep population-basedcohort study was designed to reduce the burden of car-diovascular and neurological diseases in the region byassessing and modifying risk factors through the implemen-tation of intervention strategies directed at informing peopleabout their health status and the best ways to improve itaccording to specific situations The main protocols of thisproject have been registered at httpwwwclinicaltrialsgov(NCT01627600 NCT01831908 and NCT01877616) and theinformed consent forms for all substudies of the Atahualpa

Project have been approved by the IRB of Hospital-ClınicaKennedy Guayaquil-Ecuador (FWA 00006867)

23 Study Design This substudy of the Atahualpa Projectfocused on the evaluation of prevalence incidence mortalityand clinical correlates of PAD It has been divided into threemain phases In Phase I trained field personnel (includingrural doctors) screened all Atahualpa residents aged ge40years to identify those with suspected PAD Residents weredefined as persons who had been living in the village forat least six months before the start of the survey (15 June2013) Persons declining to sign the informed consent wereexcluded At this time cardiovascular risk factors and historyof vascular events (stroke and ischemic heart disease) wereassessed During Phase II the ankle-brachial index (ABI) willbe used as the gold standard for diagnosis of PAD in orderto test the reliability of the screening instruments as well asto determine the actual prevalence of PAD and its clinicalcorrelates In Phase III all participants will be followed up ona yearly basis to estimate the relevance of PAD as a predictorof vascular outcomes and death

24 Phase I (Basal Survey)

241 Detection of Persons with Suspected PAD We used theEdinburgh claudication questionnaire (ECQ) for detectionof cases with suspected symptomatic PAD [19] This reliableinstrument consists of six questions directed not only todetect suspected PAD cases but also to grossly assess theirseverityTheECQwas independently translated from its orig-inal English version to Spanish by bilingual physicians fromour group (OHD RMM)Then the Spanish version of theECQ was culturally adaptedmdashincluding vernacular Spanishwords used by local peoplemdashwith the aid of Atahualparsquoscommunity leaders and rural doctors working in the villageand tested in a random sample of the population beforethe study (Table 1) In addition the pulse pressure wasrecorded due to its relevance in the evaluation of patients withsuspected PAD It was calculated by subtracting the diastolicpressure from the systolic pressure and a value ge65mmHgwas considered as suggestive of asymptomatic PAD [20]On the basis of results from the ECQ and pulse pressuredeterminations persons were classified into the followingthree groups (1) suspected symptomatic PAD (2) suspectedasymptomatic PAD and (3) nonsuspected PAD (Table 2)

242 Identification of Patients with Stroke and IschemicHeart Disease To recognize persons with a history of strokeand ischemic heart disease all Atahualpa residents werescreenedmdashduring the surveymdashby rural doctors with the useof validated field questionnaires The field instrument forthe detection of stroke cases was that used for assessmentof stroke prevalence in previous surveys performed by ourgroup in the same village [21 22] For the detection ofcases of ischemic heart disease we used a validated Spanishtranslation of the Rose questionnaire [23] and we also askedeach person if they have ever had a diagnosis of myocar-dial infarction Then certified neurologists and cardiologists

International Journal of Vascular Medicine 3

Table 1 Culturally adapted Spanish translation of the Edinburgh claudication questionnaire [with original English version] used in Atahualparesidents

(1) Usted siente dolor o una sensacion desagradable en una o ambas piernas cuando camina [Do you get a pain or discomfort in yourleg(s) when you walk]◻1

Si [yes]◻2

No [no]◻3

No puedo caminar [I am unable to walk]Si usted contesto que ldquosirdquo a la pregunta 1 por favor responda las siguientes preguntas En caso contrario no hay necesidad deseguir adelante [If you answered ldquoyesrdquo to question (1) please answer the following questions Otherwise you need not continue](2) Este dolor a veces comienza cuando usted se encuentra quieto de pie o sentado [Does this pain ever begin when you are standingstill or sitting]◻1

Si [yes]◻2

No [no](3) Este dolor se presenta cuando usted camina cuesta arriba o de prisa [Do you get it if you walk uphill or hurry]◻1

Si [yes]◻2

No [no](4) Este dolor se presenta cuando usted camina a paso normal a nivel de la tierra [Do you get it when you walk at an ordinary pace onthe level]◻1

Si [yes]◻2

No [no](5) Que sucede con este dolor si usted deja de caminar y se queda parado [What happens to it if you stand still]◻1

Suele persistir por mas de 10 minutos [Usually continues more than 10 minutes]◻2

Suele desaparecer en 10 minutos o menos [Usually disappears in 10 minutes or less](6) Senale con una ldquoxrdquo en este dibujo en que parte (de las piernas) siente usted el dolor o la sensacion desagradable [Where do you getthis pain or discomfort Mark the place(s) with ldquoxrdquo on the diagram below]

Table 2 Operational categories of PAD suspicion used in theAtahualpa Project

Suspected Symptomatic PAD(i) Positive Edinburgh claudication questionnaire andincreased pulse pressurelowast

(ii) Positive Edinburgh claudication questionnaire and normalpulse pressureSuspected Asymptomatic PADNegative Edinburgh claudication questionnaire andincreased pulse pressurelowast

Nonsuspected PADNegative Edinburgh claudication questionnaire and normalpulse pressurelowastDefined as ge65mmHg

moved to Atahualpa in order to evaluate all suspected casesand a random sample of negative individuals matched byage and sex for each positive case Stroke was diagnosedaccording to the World Health Organization definition inpatients who had experienced a rapidly developing eventcharacterized by clinical signs of focal or global disturbance ofcerebral function lasting ge24 hours with no apparent causeother than a vascular cause [24] Patients were considered tohave ischemic heart disease on the basis of clinical judgmentor ECG findings [25]

243 Assessment of Risk Factors During the survey demo-graphic characteristics cardiovascular risk factor and otherPAD correlates of all enrolled persons such as edentulismwere recorded Relevant demographic data included agesex educational level and alcohol intake (dichotomized inlt50 and ge50 g per day) Cardiovascular risk factors wereassessed in the field by determining the cardiovascular health(CVH) status of participants For this we used the sevenCVH metrics proposed by the American Heart Association[26]These included smoking status bodymass index (BMI)physical activity diet blood pressure (BP) fasting glucoseand total cholesterol levels Smoking status and physicalactivity were based on a self-report BMI (kgm2) wascalculated after obtaining the personrsquos height and weight dietwas assessed by direct interviews with the aid of a validatedfood frequency questionnaire [27] BP was measured witha Microlife BP A200 AFIBcopy digital sphygmomanometer(Microlife Corporation Taipei Taiwan) using a well-definedprotocol described elsewhere [28] and fasting glucose andtotal cholesterol levels weremeasured by obtaining a capillaryblood sample using Accu-chek Active and Accutrend Plusdevices (Roche Diagnostics Mannheim Germany) respec-tively Each CVHmetric was classified as ideal intermediateor poor and the CVH status of a person was classified as poorif at least one CVH metric was in the poor range (Table 3)

Edentulism which was used as a proxy of periodontitisand chronic inflammation was also investigated in the entirepopulation as some studies have shown an association


Table 3 Cardiovascular health metrics and status according to the American Heart Association

Cardiovascular Health Metrics(1) Smoking ideal (never or quit gt1 year) intermediate (quit le1 year) and poor (current smoker)(2) Body mass index ideal (lt25 kgm2) intermediate (25 to lt30 kgm2) and poor (ge30 kgm2)(3) Physical activity ideal (ge150 minutesweek moderate intensity or ge75 minutesweek vigorous intensity or equivalentcombination) intermediate (1ndash149 minutesweek moderate intensity or 1ndash74 minutesweek vigorous intensity or equivalentcombination) and poor (no moderate and vigorous activity)(4) Diet ideal (4-5 healthy components) intermediate (2-3 healthy components) and poor (0-1 healthy component) based on 5health dietary components (ge45 cups fruits and vegetablesday getwo 35-oz servings fishweek gethree 1-oz equivalent servingsfiber-rich whole grainsday lt1500mg sodiumday and le450 kcal sugar-sweetened beveragesweek)(5) Total cholesterol ideal (untreated and lt200mgdL) intermediate (treated to lt200mgdL or 200ndash239mgdL) and poor(ge240mgdL)(6) Blood pressure ideal (untreated and lt120lt80mmHg) intermediate (treated to lt120lt80mmHg or 120ndash13980ndash89mmHg) andpoor (ge14090mmHg)(7) Fasting glucose ideal (untreated and lt100mgdL) intermediate (treated to lt100mgdL or 100ndash125mgdL) and poor(ge126mgdL)Cardiovascular Health Status(1) Ideal CVH status all seven CVHmetrics in the ideal range(2) Intermediate CVH status CVH metrics in the ideal and intermediate range but no poor metrics(3) Poor CVH status at least one CVHmetric in the poor range

between this covariate and PAD [29 30] For this a ruraldentist performed an oral exam during the survey withemphasis on the number of remaining teeth Individuals wereclassified in three groups according to whether they had lt1010ndash19 or ge20 teeth

25 Phase II (Confirmation of Suspected Cases of PAD) Forthis phase of the study trained medical studentsmdashunderthe supervision of a certified cardiologistmdashwill perform theankle-brachial index (ABI) in all persons whowere suspectedto have symptomatic (ECQ positive) and asymptomatic PAD(pulse pressure ge 65mmHg with a negative ECQ) duringPhase I and in a random sample of a similar number ofnegative individuals that will be matched by age and sex withsuspected cases Those with amputations fractures or legulcers preventing ABI measurements will be excluded

A manual sphygmomanometer (Welch Allyn Tycoscopy7670-01) and a portable vascular Doppler (Nicolet n800copy)with an 8MHz probe will be used for all BP determinationswhich will be carried out at the community center of theAtahualpa Project under comfortable temperature levels withthe patient resting in the supine position for at least 10minutes before the test According to the recommendationsof the American Heart Association regarding cuff size andpositions BP will be measured in both arms and legs withthe aid of both devices (the sphygmomanometer and theDoppler) following a counterclockwise sequence right armright posterior tibial right dorsalis pedis left posterior tibialleft dorsalis pedis and left arm [31] ABIs will be reportedseparately for each leg and calculated by dividing the higherof the posterior tibial or dorsalis pedis BP by the higher rightor left arm systolic BP An ABI le 09 will be considered as adiagnostic of lower-limb PAD Persons with an ABI ge 14 willnot be diagnosed as PAD and will be excluded from the main

analysis but will be considered at an increased risk forvascular events and death as these high indices are suggestiveof a rigid and incompressible wall in an artery affected byatherosclerosis [32] Those persons will be followed up andevaluated in a separate analysis

26 Phase III (Cohort Study) All participants in the PhaseI survey will be followed up yearly for at least five yearsto evaluate PAD progression (defined as a decrease ge015in the ABI) the rate of transformation of asymptomatic tosymptomatic PAD and the quality of life of symptomaticpatients The latter will be evaluated by the use of thewalking impairment questionnaire [33] and the vascularquality of life questionnaire-6 (VascQoL-6) which is anabridged yet equally reliable version of the Vasc-QoL-25[34] In addition we will assess the prospective incidenceof stroke and ischemic heart disease as well as the mortalityrate among persons with and without PAD For this we willreview death certificates and medical records from the singleHealth Center of Atahualpa and conduct yearly door-to-doorsurveys using the same approach as described for Phase IBy the end of the study it will be possible to estimate therelevance of PAD as a predictor of vascular outcomes anddeath

27 Statistical Analyses All analyses are carried out by usingSTATA version 13 (College Station TX USA) Descriptivestatistics are presented as means plusmn standard deviations forcontinuous variables and as percentages with 95 CI forcategorical variables A 119875 value of less than 005 is consideredsignificant For Phase I results differences on traditionaland nontraditional cardiovascular risk factors across per-sons with and without suspected PAD (symptomatic andasymptomatic) were presented During Phase II reliability


Table 4 Characteristics of Atahualpa residents aged ge40 years according to pulse pressure levels

Total series119899 = 665

Pulse pressure (mmHg)119875 value

ge65 (119899 = 205) lt65 (119899 = 460)Age (mean plusmn SD) 595 plusmn 126 684 plusmn 117 556 plusmn 109 00001Women 119899 () 384 (58) 134 (65) 250 (54) 0008Up to primary school 119899 () 426 (64) 157 (77) 269 (58) 00001Alcohol intake ge50 gday 119899 () 114 (17) 23 (11) 91 (20) 0007Current smokers 119899 () 12 (2) 3 (15) 9 (2) 0659Body mass index kgm2 (mean plusmn SD) 27 plusmn 5 27 plusmn 5 27 plusmn 5 sdot sdot sdot

Fasting glucose mgdL (mean plusmn SD) 140 plusmn 86 142 plusmn 92 135 plusmn 83 0332Total cholesterol mgdL (mean plusmn SD) 199 plusmn 33 198 plusmn 32 199 plusmn 33 0716Poor CVH status 119899 () 464 (70) 187 (91) 277 (60) 00001Severe edentulism 119899 () 192 (29) 85 (41) 107 (23) 00001Stroke or ischemic heart disease 119899 () 41 (6) 25 (12) 16 (3) 00001

of the ECQ and pulse pressure calculation for detection ofpatients with symptomatic and asymptomatic PAD will beassessed by calculating their sensitivity and specificity aswell as their positive and negative predictive values (usingnumbers of true and false positive suspected cases and thoseof true and false negative controls) Using generalized linearanalysis we will evaluate the association between confirmedPAD and all the other variables after adjusting for age sexeducation and alcohol intake Univariate and multivariateanalyses will be performed with PAD as the dependentvariable the output of the model will be the odds ratio ofa given relationship To compare the incidence of vascularevents and death between thosewith andwithout PAD (PhaseIII) we will use time-to-event univariate methods such asKaplan-Meir curves and the log rank test Cox proportionalregression models (hazard ratios and 95 CI) and Poissonregressionmodels (adjusted incidence rates and 95CI) willbe used to evaluate progression of PAD and the associationbetween PAD and the incidence of vascular events and deathafter adjusting for demographics cardiovascular risk factorsand other confounders

3 Results (Phase I)

The door-to-door census identified 688 Atahualpa residentsaged ge40 years 23 (33) of whom declined to participateMean age of the 665 enrolled persons was 595 plusmn 126 years384 (58) were women and 426 (64) had up to primaryschool education Alcohol consumption ge 50 g per day wasadmitted by 114 (17) persons

Mean values for the quantitative measures obtained wereas follows height 149 plusmn 9 cm weight 60 plusmn 12 kg BMI 27 plusmn5 kgm2 systolic BP 138 plusmn 25mmHg diastolic BP 77 plusmn12mmHg pulse pressure 61plusmn 21mmHg fasting glucose 140 plusmn86mgdL and total cholesterol 199 plusmn 33mgdL In the studycohort 75 persons (11) were on antihypertensive 68 (10)on hypoglycemic and 16 (24) on hypocholesterolemicdrugs (15 were taking combinations of these drugs)

Overall 10 persons (15) had all seven CVH metricsin the ideal range (ideal CVH status) 191 (29) had acombination of ideal and intermediate but not poor CVHmetrics (intermediate CVH status) and the remaining 464(70) had one or more CVHmetrics in the poor range (poorCVH status) Most of these individuals have only one or twoCVH metrics in the poor range (mean plusmn SD11 plusmn 1) Theindividual CVHmetric that was most often in the poor rangewas BP (36) followed by fasting glucose levels (30) andBMI (25) On the oral exam 192 (29) had lt10 remainingteeth (severe edentulism) A total of 41 persons (6) had ahistory of a vascular event including stroke in 27 cases andischemic heart disease in 14 (there were no individuals withhistory of both stroke and ischemic heart disease)

A total of 205 persons (31) had a pulse pressure ge65mmHg Persons with a high pulse pressure were oldermore often women and less educated than those with a pulsepressure lt 65mmHg In contrast alcohol intake ge50 g perday was most common among persons with normal pulsepressure valuesTherewere no significant differences inmeanvalues of BMI fasting glucose and total cholesterol levelsacross groups of pulse pressure values but a poor CVH statusand severe edentulism were more frequent in those withincreased pulse pressure Also a history of stroke or ischemicheart disease was more common among persons with anincreased pulse pressure (Table 4)

A total of 44 persons (7) were positive on the ECQThirty-five of them also had increased values of pulsepressure Only nine of these 44 persons had grade II(severe) suspected intermittent claudication defined as apositive response to question number 4 (Table 1) Per-sons with a positive ECQ were older more frequentlywomen than those with a negative ECQ There wereno differences in educational levels alcohol intake BMItotal cholesterol blood levels severe edentulism or his-tory of vascular events across both groups However meanfasting glucose levels were higher and the CVH statuswas more often poor among persons with a positive ECQ(Table 5)


Table 5 Characteristics of Atahualpa residents aged ge40 years according to the Edinburgh claudication questionnaire


Edinburgh claudication questionnaire119875 value

positive (119899 = 44) negative (119899 = 621)Age (mean plusmn SD) 595 plusmn 126 663 plusmn 119 59 plusmn 125 00001Women 119899 () 384 (58) 32 (73) 352 (57) 0054Up to primary school 119899 () 426 (64) 30 (68) 396 (64) 067Alcohol intake ge50 gday 119899 () 114 (17) 5 (11) 109 (18) 0396Current smokers 119899 () 12 (2) 1 (23) 11 (18) 0809Body mass index kgm2 (mean plusmn SD) 27 plusmn 5 27 plusmn 5 27 plusmn 5 sdot sdot sdot


Table 6 Characteristics of Atahualpa residents aged ge40 years according to the categories of peripheral artery disease (PAD) suspicion

Total series(119899 = 665)

Suspectedsymptomatic PAD

(119899 = 44)lowast

Suspectedasymptomatic PAD

(119899 = 170)sectNonsuspected PAD

(119899 = 451)Dagger 119875 value

Age (mean plusmn SD) 595 plusmn 126 663 plusmn 119 681 plusmn 12 556 plusmn 109 00001Women 119899 () 384 (58) 32 (73) 108 (64) 244 (54) 0015Up to primary school 119899 () 426 (64) 30 (68) 134 (79) 262 (58) 00001Alcohol intake ge50 gday 119899 () 114 (17) 5 (11) 19 (11) 90 (20) 002Current smokers 119899 () 12 (2) 1 (23) 2 (12) 9 (2) 0767Body mass index kgm2 (mean plusmn SD) 27 plusmn 5 27 plusmn 5 27 plusmn 5 27 plusmn 5 sdot sdot sdot

Systolic BP mmHg (mean plusmn SD) 138 plusmn 25 158 plusmn 26 164 plusmn 27 126 plusmn 13 00001Diastolic BP mmHg (mean plusmn SD) 77 plusmn 12 78 plusmn 13 79 plusmn 15 77 plusmn 10 0159BP ge14090mmHg 119899 () 242 (36) 32 (73) 138 (81) 72 (16) 00001Fasting glucose mgdL (mean plusmn SD) 140 plusmn 86 173 plusmn 105 148 plusmn 91 133 plusmn 81 0004Fasting glucose ge126mgdL 119899 () 197 (30) 21 (48) 59 (35) 117 (26) 0003Total cholesterol mgdL (mean plusmn SD) 199 plusmn 33 200 plusmn 30 198 plusmn 32 199 plusmn 33 0914Poor CVH status 119899 () 464 (70) 40 (91) 155 (91) 269 (60) 00001Severe edentulism 119899 () 192 (29) 16 (36) 72 (42) 104 (23) 00001Stroke or ischemic heart disease 119899 () 41 (6) 4 (9) 21 (12) 16 (4) 00002lowastPositive Edinburgh claudication questionnaire irrespective of pulse pressure levels sectincreased pulse pressure levels and a negative Edinburgh claudicationquestionnaire Daggernormal pulse pressure levels and a negative Edinburgh claudication questionnaire

Table 6 summarizes the characteristics of enrolled per-sons according to whether they were suspected or nonsus-pected cases of PAD There were no differences in demo-graphics or in cardiovascular risk factors across categoriesof suspected PAD (symptomatic or asymptomatic) In con-trast with the exception of BMI diastolic BP and totalcholesterol blood levels persons with nonsuspected PADdiffered significantly from those with either symptomatic orasymptomatic PAD

4 Discussion

It has been estimated that more than 200 million individualsworldwide are afflicted with PAD [4] The disease has been

described as a pandemic sparing no nation [35] The currentstudy confirms a high prevalence of suspected PAD in theadult population of a rural village located in coastal EcuadorForty-four persons (7) had suspected symptomatic PADand 170 (26) had suspected asymptomatic PADWhile thesenumbers have to be confirmed during Phase II of this studythey are consistent with the high stroke prevalence (31permil) andwith the high number of fatal ischemic heart disease casesthat we recently found in Atahualpa [22 36] Of note thesefindings support previous estimates that the incidence of car-diovascular diseases is increasing in underserved populationsof Latin America [2] Consistent with previous studies [37]individuals with suspected PADwere more often women andhad more modifiable cardiovascular risk factors than thosewithout suspected PAD


Published data on PAD from Latin America are scarce Arecent comprehensive review identified 12 population-basedstudies conducted in low- and middle-income countries ofwhich only two came from urban centers in Latin Americaand none were from rural areas [4] In the Brazilian study(1008 subjects aged ge30 years) the prevalence of PAD was20 [38] while in the Mexican study (400 subjects aged ge 40years) it was 10 [39] In both studies PAD was associatedwith more cardiovascular risk factors however both studieswere cross-sectional and no data on the incidence of vascularevents was available Our cohort study will fill a gap in theliterature by proving unbiased data on PAD prevalence clin-ical correlates progression and related vascular outcomes incommunity-dwelling adults living in a rural South Americanvillage The methodology and operational definitions usedin this Atahualpa Project-ancillary study could be appliedin other population-based studies conducted in rural areasof other middle- and low-income countries to help healthauthorities to implement strategies directed to reduce theburden of cardiovascular diseases in the region

The rigorous methodology and comprehensive inclusionof residents of an isolated community in this study willprovide a unique opportunity to estimate the prevalence ofPAD and its risk factors However we will use the ABI toconfirm the diagnosis and not physiologic methods of PADdetection Therefore it is possible that the true prevalenceof PAD might be underestimated this is a limitation ofthe current study Another potential limitation could be therelatively small sample size whichmay create some problemsin the multivariate adjusted model that will be used duringPhase II and Phase III of this study

In summary PAD appears to be highly prevalent in thisrural population in Ecuador confirming the global nature ofthe PAD pandemic and its predilection for persons of bothsexes with modifiable cardiovascular risk factors in low- andmiddle-income countries

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

Acknowledgment

This study was partially supported by an unrestrictedgrant from Universidad Espıritu Santo-Ecuador Guayaquil-Ecuador

References

[1] A R Omran ldquoThe epidemiologic transition A theory of theepidemiology of population changerdquo The Milbank MemorialFund Quarterly vol 49 no 4 pp 509ndash538 1971

[2] P M Lavados A J M Hennis J G Fernandes et al ldquoStrokeepidemiology prevention and management strategies at aregional level Latin America and the Caribbeanrdquo The LancetNeurology vol 6 no 4 pp 362ndash372 2007

[3] O H Del Brutto C Dong T Rundek M S V Elkind VJ Del Brutto and R L Sacco ldquoCardiovascular health status

among Caribbean Hispanics living in northern Manhattanand Ecuadorian nativesmestizos in rural coastal Ecuador acomparative studyrdquo Journal of Community Health vol 38 no4 pp 634ndash641 2013

[4] FG R FowkesD Rudan I Rudan et al ldquoComparison of globalestimates of prevalence and risk factors for peripheral arterydisease in 2000 and 2010 a systematic review and analysisrdquoTheLancet vol 382 no 9901 pp 1329ndash1440 2013

[5] J MMurabito J C Evans K Nieto M G Larson D Levy andPW FWilson ldquoPrevalence and clinical correlates of peripheralarterial disease in the Framingham Offspring Studyrdquo AmericanHeart Journal vol 143 no 6 pp 961ndash965 2002

[6] M T Alzamora R Fores G Pera et al ldquoAnkle-brachial indexand the incidence of cardiovascular events in theMediterraneanlow cardiovascular risk population ARTPER cohortrdquo BMCCardiovascular Disorders vol 13 article 119 2013

[7] J Gronewold D M Hermann N Lehmann et al ldquoAnkle-brachial index predicts stroke in the general population inaddition to classical risk factorsrdquo Atherosclerosis vol 233 no2 pp 545ndash550 2014

[8] MMMcDermott ldquoAnkle-brachial index screening to improvehealth outcomes where is the evidencerdquo Annals of InternalMedicine vol 159 no 5 pp 362ndash363 2013

[9] M J Salameh T Rundek B Boden-Albala et al ldquoSelf-reportedperipheral arterial disease predicts future vascular events in acommunity-based cohortrdquo Journal of General InternalMedicinevol 23 no 9 pp 1423ndash1428 2008

[10] J S Lin C M Olson E S Johnson and E P Whitlock ldquoTheankle-brachial index for peripheral artery disease screening andcardiovascular disease prediction among asymptomatic adultsa systematic evidence review for the US preventive servicestask forcerdquo Annals of Internal Medicine vol 159 no 5 pp 333ndash341 2013

[11] V A Moyer ldquoScreening for peripheral artery disease andcardiovascular disease risk assessment with the ankle-brachialindex in adults US preventive services task force recommen-dation statementrdquo Annals of Internal Medicine vol 159 no 5pp 342ndash348 2013

[12] C U Odenigbo C Ajaero and O C Oquejiofor ldquoPrevalenceof Peripheral artery disease in adult hypertensive patients inrdquoSahel Medical Journal vol 16 no 1 pp 15ndash18 2013

[13] M Guerchet V Aboyans P Mbelesso et al ldquoEpidemiologyof peripheral artery disease in elder general population oftwo cities of central Africa bangui and Brazzavillerdquo EuropeanJournal of Vascular and Endovascular Surgery vol 44 no 2 pp164ndash169 2012

[14] J Woo and J Leung ldquoDoes measurement of ankle-brachialindex contribute to prediction of adverse Health outcomes inolder Chinese peoplerdquo Internal Medicine Journal vol 43 no 9pp 1017ndash1023 2013

[15] M Nakdisse L R Ramos F Moreira et al ldquoA risk score forpredicting peripheral artery disease in individuals 75 years orolderrdquo Arquivos Brasileiros de Cardiologia vol 88 no 3 pp630ndash636 2007

[16] O H del Brutto E Pe E Ochoa et al ldquoDoor-to-door surveyof cardiovascular Health stroke and ischemic Heart diseasein rural coastal Ecuadormdashthe Atahualpa Project methodologyand operational definitionsrdquo International Journal of Stroke vol9 no 3 pp 367ndash371 2014

[17] O H Del Brutto ldquoImplications and expectancies of theldquoAtahualpa Projectrdquo a population-based survey designed to


reduce the burden of stroke and cardiovascular diseases in ruralEcuadorrdquo Journal of Neurosciences in Rural Practice vol 4 no3 pp 363ndash365 2013

[18] O H Del Brutto R M Mera R Farfan and P R CastilloldquoCerebrovascular correlates of sleep disordersmdashrational andprotocol of a door-to-door survey in rural coastal EcuadorrdquoJournal of Stroke amp Cerebrovascular Diseases vol 23 no 5 pp1030ndash1039 2014

[19] G C Leng and F G R Fowkes ldquoThe Edinburgh claudicationquestionnaire an improved version of the WHORose Ques-tionnaire for use in epidemiological surveysrdquo Journal of ClinicalEpidemiology vol 45 no 10 pp 1101ndash1109 1992

[20] P Korhonen H Kautiainen and P Aarnio ldquoPulse pressureand subclinical peripheral artery diseaserdquo Journal of HumanHypertension vol 28 no 4 pp 242ndash245 2014

[21] O H Del Brutto L Idrovo A Mosquera et al ldquoStroke in ruralEcuador a three-phase door-to-door surveyrdquo Neurology vol63 no 10 pp 1974ndash1975 2004

[22] O H Del Brutto M Santamarıa M Zambrano et al ldquoStrokein rural coastal Ecuador a community-based surveyrdquo Interna-tional Journal of Stroke vol 9 no 3 pp 365ndash366 2014

[23] J Cosın E Asın J Marrugat et al ldquoPrevalence of anginapectoris in Spainrdquo European Journal of Epidemiology vol 15 no4 pp 323ndash330 1999

[24] S Hatano ldquoExperience from a multicentre stroke register apreliminary reportrdquo Bulletin of the World Health Organizationvol 54 no 5 pp 541ndash553 1976

[25] L Lopez-Bescos J Cosın R Elosua et al ldquoPrevalencia deangina y factores de riesgo cardiovascular en las diferentescomunidades autonomas de Espana estudio PAMESrdquo RevistaEspanola de Cardiologıa vol 52 no 12 pp 1045ndash1056 1999

[26] D M Lloyd-Jones Y Hong D Labarthe et al ldquoDefining andsetting national goals for cardiovascular health promotion anddisease reduction the American heart associationrsquos strategicimpact goal through 2020 and beyondrdquo Circulation vol 121 no4 pp 586ndash613 2010

[27] G Block A M Hartman and C M Dresser ldquoA data-basedapproach to diet questionnaire design and testingrdquoThe Ameri-can Journal of Epidemiology vol 124 no 3 pp 453ndash469 1986

[28] P E Pergola C L White J W Graves et al ldquoReliabilityand validity of blood pressure measurement in the SecondaryPrevention of Small Subcortical Strokes studyrdquo Blood PressureMonitoring vol 12 no 1 pp 1ndash8 2007

[29] H Hung W Willett A Merchant B A Rosner A AscherioandK J Joshipura ldquoOral health and peripheral arterial diseaserdquoCirculation vol 107 no 8 pp 1152ndash1157 2003

[30] U Soto-Barreras J O Olvera-Rubio J P Loyola-Rodriguezet al ldquoPeripheral arterial disease associated with caries andperiodontal diseaserdquo Journal of Periodontology vol 84 no 4pp 486ndash494 2013

[31] V Aboyans M H Criqui P Abraham et al ldquoMeasurement andinterpretation of the ankle-brachial index a scientific statementfrom the AmericanHeart AssociationrdquoCirculation vol 126 no24 pp 2890ndash2909 2012

[32] F G R Fowkes G D Murray I Butcher et al ldquoAnkle brachialindex combined with Framingham risk score to predict cardio-vascular events and mortality a meta-analysisrdquo The Journal ofthe American Medical Association vol 300 no 2 pp 197ndash2082008

[33] A Jain K Liu L Ferrucci et al ldquoDecliningwalking impairmentquestionnaire scores are associated with subsequent increased

mortality in peripheral artery diseaserdquo Journal of the AmericanCollege of Cardiology vol 61 no 17 pp 1820ndash1829 2013

[34] J Nordansting C Wann-Hansson J Karlsson M LundstromM Pettersson and M B Morgan ldquoVascular quality of lifequestionnaire-6 facilitates health-related quality of life assess-ment in peripheral arterial diseaserdquo Journal of Vascular Surgeryvol 59 no 3 pp 700ndash707 2014

[35] A T Hirsch and S Duval ldquoThe global pandemic of peripheralartery diseaserdquoTheLancet vol 382 no 9901 pp 1312ndash1314 2013

[36] E Penaherrera F Pow-Chon-Long and O H Del Brutto ldquoLowprevalence of ischemic heart disease in rural coastal Ecuadoran issue of high mortality raterdquo Rural Remote Health vol 14 p2623 2014

[37] E Selvin and T P Erlinger ldquoPrevalence of and risk factors forperipheral arterial disease in the United States results fromthe National Health and Nutrition Examination Survey 1999-2000rdquo Circulation vol 110 no 6 pp 738ndash743 2004

[38] L Garofolo N Barros Jr F Miranda Jr V DrsquoAlmeida LC Cardien and S R Ferreira ldquoAssociation of increasedlevels of homocysteine and peripheral arterial disease in aJapanese-Brazilian populationrdquo European Journal of Vascularand Endovascular Surgery vol 34 no 1 pp 23ndash28 2007

[39] L V Buitron-Granados C Martınez-Lopez and J Escobedo-de la Pena ldquoPrevalence of Peripheral arterial disease and relatedrisk factors in an urbanMexican populationrdquoAngiology vol 55no 1 pp 43ndash51 2004

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


MEDIATORSINFLAMMATION

of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

Prevalence correlates and prognosis of peripheral artery disease in rural ecuador-rationale protocol and phase I results of a population-based survey an atahualpa project-ancillary study

Recommended Citation

Authors

tmp1416286044pdfXYHgK

Authors Authors Oscar H Del Brutto Mark J Sedler Robertino M Mera Pablo R Castillo Elizabeth H Cusick Jadry A Gruen Kelsie J Phelan Victor J Del Brutto Mauricio Zambrano and David L Brown

This open access publication is available at Digital CommonsBecker httpsdigitalcommonswustleduopen_access_pubs3486











1 Introduction






2 Methods











Si [yes]◻2

No [no]◻3


Si [yes]◻2


Si [yes]◻2


Si [yes]◻2



























3 Results (Phase I)















(119899 = 44)lowast



(119899 = 451)Dagger 119875 value




4 Discussion









Acknowledgment


References

















































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















Authors












1 Introduction






2 Methods











Si [yes]◻2

No [no]◻3


Si [yes]◻2


Si [yes]◻2


Si [yes]◻2



























3 Results (Phase I)















(119899 = 44)lowast



(119899 = 451)Dagger 119875 value




4 Discussion









Acknowledgment


References

















































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















Authors




2 Methods











Si [yes]◻2

No [no]◻3


Si [yes]◻2


Si [yes]◻2


Si [yes]◻2



























3 Results (Phase I)















(119899 = 44)lowast



(119899 = 451)Dagger 119875 value




4 Discussion









Acknowledgment


References

















































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















Authors





Si [yes]◻2

No [no]◻3


Si [yes]◻2


Si [yes]◻2


Si [yes]◻2



























3 Results (Phase I)















(119899 = 44)lowast



(119899 = 451)Dagger 119875 value




4 Discussion









Acknowledgment


References

















































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















Authors


















3 Results (Phase I)















(119899 = 44)lowast



(119899 = 451)Dagger 119875 value




4 Discussion









Acknowledgment


References

















































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















Authors











(119899 = 44)lowast



(119899 = 451)Dagger 119875 value




4 Discussion









Acknowledgment


References

















































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















Authors








Acknowledgment


References

















































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















Authors
































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















Authors


prevalence, correlates, and prognosis of peripheral artery

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