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Correspondence

Coronary Bypass Grafting in Patients With Concomitant Peripheral Arterial Disease: Do Not Underestimate Asymptomatic Disease

Department of Thoracic & Cardiovascular Surgery and Vascular Medicine, Dupuytren University Hospital, 2 Ave Martin Luther King, Limoges, 87042 France

(Email: victor.aboyans{at}unilim.fr).

To the Editor:

Chu and colleagues [1] reported poor long-term prognosis after coronary artery bypass grafting (CABG) in patients who also have peripheral vascular disease (PVD). The latter condition, determined by a constellation of findings ranging from a history of peripheral revascularization to a diminished peripheral pulse, was found in 32% of their patients undergoing CABG. Overall, the authors reported no prognostic difference in 30-day events but did report higher total mortality during follow-up in patients with PVD, even after adjustment for several confounding factors. The authors stressed that they were unable to provide further data on the cause (cardiovascular or not) of death. They also acknowledged that they used criteria, such as diminished or absent peripheral pulse, that actually lack objectiveness. Although normal pulses in the presence of PVD would be quite improbable (good negative-predictive value), the positive-predictive value of abnormal pulses is poor [2]. Therefore, it would be useful to provide additional data on the prognosis of patients with PVD by excluding those whose PVD diagnosis was only based on an abnormal pulse.

In contrast to pulse palpation, measurement of the ankle-brachial index (ABI) is an easy and objective method for the diagnosis of asymptomatic PVD with high sensitivity and specificity [3, 4]. Almost all current epidemiologic and clinical studies on PVD do not use pulse palpation and use ABI instead [5]. In an earlier study with a similar number of CABG patients [6], we found that patients with symptomatic PVD and those with asymptomatic PVD (clinically silent but abnormal ABI) had a poorer long-term prognosis, than those without PVD. Notably, two-thirds of our patients with PVD were asymptomatic and were only detected by the ABI.

Furthermore, we found an even stronger association between PVD and cardiovascular death [6]. This suggests that the poor prognosis of PVD patients undergoing CABG is related to more cardiovascular events. Conversely to Chu and colleagues' findings, we reported higher rates of mortality beginning in the postoperative period. Beyond some differences in population characteristics and confounding factor adjustments, we think that these contradictory results are related to a more objective definition of PVD in our study. Thus, we advocate the use of the ABI for defining PVD during risk stratification of candidates for CABG operations.

	References

Top References

 

1. Chu D, Bakaeen FG, Wang XL, et al. The impact of peripheral vascular disease on long-term survival after coronary artery bypass graft surgery Ann Thorac Surg 2008;86:1175-1180.[Abstract/Free Full Text]
2. Criqui MH, Fronek A, Klauber MR, Barrett-Connor E, Gabriel S. The sensitivity, specificity, and predictive value of traditional clinical evaluation of peripheral arterial disease; results from non invasive testing in a defined population Circulation 1985;71:516-522.[Abstract/Free Full Text]
3. Carter SA. Clinical measurement of systolic pressures in limbs with arterial occlusive disease J Am Med Assoc 1969;207:1869-1874.[Abstract/Free Full Text]
4. Stoffers HE, Kester AD, Kaiser V, Rinkens PE, Kitslaar PJ, Knottnerus JA. The diagnostic value of the measurement of the ankle-brachial systolic pressure index in primary health care J Clin Epidemiol 1996;49:1401-1405.[Medline]
5. Aboyans V, Criqui MH. The epidemiology of peripheral arterial diseaseIn: Dieter RS, Dieter Jr RA, Dieter 3rd RA, editors. Peripheral arterial disease. New York: McGraw Hill; 2009[in press].
6. Aboyans V, Lacroix P, Postil A, et al. Subclinical peripheral arterial disease and incompressible ankle arteries are both long-term prognostic factors in patients undergoing coronary artery bypass grafting J Am Coll Cardiol 2005;46:815-820.[Abstract/Free Full Text]

This article has been cited by other articles:

				D. Chu and F. G. Bakaeen Reply Ann. Thorac. Surg., June 1, 2009; 87(6): 2004 - 2004. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Victor Aboyans Marc Laskar Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Aboyans, V. Articles by Laskar, M. Search for Related Content PubMed PubMed Citation Articles by Aboyans, V. Articles by Laskar, M. Related Collections Coronary disease Related Article