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Risk Factors for Prevalence and Progression of Asymptomatic Carotid Disease in Patients with Peripheral Arterial Disease
Francesco A. Aiello, MD1, Andrew Meltzer, MD2, Nii-Kabu Kabutey, MD3, Melinda Espiritu4, MD, Brian Cohen4, MD, Jason Burmeister4, MD, Rahima Hoque4, MD, James McKinsey, MD4, Gautam Shrikhande, MD4.
1University of Massachusetts Medical School, Worcester, MA, USA, 2New York Presbyterian Hospital: Weill Cornell Medical Center, New York, NY, USA, 3New York Presbyterian Hospital: Columbia and Cornell Medical Campus, New York, NY, USA, 4New York Presbyterian Hospital: Columbia University Medical Center, New York, NY, USA.
OBJECTIVES:
Determine contributing factors affecting severity and progression of carotid artery stenosis in neurologically asymptomatic patients with peripheral arterial disease (PAD).
METHODS:
A retrospective analysis of consecutive patients undergoing peripheral vascular studies and carotid artery duplex ultrasound (DUS) was performed. Incidence and degree of stenosis and disease progression was assessed. Patient demographics, comorbidities, and aspirin, clopidogrel or statin use were recorded. Patients with previous carotid intervention or neurologic events within three years were excluded. Bivariate analysis with Pearson chi-square test identified risk factors for presence of asymptomatic carotid disease (>50%) by initial surveillance DUS and for progression of disease over serial DUS. Multivariate logistic regression models for these distinct endpoints were developed.
RESULTS:
Between 2004 and 2010, 1074 carotid arteries in 542 patients underwent DUS with a mean follow-up of 32(12-84) months for those with repeat DUS. Average age was 72±10 years and 54.2% were male. Initial DUS revealed ≥50% stenosis in 20.1% of carotid arteries and 1.4% were occluded. Multivariate analysis revealed active smoking (OR 1.44; p=0.002), ABI 0.8-0.5 (OR 1.82; p=0.001) and ABI≤0.5 (OR 2.23; p=0.001) as playing a significant role at screening duplex. Smoking history showed a trend toward increased disease burden on screening DUS(p=0.056) while female gender trended toward a protective role but also failed to reach statistical significance (OR=0.74; p=0.060). Aspirin, clopidogrel and statin use at initial DUS was not statistically significant in predicting CAS. Surveillance DUS revealed progression in 11.4% of all carotid arteries. Overall, 23(2.1%) carotid arteries progressed to clinically relevant disease including transient ischemic attacks(5), stroke(5), ≥80% stenosis(10), or occlusion(3). Multivariate analysis revealed CAD, smoking history and diabetes mellitus as independent risk factors for disease progression.
CONCLUSIONS:
Multivariate Regression for ≥50% Carotid Artery Stenosis on Screening Duplex| Risk Factors | Odds Ratio | 95% Confidence Interval | p-value | | Female Gender | 0.74 | 0.5-1.02 | 0.060 | | Smoking History | 1.98 | 0.99-2.1 | 0.056 | | Current Smoker | 1.44 | 1.3-3.1 | 0.002 | | ABI 0.5-0.8 | 1.82 | 1.3-2.5 | 0.001 | | ABI<0.5 | 2.23 | 1.4-3.5 | 0.001 |
Multivariate Regression for Carotid Artery Disease Progression| Risk Factor | Odd Ratio | 95% Confidence Interval | p-value | | Diabetes Mellitus | 3.272 | 1.28-8.35 | 0.013 | | Coronary Artery Disease | 2.341 | 0.99-5.493 | 0.051 | | Smoking History | 2.421 | 1-5.86 | 0.050 |
Patients diagnosed with PAD and ABI≤0.8, smoking history or currently smoking should undergo screening carotid artery DUS. Those patients with CAD, diabetes mellitus or history of smoking warrant surveillance with repeat carotid artery DUS due to a significantly higher incidence of disease progression.
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