http://cpr.sagepub.

com/
European Journal of Preventive Cardiology
http://cpr.sagepub.com/content/19/5/901
The online version of this article can be found at:

DOI: 10.1177/1741826711420346
2012 19: 901 originally published online 11 August 2011 European Journal of Preventive Cardiology
Pivi E Korhonen, Tellervo Seppl, Hannu Kautiainen, Salme Jrvenp, Pertti T Aarnio and Sirkka-Liisa Kivel
brachial index and health-related quality of life Ankle

Published by:
http://www.sagepublications.com
On behalf of:

European Society of Cardiology

European Association for Cardiovascular Prevention and Rehabilitation
can be found at: European Journal of Preventive Cardiology Additional services and information for

http://cpr.sagepub.com/cgi/alerts Email Alerts:

http://cpr.sagepub.com/subscriptions Subscriptions:
http://www.sagepub.com/journalsReprints.nav Reprints:

http://www.sagepub.com/journalsPermissions.nav Permissions:

What is This?

- Aug 11, 2011 OnlineFirst Version of Record

- Sep 7, 2012 Version of Record >>

at Universidad Nacional Aut Mexic on September 6, 2014 cpr.sagepub.com Downloaded from at Universidad Nacional Aut Mexic on September 6, 2014 cpr.sagepub.com Downloaded from
EUROPEAN
SOCIETY OF
CARDIOLOGY

Original scientific paper

Anklebrachial index and health-related
quality of life
Paivi E Korhonen
1
, Tellervo Seppala
2
, Hannu Kautiainen
3
,
Salme Jarvenpaa
4
, Pertti T Aarnio
5
and Sirkka-Liisa Kivela
1
Abstract
Background: Data from population studies using anklebrachial index (ABI) measurement to screen patients for
peripheral arterial disease (PAD) demonstrate that most patients with PAD have no symptoms or atypical symptoms
besides classical intermittent claudication. We aimed at comparing health-related quality of life and ABI in a cohort of
cardiovascular risk persons in a general population.
Methods: SF-36 questionnaire was completed and ABI measured from 915 individuals aged 4570 years with hyper-
tension, metabolic syndrome, pre-diabetes, newly detected diabetes, body mass index 30 kg/m
2
, or a 10-year risk of
cardiovascular disease death of 5% or more according to the Systematic Coronary Risk Evaluation (SCORE) system.
None of the subjects had symptoms of intermittent claudication.
Results: The prevalence of PAD (defined as ABI 0.90) and borderline PAD (defined as ABI 0.911.00) were 5% (95%
CI 47%) and 20% (95% CI 1823%), respectively. Patients with PAD had significantly lower quality of life dimension
scores for physical functioning, role-physical, general health, and vitality than subjects with normal ABI. Among those with
borderline PAD, quality of life was reduced on the general health perception compared to subjects with normal ABI.
Conclusion: Health-related quality of life of individuals with asymptomatic or atypical PAD or borderline PAD is worse
than that of individuals with normal ABI. The level of ABI is independently related to physical functioning.
Keywords
Anklebrachial index, health-related quality of life, peripheral arterial disease, physical functioning
Received 8 March 2011; accepted 26 July 2011
Introduction
Data from population studies using anklebrachial
index (ABI) measurement to screen patients for periph-
eral arterial disease (PAD) demonstrate that for every
patient with intermittent claudication there are from
three to four patients having PAD without symptoms
or with atypical leg symptoms.
13
Functional disability
has been detected also in PAD patients without classic
intermittent claudication symptoms.
4
There is also an
inverse linear relationship between subclinical PAD
and cardiovascular disease outcomes even at ABI
values between 0.91 and 1.00.
5
However, little is
known about relationships between ABI and function-
ing in daily activities in a population level.
We had the opportunity to compare health-related
quality of life and ABI in a cohort of cardiovascular
risk persons in a general population. In order to mini-
mize the deleterious eects of long-lasting conditions
aecting vasculature and quality of life, we excluded
patients with established cardiovascular or renal disease
and previously diagnosed diabetes.
Methods
Subjects
The cardiovascular risk subjects were drawn from a
population survey, the Harmonica Project, which was
1
University of Turku, Turku, Finland.
2
Pori Health Center, Pori, Finland.
3
Kuopio University Hospital, Kuopio, Finland.
4
Medcare Foundation, A

anekoski, Finland.
5
Satakunta Hospital District, Pori, Finland.
Corresponding author:
Paivi Korhonen, Jokikatu 3, 29200 Harjavalta, Finland
Email: paivi.e.korhonen@fimnet.fi
European Journal of Preventive
Cardiology
19(5) 901907
! The European Society of
Cardiology 2011
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1741826711420346
ejpc.sagepub.com
at Universidad Nacional Aut Mexic on September 6, 2014 cpr.sagepub.com Downloaded from
carried out in the rural town of Harjavalta in south-
western Finland in 200506.
A cardiovascular risk factor survey was mailed to all
home-dwelling inhabitants aged 4570 years
(n 2856). Out of the 2085 (73%) subjects willing to
participate in the project, those having at least one car-
diovascular risk factor (n 1469) were invited to labo-
ratory tests (2-h oral glucose tolerance test, plasma
lipids), generic health survey, and physical examination
(height, weight, body mass index, waist circumference,
blood pressure) performed by a trained nurse.
ABI was measured by a physician from all the sub-
jects (n 1076) with hypertension, metabolic syndrome
dened by the International Diabetes Federation crite-
ria,
6
pre-diabetes, diabetes, body mass index 30 kg/
m
2
, or a 10-year risk of cardiovascular disease death
of 5% or more according to the Systematic Coronary
Risk Evaluation (SCORE) system.
7
For the analyses
described here, we excluded participants with previ-
ously diagnosed diabetes or cardiovascular or renal dis-
ease, yielding an analytic cohort of 915 individuals.
None of the subjects had intermittent claudication,
which was specically asked for: Have you experienced
exertional pain localized to the calf or thigh or but-
tocks, which causes you to stop walking and is relieved
by rest.
Comorbid chronic diseases
Information about chronic comorbidities was gathered
from questionnaires, medical records, medications and
physical examination. Categorization was as follows:
musculoskeletal and connective tissue disorders (osteo-
arthritis, rheumatoid arthritis, spinal stenosis, spinal
disk disease, spondylarthritis), neurological disorders
(Parkinsons disease, myasthenia gravis, sequelae of
polio), pulmonary disorders (asthma or chronic
obstructive lung disease needing continuous medica-
tion, sequelae of tuberculosis or sarcoidosis, bronchiec-
tasis), and cancer.
Measurements
Plasma glucose levels and lipid proles were determined
in blood samples which were obtained after at least 12 h
of fasting. Oral glucose tolerance test was performed by
measuring fasting plasma glucose and 2-h plasma glu-
cose from capillary blood after ingestion of a glucose
load of 75 g anhydrous glucose dissolved in water.
Blood pressure was measured by a trained nurse
with a calibrated mercury sphygmomanometer with
subjects in a sitting posture, after resting at least
5 min. In each subject the mean of the two readings
taken at intervals of at least 2 min was used. Pulse pres-
sure was calculated by subtracting the mean diastolic
blood pressure from the mean systolic blood pressure.
Height and weight were measured by the nurse.
Body mass index was calculated as weight (kg) divided
by the square of height (m
2
).
ABI was determined from blood pressure mea-
surements in the arms and ankles with the patient
supine. Systolic blood pressure (SBP) in the brachial
artery was measured in both arms using a blood
pressure cu and Doppler instrument (PD1v with a
vascular probe of 5 MHz; UltraTec, UK) in the
antecubital fossa. SBP at the left and right dorsalis
pedis arteries (if not found, at the left and right
posterior tibial arteries) was then measured with
Doppler detection with a blood pressure cu applied
to the ankle just proximal to the malleoli. ABI was
calculated for each leg by dividing the lower ankle
SBP by the higher brachial SBP.
8
This method was
chosen because we believed that the artery with
poorest perfusion would have the greatest eect on
lower extremity functioning.
Participants who had an ABI 0.90 in either leg
were categorized as having PAD. Subjects with an
ABI between 0.91 and 1.00 were considered as border-
line PAD cases. ABI >1.00 was considered as normal.
Questionnaires
Subjects completed self-administrated question-
naires at the clinic before the physical examination
was perfomed: sociodemographic factors, occupational
status, leisure-time physical activity level, smoking
status, health-related quality of life (SF-36),
9
and
Becks Depression Inventory (BDI).
10
Leisure-time physical activity (LTPA) was classied
as follows: (i) high: LTPA 30 min at a time for at least
six times a week; (ii) moderate: LTPA 30 min at a
time from four to ve times a week; and (iii) low:
LTPA 30 min at a time three times a week or less.
The SF-36 is a scale measuring health-related quality
of life which consists of eight domains measuring phys-
ical functioning, role limitation due to physical prob-
lems, bodily pain, general health perception, vitality,
social functioning, role limitation due to emotional
problems, and mental health. Each category is scored
on a scale from 0 to 100, where 0 represents the worst
overall status and 100 the best status.
11
Two standard-
ized summary scales provide a concise approximation
of the physical and mental components of health-
related quality of life. The physical component sum-
mary scale (sum points from 0 to 100) is composed of
physical functioning, role-physical, bodily pain, and
general health scales. The mental component summary
scale (sum points from 0 to 100) is obtained by sum-
mating vitality, role-emotional, social functioning, and
mental health.
902 European Journal of Preventive Cardiology 19(5)
at Universidad Nacional Aut Mexic on September 6, 2014 cpr.sagepub.com Downloaded from
Informed consent
The study protocol and consent forms were reviewed
and approved by the ethics committee of Satakunta
hospital district. All participants provided written
informed consent for the project and subsequent med-
ical research.
Statistical analysis
The data is presented as the means with standard devi-
ations (SD) or as counts with percentages. The 95%
condence intervals are given for the most important
outcomes. Statistical comparisons between groups in
baseline characteristics were made by analysis of vari-
ance or chi-squared test. The statistical signicance for
linearity across groups in SF-36 domains was deter-
mined by bootstrap type analysis of covariance with
an appropriate contrast. Multivariate ordered logistic
regression model was used to identify patient charac-
teristics associated with physical and mental summary
scales of the SF-36 questionnaire.
Results
Baseline characteristics
The study included 915 cardiovascular risk subjects
without intermittent claudication (mean age 597
years, 54% females), and with data available on the
SF-36 questionnaire and ABI measurement. The prev-
alence of PAD and borderline PAD were 5% (95% CI
47%) (48/915) and 20% (95% CI 1823%) (186/915),
respectively.
The characteristics of the subjects according to ABI
categories are shown in Table 1. The mean age was the
highest in persons with PAD and the lowest in subjects
with normal ABI. For each dimension of the physical
components of the SF-36 scale there was a gradual
decrease in the crude mean scores across categories of
ABI.
Relationships between ABI and quality of life
Table 2 shows the results of multivariate ordered logis-
tic regression analyses relating patient characteristics to
physical health and mental health component summary
scales of the SF-36 questionnaire. After adjusting for all
other variables, higher ABI was independently related
to better physical health as were male sex, younger age,
lower body mass index, higher education, and higher
leisure time physical activity. Higher age and higher
BMI were related to better mental health.
Figure 1 displays quality of life dimension scores by
categories of ABI (normal, borderline PAD, PAD).
Patients with PAD had signicantly lower scores for
physical functioning, role-physical, general health and
vitality than subjects with normal ABI when adjusted
for age and sex. Among those with borderline PAD,
quality of life was reduced on the general health per-
ception compared to subjects with normal ABI.
Discussion
This study shows that patients with PAD without clas-
sic intermittent claudication and even patients with
borderline PAD have reduced health-related quality
of life. Patients with PAD have worse quality of life
than subjects with normal ABI in regard to all compo-
nents of physical quality of life except bodily pain in
this patient population without intermittent claudica-
tion. However, we cannot rule out the possibility that
claudication might be absent in these subjects with sub-
clinical disease, because they may spontaneously avoid
physical activity.
Our study suggests that patients with PAD have leg
symptoms other than intermittent claudication which
reduce their quality of life. We did not ask the subjects
to specify their lower limb symptoms, which is a limi-
tation. But the fact that all domains of the physical
quality of life were reduced, refers to physical symp-
toms on functioning during daily activities.
McDermott et al. have documented the spectrum of
leg symptoms reported by patients with PAD. They
identied two groups experiencing atypical exertional
leg symptoms: individuals who have symptoms that
do not stop the individual from walking, and individ-
uals who have symptoms that do stop the individual
from walking but do not resolve at rest.
4
We asked
our study subjects if they had experienced exertional
leg pain, but it is possible that impaired circulation in
the lower extremities might be experienced also as
muscle fatigue or discomfort or numbness which are
relieved by rest.
Studies using the SF-36 questionnaire have con-
rmed that PAD, particularly when claudication is pre-
sent, impairs health-related quality of life.
12,13
The
physical component score of SF-36 has been shown
to be lower in persons with PAD compared to persons
without PAD.
14,15
The PARTNERS study, which was
conducted in primary care oce practices across the
USA, also showed that patients with PAD and patients
with other cardiovascular disease have a similarly and
signicantly lower physical function score in the SF-36
than the reference group with no evidence of PAD or
other cardiovascular disease.
15
Our study is, to the best of our knowledge, the rst
study to assess health-related quality of life in patients
with atypical or asymptomatic PAD screened by using
non-invasive measurements in a cohort of
Korhonen et al. 903
at Universidad Nacional Aut Mexic on September 6, 2014 cpr.sagepub.com Downloaded from
T
a
b
l
e
1
.
C
h
a
r
a
c
t
e
r
i
s
t
i
c
s
o
f
t
h
e
s
t
u
d
y
s
u
b
j
e
c
t
s
a
c
c
o
r
d
i
n
g
t
o
c
a
t
e
g
o
r
i
e
s
o
f
a
n
k
l
e

b
r
a
c
h
i
a
l
i
n
d
e
x
N
o
r
m
a
l
A
B
I
>
1
.
0
0
(
n

6
8
1
,
7
4
.
4
%
)
B
o
r
d
e
r
l
i
n
e
P
A
D
A
B
I
0
.
9
1

1
.
0
0
(
n

1
8
6
,
2
0
.
3
%
)
P
A
D
A
B
I

0
.
9
0
(
n

4
8
,
5
.
2
%
)
p
-
v
a
l
u
e
t
r
e
n
d
C
h
r
o
n
i
c
c
o
m
o
r
b
i
d
i
t
i
e
s
M
u
s
c
u
l
o
s
k
e
l
e
t
a
l
a
n
d
c
o
n
n
e
c
t
i
v
e
t
i
s
s
u
e
d
i
s
o
r
d
e
r
s
5
4
(
7
.
9
)
2
1
(
1
1
.
3
)
6
(
1
2
.
5
)
0
.
2
4
N
e
u
r
o
l
o
g
i
c
a
l
d
i
s
o
r
d
e
r
s
3
(
0
.
4
)
0
(
0
.
0
)
0
(
0
.
0
)
0
.
6
0
P
u
l
m
o
n
a
r
y
d
i
s
o
r
d
e
r
s
2
0
(
2
.
9
)
6
(
3
.
2
)
0
(
0
.
0
)
0
.
3
9
C
a
n
c
e
r
7
(
1
.
0
)
3
(
1
.
6
)
1
(
2
.
1
)
0
.
6
9
F
e
m
a
l
e
3
5
7
(
5
2
)
1
1
1
(
6
0
)
3
(
6
)
0
.
2
1
A
g
e
(
y
e
a
r
s
)
5
8

7
5
9

7
6
1

5
0
.
0
1
6
B
o
d
y
m
a
s
s
i
n
d
e
x
(
k
g
/
m
2
)
2
9
.
4

4
.
8
2
9
.
2

5
.
3
2
9
.
7

7
.
1
0
.
8
5
0
-
h
g
l
u
c
o
s
e
(
m
m
o
l
/
l
)
5
.
6
7

0
.
8
8
5
.
6
1

0
.
9
4
5
.
7
3

0
.
9
7
0
.
6
2
2
-
h
g
l
u
c
o
s
e
(
m
m
o
l
/
l
)
7
.
6
4

2
.
4
9
7
.
6
0

2
.
4
0
8
.
3
0

2
.
5
3
0
.
1
8
S
y
s
t
o
l
i
c
b
l
o
o
d
p
r
e
s
s
u
r
e
(
m
m
H
g
)
1
4
8

1
7
1
5
1

1
8
1
6
0

1
8
<
0
.
0
0
1
D
i
a
s
t
o
l
i
c
b
l
o
o
d
p
r
e
s
s
u
r
e
(
m
m
H
g
)
8
9

9
8
9

7
9
0

1
0
0
.
4
1
P
u
l
s
e
p
r
e
s
s
u
r
e
(
m
m
H
g
)
5
9

1
3
6
2

1
5
7
0

1
3
<
0
.
0
0
1
T
o
t
a
l
c
h
o
l
e
s
t
e
r
o
l
(
m
m
o
l
/
l
)
5
.
3
0

0
.
9
4
5
.
3
3

0
.
9
6
5
.
3
6

0
.
9
8
0
.
8
4
H
D
L
-
c
h
o
l
e
s
t
e
r
o
l
(
m
m
o
l
/
l
)
1
.
4
7

0
.
4
0
1
.
5
5

0
.
4
0
1
.
5
5

0
.
4
7
0
.
0
2
9
L
D
L
-
c
h
o
l
e
s
t
e
r
o
l
(
m
m
o
l
/
l
)
3
.
2
0

0
.
8
3
3
.
1
7

0
.
8
8
3
.
1
3

0
.
9
2
0
.
7
9
T
r
i
g
l
y
c
e
r
i
d
e
s
(
m
m
o
l
/
l
)
1
.
4
1

0
.
6
9
1
.
3
5

0
.
6
4
1
.
5
6

0
.
7
6
0
.
1
8
C
u
r
r
e
n
t
s
m
o
k
i
n
g
1
0
0
(
1
5
)
4
1
(
2
2
)
1
4
(
2
9
)
0
.
0
0
4
1
L
e
i
s
u
r
e
t
i
m
e
p
h
y
s
i
c
a
l
a
c
t
i
v
i
t
y
L
o
w
1
1
4
(
1
8
)
3
2
(
1
8
)
1
2
(
2
9
)
0
.
3
7
M
o
d
e
r
a
t
e
3
1
5
(
5
0
)
9
2
(
5
2
)
2
0
(
4
9
)
H
i
g
h
2
0
3
(
3
2
)
5
2
(
3
0
)
9
(
2
2
)
O
c
c
u
p
a
t
i
o
n
a
l
s
t
a
t
u
s
B
l
u
e
c
o
l
l
a
r
w
o
r
k
e
r
4
7
1
(
7
4
)
1
4
3
(
8
0
)
3
0
(
7
1
)
0
.
1
9
B
D
I
(
s
c
o
r
e
)
6
.
4

7
.
1
6
.
1

4
.
7
6
.
7

7
.
2
0
.
8
9
M
e
d
i
c
a
t
i
o
n
V
a
s
o
d
i
l
a
t
a
t
o
r
s
1
8
6
(
2
7
)
6
5
6
(
3
5
)
1
8
(
3
8
)
0
.
0
4
4
D
i
u
r
e
t
i
c
s
6
1
(
9
)
2
3
(
1
2
)
9
(
1
9
)
0
.
0
5
1
B
e
t
a
b
l
o
c
k
e
r
s
1
3
5
(
2
0
)
4
0
(
2
2
)
1
7
(
3
5
)
0
.
0
3
7
S
t
a
t
i
n
s
9
5
(
1
4
)
3
2
(
1
7
)
1
0
(
2
1
)
0
.
2
8
V
a
l
u
e
s
a
r
e
m
e
a
n

s
t
a
n
d
a
r
d
d
e
v
i
a
t
i
o
n
o
r
n
(
%
)
.
A
B
I
,
a
n
k
l
e

b
r
a
c
h
i
a
l
i
n
d
e
x
;
B
D
I
,
B
e
c
k

s
D
e
p
r
e
s
s
i
o
n
I
n
v
e
n
t
o
r
y
;
H
D
L
,
h
i
g
h
-
d
e
n
s
i
t
y
l
i
p
o
p
r
o
t
e
i
n
;
L
D
L
,
l
o
w
-
d
e
n
s
i
t
y
l
i
p
o
p
r
o
t
e
i
n
;
P
A
D
,
p
e
r
i
p
h
e
r
a
l
a
r
t
e
r
i
a
l
d
i
s
e
a
s
e
.
904 European Journal of Preventive Cardiology 19(5)
at Universidad Nacional Aut Mexic on September 6, 2014 cpr.sagepub.com Downloaded from
Table 2. Multivariate ordered logistic regression models for the physical and mental health component summary scales of SF-36
Physical health p-value Mental health p-value
Male sex 1.71 (1.272.28) <0.001 1.33 (1.001.77) 0.052
Age 0.95 (0.930.97) <0.001 1.03 (1.001.05) 0.023
Body mass index 0.94 (0.910.97) <0.001 1.04 (1.011.07) 0.021
Blue collar work 0.68 (0.500.93) 0.014 0.91 (0.671.23) 0.53
Smoking
Never 1 (reference) 0.45 1 (reference) 0.79
Former 0.91 (0.651.25) 1.02 (0.741.42)
Current 0.78 (0.531.15) 1.14 (0.781.66)
LTPA
Low 1 (reference) 0.023
a
1 (reference) 0.16
a
Moderate 1.41 (0.972.05) 1.42 (0.992.04)
High 1.65 (1.092.50) 1.40 (0.932.11)
Vasodilatators 0.87 (0.631.21) 0.42 0.98 (0.711.36) 0.93
Diuretics 1.23 (0.761.99) 0.40 0.78 (0.481.26) 0.31
Beetablockers 0.96 (0.691.35) 0.82 0.77 (0.551.08) 0.12
Statins 0.80 (0.541.17) 0.24 1.12 (0.761.64) 0.56
ABI
>1.00 1 (reference) <0.001
a
1 (reference) 0.12
a
0.911.00 0.64 (0.460.91) 1.07 (0.761.49)
<0.91 0.31 (0.160.60) 0.45 (0.240.86)
The impact of each independent variable on the outcome is displayed after adjusting for all other variables. The dependent variables are divided into
tertiles. Values in parentheses are 95% confidence intervals.
a
p for linearity. ABI, anklebrachial index; LTPA, leisure-time physical activity.
Physical functioning p=0.002
p<0.001
p=0.002
p<0.001
p=0.016
p=0.088
p=0.15
p=0.064
Role-physical
>1.00
0.911.00
<0.91
Bodily pain
General health
Vitality
Social functioning
Role-emotional
Mental health
30 40 50 60 70
Score
80 90 100
Figure 1. Health-related quality of life dimensions according to categories of anklebrachial index. Values are mean95% confi-
dence intervals. p-values for linearity are adjusted for age and sex.
Korhonen et al. 905
at Universidad Nacional Aut Mexic on September 6, 2014 cpr.sagepub.com Downloaded from
cardiovascular risk subjects drawn from general popu-
lation and who had no previously known comorbidities
aecting vasculature. The subjects completed the SF-36
questionnaire before ABI was measured and, thus, the
awareness of having a chronic disease may not contrib-
ute to quality of life scores.
In this clinical study performed in primary care oce
practice, we did not have the opportunity to use angio-
grams or any novel methods to diagnose peripheral
arterial disease (PAD). However, noninvasive testing
with the anklebrachial index is the clinical standard
for diagnosing PAD. International cooperation
between medical and surgical vascular, cardiovascular,
vascular radiology and cardiology societies provided a
new consensus statement about diagnosis and manage-
ment of PAD in 2007. This 2007 Inter-Society
Consensus for the Management of Peripheral Arterial
Disease (TASC II) denes cut-o value of ABI 0.90
for diagnosing PAD by using the higher of the two
ankle pressures in calculating ABI.
16
This method has
been recently shown to underestimate the true preva-
lence of PAD. With regard to cardiovascular prognosis,
more patients at risk could be identied using the lower
instead of the higher ankle pressure in calculating ABI.
8
A person having ABI 0.90 using the higher of the two
ankle pressures has presumably occlusive arterial dis-
ease in a proximal artery of the leg or in both ankle
arteries, whereas a person with ABI 0.90 using the
lower of the ankle pressures may have isolated athero-
sclerosis of dorsalis pedis or posterior tibial arteries. We
used the last mentioned method, which may partly
explain the non-claudicant symptoms of our patients.
It is suggested that comorbid diseases and limited
activity levels to avoid the pain may alter PAD-asso-
ciated leg symptoms.
4
Only 13% (120/914) of our study
subjects had a chronic comorbid disease, because we
excluded patients with established cardiovascular or
renal disease and previously diagnosed diabetes. Our
study population was quite young (mean age 59 7
years) and the range of ABI was 0.601.39 (mean
1.08 0.12). In this quite healthy study population,
comorbid diseases and physical activity level did not
contribute to leg symptoms or physical functioning of
the PAD patients. Nor did use of antihypertensive med-
ication or statins have impact on quality of life.
According to the multivariate analysis, borderline
PAD and especially PAD even with atypical or absent
symptoms outstandingly reduce physical health of the
subjects after adjusting for all other variables. This
probably explains the reduced physical activity
reported by the subjects with PAD. Age and body
mass index inuenced only weakly on the summary
scores of SF-36 after adjusting for other variables. It
is well documented that exercise-based interventions in
patients with intermittent claudication have positive
eects on the SF-36 physical functioning scale.
17
Studies on the eects of exercise on health-related qual-
ity of life of subjects with atypical PAD are clearly
needed.
In conclusion, health-related quality of life of indi-
viduals with asymptomatic or atypical PAD or border-
line PAD is worse than that of individuals with normal
ABI. The level of ABI is independently related to phys-
ical functioning. Identifying PAD and borderline PAD
is important, because this widespread but underdiag-
nosed disease is associated with increased cardiovascu-
lar mortality, functional impairment, and decreased
quality of life.
Funding
This research was supported by the Satakunta Hospital
District and Orion-Farmos Research Foundation.
Conflict of interest
None
References
1. Fowkes FG, Housley E, Cawood EH, Macintyre CC,
Ruckley CV and Prescorr RJ. Edinburgh Arterial Study:
prevalence of asymptomatic and symptomatic peripheral
arterial disease in the general population. Int J Epidemiol
1991; 20(2): 384392.
2. Hirsch A, Criqui M, Treat-Jacobson D, Regensteiner J,
Creager M, Olin J, et al. Peripheral arterial disease detec-
tion, awareness, and treatment in primary care. JAMA
2001; 286(11): 13171324.
3. Selvin E and Erlinger TP. Prevalence of and risk factors
for peripheral arterial disease in the United States: results
from the National Health and Nutrition Examination
Survey 19992000. Circulation 2004; 110(6): 738743.
4. McDermott MM, Greenland P, Liu K, Guralnik JM,
Criqui MH, Dolan NC, et al. Leg symptoms in peripheral
arterial disease. Associated clinical characteristics and
functional impairment. JAMA 2001; 286(13): 15991606.
5. Fowkes FGR, Murray GD, Butcher I, Heald CL, Lee RJ,
Chambless LE, et al. Ankle brachial index combined with
Framingham risk score to predict cardiovascular events
and mortality. A Meta-analysis. JAMA 2008; 300(2):
197208.
6. Alberti KG, Zimmet P and Shaw J; IDF Epidemiology
Task Force Consensus Group. The metabolic syndrome
a new worldwide definition. Lancet 2005; 366(9491):
10591062.
7. Conroy RM, Pyo ra la K, Fitzgerald AP, Sans S, Menotti
A, De Backer G, et al. on behalf of the SCORE project
group. Estimation of ten-year risk of fatal cardiovascular
disease in Europe: the SCORE project. Eur Heart J 2003;
24(11): 9871003.
8. Espinola-Klein C, Rupprecht HJ, Bickel C, Lackner K,
Savvidis S, Messow CM, et al. Different calculations of
ankle-brachial index and their impact on cardiovascular
risk prediction. Circulation 2008; 118(9): 961967.
906 European Journal of Preventive Cardiology 19(5)
at Universidad Nacional Aut Mexic on September 6, 2014 cpr.sagepub.com Downloaded from
9. Hays RD and Morales LS. The SF-36 measure of
health-related quality of life. Ann Med 2001; 33(5):
350357.
10. Beck AT, Wand CH and Mendelson M. An inventory for
measuring depression. Arch Gen Physchiatry 1961; 4(6):
561571.
11. Fayers P. Quality of life. Assessment, analysis and inter-
pretation, 2nd edn. Chichester, England: John Wiley &
Sons, 2000.
12. McDermott MM, Mehta S, Liu K, Guralnik JM, Martin
GJ, Criqui MH, et al. Leg symptoms, the ankle-brachial
index, and walking ability in patients with peripheral
arterial disease. J Gen Intern Med 1999; 1(3): 173181.
13. Long J, Modrall JG, Parker BJ, Swann A, Welborn MB
and Anthony T. Correlation between ankle-brachial
index, symptoms, and health-related quality of life in
patients with peripheral vascular disease. J Vasc Surg
2004; 39(4): 723727.
14. Collins TC, Petersen NJ, Suarez-Almazor M and Ashton
CM. Ethnicity and peripheral arterial disease. Mayo Clin
Proc 2005; 80(1): 4854.
15. Regensteiner JG, Hiatt WR, Coll JR, Criqui MH, Treat-
Jacobson D, McDermott MM, et al. The impact of
peripheral arterial disease on health-related quality of
life in the Peripheral Arterial Disease Awareness, Risk,
and Treatment: new resources for survival (PARTNERS)
program. Vasc Med 2008; 13(1): 1524.
16. Norgren L, Hiatt WR, Dormandy JA, Nehler MR,
Harris KA and Fowkes FGR; on behalf of the TASC
II Working Group. Inter-Society Consensus for the
Management of Peripheral Arterial Disease (TASC II).
Eur J Vasc Endovasc Surg 2007; 33(1): S1S75.
17. Guidon M and McGee H. Exercise-based interventions
and health-related quality of life in intermittent claudica-
tion: a 20-year (19892008) review. Eur J Cardiovasc Prev
Rehabil 2010; 17(2): 140154.
Korhonen et al. 907
at Universidad Nacional Aut Mexic on September 6, 2014 cpr.sagepub.com Downloaded from