September 1, 2006 • www.internalmedicinenews.com Cardiovascular Medicine 43 Functional Performance Reduced Vascular Events Measures Assess PAD In Peripheral Arterial Disease BY MITCHEL L. ZOLER larization) was 26% in the -treated BY ALICIA AULT as they can during the 6 minutes, with no Philadelphia Bureau group and 33% in the placebo group, a Associate Editor, Practice Trends conversation during the test. statistically significant difference, report- The 6-minute walk test was shown to be P HILADELPHIA — Statin use cut the ed Dr. Bulbulia, a researcher with the clin- WASHINGTON — Using validated reliable in a 1998 study (J. Amer. Geriatr. incidence of major vascular events in pa- ical trial service unit of the University of functional performance measures is bet- Soc. 1998;46:706-11). Dr. McDermott and tients with peripheral arterial disease in Oxford (England). ter than relying on patient reporting to her colleagues have completed a study, a subanalysis of results from the Heart The degree of event reduction from determine walking ability and the effects which has been submitted for publication, Protection Study. statin therapy in this subgroup was very of treatments in peripheral arterial dis- showing that 6-minute walk performance The results show that “all patients similar to what was seen in the entire ease, according to Dr. Mary McGrae Mc- at baseline predicts mortality. In addition with peripheral arterial disease [PAD] study, and in the subset of patients who Dermott. to the 6-minute walk, clinicians should should be on a statin regardless of their did not have PAD at entry. PAD patients may underreport leg consider three other tests that measure leg baseline lipid level,” Dr. Richard Bulbu- Statin treatment led to a significant re- symptoms because they often restrict their strength, balance, and walking speed. To- lia said at the Vascular Annual Meeting. duction in vascular events regardless of activity to avoid experiencing those symp- gether, these additional diagnostics con- “This is probably the first study to whether patients started with a serum toms, said Dr. McDermott at a conference stitute the summary performance score show the benefit of statin treatment in a level of low density lipoprotein (LDL) sponsored by the Society for Vascular (SPS). Each is scored on a 0-4 scale and is predominantly PAD group. [These are] cholesterol above or below 116 mg/dL. Surgery. The use of functional measures added to create a total score of 0-12. very important data,” commented Dr. These results also probably underesti- such as the 6-minute walk test can sub- The first component is the 4-meter Thomas F. Lindsay, director of the vas- mated the impact of simvastatin treat- stantially increase diagnostic and treat- walk test, which is conducted in a corri- cular center at Toronto General Hospital. ment because some patients in the statin ment accuracy, said Dr. McDermott, of dor with a stopwatch. Dr. McDermott has The study used data collected in the group stopped taking their drugs, and the department of medicine at North- found that patients who do not walk reg- Heart Protection Study, a British trial some patients in the placebo group even- western University, Chicago. ularly for exercise have the greatest de- with more than 20,000 patients that tually started on a statin, Dr. Bulbulia said. Each measure has positives and nega- cline in the 4-meter speed. The SPS also compared treatment with 40 mg of sim- Another analysis of the data, using the tives, said Dr. McDermott, the lead inves- includes a standing balance test and time vastatin daily with placebo (Lancet 2002; entire study group, looked at the ability tigator in (the Walking and Leg Circulation to arise five times consecutively from a 360:7-22). The total group included pa- of statin treatment to cut the incidence Study, WALCS). That study used several seated position. Lower SPS scores are as- tients with coronary disease, other oc- of major peripheral vascular events. performance measures of walking and leg sociated with a higher risk of death, nurs- clusive arterial disease, or . In the These were defined as noncoronary function, including the 6-minute walk test, ing home placement, and a reduction in overall study, treatment with the statin revascularizations, aneurysm repair, ma- repeated chair stands, a standing balance the ability to perform activities of daily was linked to a relative cut in deaths of jor amputations, or deaths due to PAD. test, and a test of walking speed (Ann. In- living, she said. 13% and lowered major vascular events These events occurred in 4.7% of the tern. Med. 2002;136:1-32). Physical activity can be measured with by 24% during 5 years of follow-up. statin-treated patients and in 5.5% of One of the most often-used perfor- a vertical accelerometer, said Dr. McDer- The new analysis focused on the 6,748 those on placebo, a statistically significant mance measures is the treadmill walking mott, who has conducted several valida- patients who entered the study with doc- difference. The impact of statin therapy test, but some data suggest it might not tion studies of the Caltrac version (Mus- umented PAD. This subgroup included on reducing peripheral vascular events has mimic actual walking, Dr. McDermott cle Dynamics Fitness Network). patients with coincident coronary dis- not been previously reported in any oth- said. And older patients may experience In the trials, PAD patients were given the ease, coincident , er statin-treatment study, Dr. Bulbulia anxiety or balance problems that have an beeperlike device to wear for 7 days, except coincident diabetes, and more than 1,400 said. This effect by simvastatin treatment impact on results, she said. A 6-minute when sleeping or bathing. Dr. McDermott patients who had PAD as their only pre- was primarily driven by a lower rate of walk test conducted in a corridor may be and her colleagues found that PAD patients existing disorder. peripheral revascularization procedures. easier and more productive for older pa- had much lower activity than non-PAD pa- During 5 years of follow-up of the en- These results, along with other recent tients, according to Dr. McDermott. The tients, and that the performance correlat- tire PAD subgroup, the rate of major findings on statin therapy, suggest that test should be done in a 100-foot-long ed with 6-minute walk test results (J. Am. vascular events (coronary death, nonfatal the lower the level of LDL cholesterol in hallway, with patients told to walk as far Geriatr. Soc. 2001;49:747-54). ■ , , or revascu- patients with PAD the better. ■ New Questions on PAD Alter Framingham Risk Assessment

BY BRUCE JANCIN egory who answered in the neg- with an intermediate Framing- vascular event rates were 8.4%, rate of 23.4% in the intermedi- Denver Bureau ative, said Dr. Salameh of Co- ham risk score who had self-re- 23.4%, and 58.2% for individuals ate-risk group means those indi- lumbia University, New York. ported PAD than in those who in the low-, intermediate-, and viduals actually belong in the ATLANTA — Asking patients Among 3,083 participants with didn’t (11.7% vs. 8.7%). And the high-risk Framingham categories. high-risk Framingham category, two brief questions about self-re- no baseline history of major vas- disparity in event rates between The 10-year major vascular event Dr. Salameh said. ■ ported peripheral artery disease, cular events, the prevalence of those with and without self-re- as a supplement to the standard self-reported peripheral artery ported PAD was even greater in Framingham cardiovascular risk disease (PAD) as defined by an af- those in the high-risk Framing- Extrapolated 10-Year Vascular Event Rates assessment, results in reclassifi- firmative answer to one or both ham category (29.1% vs. 17.1%), Increase in Patients with Self-Reported PAD cation of a substantial proportion of the questions on the intake which is reserved for those 58.2% of patients as being at high rather questionnaire was 15%. whose Framingham score places than intermediate risk, Dr. Maya During a mean follow-up of them at an estimated 10-year risk Without PAD J. Salameh reported at the annu- 5.5 years, there were 397 major in excess of 20%. al meeting of the American Col- vascular events, defined as MI, is- Extrapolating from the North- With PAD lege of . chemic stroke, or vascular death. ern Manhattan Study 5-year re- 34.2% The two yes/no questions are: Among individuals with a low sults, the estimated 10-year vas- Do you get pain in the back of Framingham risk score, meaning cular event rates in individuals 23.4% your legs when you walk? Have their calculated 10-year risk of a without self-reported PAD who 17.4% you been told you have vascular cardiovascular event was less were in the low-, intermediate-, 8.2% 8.4% EWS disease in the legs? than 10%, the actual 5-year cu- and high-risk Framingham cate- N Participants in the Northern mulative rate of major vascular gories at baseline were 8.2%,

Manhattan Study who answered events was 4.1% in participants 17.4%, and 34.2%, respectively, EDICAL yes to one or both questions without self-reported PAD and a which is consistent with how the Low risk Intermediate risk High risk M Framingham Risk Category went on to have a higher inci- nearly identical 4.2% in those risk score is supposed to operate. LOBAL dence of major vascular events, with self-reported PAD. Patients with self-reported Note: Based on a study of 3,083 patients. G compared with patients in the But 5-year vascular event rates PAD, however, were another sto- Source: Dr. Salameh LSEVIER same Framingham risk score cat- were higher in those individuals ry. Their extrapolated 10-year E