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Commentary on ‘Peripheral Arterial Disease Incidence and Associated Risk Factors in a Mediterranean Population Based Cohort. The REGICOR Study’
Eur J Vasc Endovasc Surg (2016) 51, 706
INVITED COMMENTARY
Commentary on ‘Peripheral Arterial Disease Incidence and Associated Risk Factors in a Mediterranean Population Based Cohort. The REGICOR Study’ L. Norgren Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
While the prevalence of peripheral arterial disease (PAD) is increasing globally, both in high, middle and low income countries,1 this Spanish report from the Girona region shows the lowest incidence of PAD reported so far, 377/100,000 person years.2 This author group has previously reported a PAD prevalence of 4.5% in the REGICOR study population,3 while Baena-Diez4 showed a corresponding incidence of 484/100,000 person years. These studies included men and women in the same age range (35e79 and 35e84 years of age, respectively). Interestingly, however, Merino5 in a study from a corresponding Mediterranean area, including only the male population, 55e74 years of age, found an incidence of PAD of 2380/100,000 person years. Whether this great difference is only based on the age differences may be discussed, as the latter study did not include the oldest group (75e84 years), and also excluded the youngest population (35e54 years). Another explanation, the exclusion of the female population, also creates some doubt, as a male predominance is seen in the present paper, while other recent reports claim equality between genders or even a higher female incidence.6 Likewise, all PAD, except intermittent claudication was shown to be more prevalent in women than in men in a Swedish study.7 Previously reported data from the REGICOR study have shown a low incidence of myocardial infarction, despite a high prevalence of cardiovascular risk factors.8 The present study points out the important role of the well known risk factors, specifically smoking and poorly controlled diabetes, the former as a higher risk in the older population, the latter at an earlier stage. The educational level is reported, but not discussed. Socioeconomic factors including educational level are known to be of importance.9e11 The present material includes more than 50% with higher than elementary school education. Comparisons with other reports would be interesting as well as a study on covariation between risk factors and the educational level. The authors make a comment that almost 28% of the cohort was only followed up based on clinical records. There is no information on what proportion of subjects were complete “nonresponders”. An underestimation of the incidence of PAD cannot be ruled out. However, from this and other studies it seems reasonable to conclude that the annual incidence of PAD is lower in the investigated Mediterranean region, despite a risk factor magnitude similar to the one found in other investigated areas. Comments on possible “preventive” factors would be of interest.
DOI of original article: http://dx.doi.org/10.1016/j.ejvs.2015.12.045 E-mail address: [email protected] (L. Norgren). 1078-5884/Ó 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvs.2016.01.005
REFERENCES 1 Fowkes FGR, Rudan D, Rudan I, Aboyans V, Denenberg JO, McDermott MM, et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet 2013;382:1329e40. 2 Velescu A, Clara A, Penafiel J, Grau M, Degano IR, Marti R, et al. Peripheral arterial disease incidence and associated risk factors in a mediterranean population-based cohort. The REGICOR Study. Eur J Vasc Endovasc Surg 2016;51:696e705. 3 Ramos R, Quesada M, Solanas P, Subirana I, Sala J, Vila J, et al. Prevalence of symptomatic and asymptomatic peripheral arterial disease and the value of the ankle brachial index to stratify cardiovascular risk. Eur J Vasc Endovasc Surg 2009;38: 305e11. 4 Baena-Diez JM, Vidal-Solsona M, Byram AO, GonzalezCasafont I, Ledesma-Ulloa G, Marti-Sans N. The epidemiology of cardiovascular disease in primary care, the Zona Franca Cohort study in Barcelona, Spain. Rev Esp Cardiol 2010;63:1261e9. 5 Merino J, Planas A, Elosua R, de Moner A, Gasol A, Contreras C, et al. Incidence and risk factors of peripheral arterial occlusive disease in a prospective cohort of 700 adult elderly men followed for 5 years. World J Surg 2010;34:1975e9. 6 Hooi JD, Kester AD, Stoffers HD, Overdijk MM, van Ree JW, Knottnerus JA. Incidence and risk factors for asymptomatic peripheral arterial occlusive disease: a longitudinal study. Am J Epidemiol 2001;153:666e72. 7 Sigvant B, Wiberg-Hedman K, Bergqvist D, Rolandsson A, Andersson B, Persson E, et al. A population-based study of peripheral arterial disease prevalence with special focus on critical limb ischemia and sex differences. J Vasc Surg 2007;45: 1185e91. 8 Masia R, Pena A, Marrugat J, Sala J, Vila J, Pavesi M, et al. High prevalence of cardiovascular risk factors in Gerona, Spain, a province with low myocardial infarction incidence. J Epidemiol Community Health 1998;52:707e15. 9 Chang P, Nead KT, Olin JW, Cooke JP, Leeper NJ. Clinical and socioeconomic factors associated with unrecognized peripheral artery disease. Vasc Med 2014;19:289e96. 10 Pande RL, Creager MA. Socioeconomic inequality and peripheral artery disease prevalence in US adults. Circ Cardiovasc Qual Outcomes 2014;7:532e9. 11 Pujades-Rodriguez M, Timmis A, Stogiannis D, Rapsomaniki E, Denaxas S, Shah A, et al. Socioeconomic deprivation and the incidence of 12 cardiovascular diseases in 1.9 million women and men: implications for risk prediction and prevention. PLoS One 2014;9:e104671.
INVITED COMMENTARY
Commentary on ‘Peripheral Arterial Disease Incidence and Associated Risk Factors in a Mediterranean Population Based Cohort. The REGICOR Study’ L. Norgren Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
While the prevalence of peripheral arterial disease (PAD) is increasing globally, both in high, middle and low income countries,1 this Spanish report from the Girona region shows the lowest incidence of PAD reported so far, 377/100,000 person years.2 This author group has previously reported a PAD prevalence of 4.5% in the REGICOR study population,3 while Baena-Diez4 showed a corresponding incidence of 484/100,000 person years. These studies included men and women in the same age range (35e79 and 35e84 years of age, respectively). Interestingly, however, Merino5 in a study from a corresponding Mediterranean area, including only the male population, 55e74 years of age, found an incidence of PAD of 2380/100,000 person years. Whether this great difference is only based on the age differences may be discussed, as the latter study did not include the oldest group (75e84 years), and also excluded the youngest population (35e54 years). Another explanation, the exclusion of the female population, also creates some doubt, as a male predominance is seen in the present paper, while other recent reports claim equality between genders or even a higher female incidence.6 Likewise, all PAD, except intermittent claudication was shown to be more prevalent in women than in men in a Swedish study.7 Previously reported data from the REGICOR study have shown a low incidence of myocardial infarction, despite a high prevalence of cardiovascular risk factors.8 The present study points out the important role of the well known risk factors, specifically smoking and poorly controlled diabetes, the former as a higher risk in the older population, the latter at an earlier stage. The educational level is reported, but not discussed. Socioeconomic factors including educational level are known to be of importance.9e11 The present material includes more than 50% with higher than elementary school education. Comparisons with other reports would be interesting as well as a study on covariation between risk factors and the educational level. The authors make a comment that almost 28% of the cohort was only followed up based on clinical records. There is no information on what proportion of subjects were complete “nonresponders”. An underestimation of the incidence of PAD cannot be ruled out. However, from this and other studies it seems reasonable to conclude that the annual incidence of PAD is lower in the investigated Mediterranean region, despite a risk factor magnitude similar to the one found in other investigated areas. Comments on possible “preventive” factors would be of interest.
DOI of original article: http://dx.doi.org/10.1016/j.ejvs.2015.12.045 E-mail address: [email protected] (L. Norgren). 1078-5884/Ó 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvs.2016.01.005
REFERENCES 1 Fowkes FGR, Rudan D, Rudan I, Aboyans V, Denenberg JO, McDermott MM, et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet 2013;382:1329e40. 2 Velescu A, Clara A, Penafiel J, Grau M, Degano IR, Marti R, et al. Peripheral arterial disease incidence and associated risk factors in a mediterranean population-based cohort. The REGICOR Study. Eur J Vasc Endovasc Surg 2016;51:696e705. 3 Ramos R, Quesada M, Solanas P, Subirana I, Sala J, Vila J, et al. Prevalence of symptomatic and asymptomatic peripheral arterial disease and the value of the ankle brachial index to stratify cardiovascular risk. Eur J Vasc Endovasc Surg 2009;38: 305e11. 4 Baena-Diez JM, Vidal-Solsona M, Byram AO, GonzalezCasafont I, Ledesma-Ulloa G, Marti-Sans N. The epidemiology of cardiovascular disease in primary care, the Zona Franca Cohort study in Barcelona, Spain. Rev Esp Cardiol 2010;63:1261e9. 5 Merino J, Planas A, Elosua R, de Moner A, Gasol A, Contreras C, et al. Incidence and risk factors of peripheral arterial occlusive disease in a prospective cohort of 700 adult elderly men followed for 5 years. World J Surg 2010;34:1975e9. 6 Hooi JD, Kester AD, Stoffers HD, Overdijk MM, van Ree JW, Knottnerus JA. Incidence and risk factors for asymptomatic peripheral arterial occlusive disease: a longitudinal study. Am J Epidemiol 2001;153:666e72. 7 Sigvant B, Wiberg-Hedman K, Bergqvist D, Rolandsson A, Andersson B, Persson E, et al. A population-based study of peripheral arterial disease prevalence with special focus on critical limb ischemia and sex differences. J Vasc Surg 2007;45: 1185e91. 8 Masia R, Pena A, Marrugat J, Sala J, Vila J, Pavesi M, et al. High prevalence of cardiovascular risk factors in Gerona, Spain, a province with low myocardial infarction incidence. J Epidemiol Community Health 1998;52:707e15. 9 Chang P, Nead KT, Olin JW, Cooke JP, Leeper NJ. Clinical and socioeconomic factors associated with unrecognized peripheral artery disease. Vasc Med 2014;19:289e96. 10 Pande RL, Creager MA. Socioeconomic inequality and peripheral artery disease prevalence in US adults. Circ Cardiovasc Qual Outcomes 2014;7:532e9. 11 Pujades-Rodriguez M, Timmis A, Stogiannis D, Rapsomaniki E, Denaxas S, Shah A, et al. Socioeconomic deprivation and the incidence of 12 cardiovascular diseases in 1.9 million women and men: implications for risk prediction and prevention. PLoS One 2014;9:e104671.