Physical activity and peripheral arterial disease among patients with coronary artery disease or congestive heart failure

    Physical activity and peripheral arterial disease among patients with coronary artery disease or congestive heart failure Paul D. Loprinzi PII: DOI: Reference:

S0167-5273(16)30147-4 doi: 10.1016/j.ijcard.2016.01.149 IJCA 21904

To appear in:

International Journal of Cardiology

Received date: Revised date: Accepted date:

26 November 2015 5 January 2016 6 January 2016

Please cite this article as: Loprinzi Paul D., Physical activity and peripheral arterial disease among patients with coronary artery disease or congestive heart failure, International Journal of Cardiology (2016), doi: 10.1016/j.ijcard.2016.01.149

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Physical Activity and Peripheral Arterial Disease among Patients with Coronary Artery Disease or Congestive Heart Failure

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Paul D. Loprinzi, PhD Director of Research Engagement – Jackson Heart Study Vanguard Center of Oxford Center for Health Behavior Research Department of Health, Exercise Science and Recreation Management The University of Mississippi, University, MS 38677

Corresponding Author Paul D. Loprinzi, PhD The University of Mississippi Director of Research Engagement – Jackson Heart Study Vanguard Center of Oxford Center for Health Behavior Research School of Applied Sciences Department of Health, Exercise Science, and Recreation Management 229 Turner Center University, MS 38677 E-Mail: [email protected] Phone: 662-915-5521 Fax: 662-915-5525

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ACCEPTED MANUSCRIPT An interrelationship between coronary artery disease (CAD), congestive heart failure (CHF) and peripheral arterial disease (PAD) has been established, as atherosclerosis has a common systemic

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pathogenesis and concurrently affects multiple circulations.1-5 It has been suggested that patients

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with diagnosed heart disease should also be screened for PAD.5 Encouragingly, regular participation in physical activity has been implicated as a potential behavior to help protect

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against incident CAD and CHF, and importantly, physical activity behavior is associated with

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PAD in the general population.6 However, the extent to which physical activity is associated with PAD among those with heart disease is less investigated within the literature. As a result, the

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purpose of this study was, among a population-based sample of adults with coronary artery disease or congestive heart failure, examine the association between physical activity and ankle

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brachial index (ABI), a proxy for PAD.

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Data from the 2003-2004 National Health and Nutrition Examination Survey was used. Participants who answered “yes” to the following question were considered to have congestive heart failure: “Has a doctor or other health professional ever told you that you had congestive heart failure?” Similarly, participants who answered “yes” to the following question were considered to have coronary artery disease: “Has a doctor or other health professional ever told you that you had coronary artery disease?” Given the limited sample size for these two groups, participants with CAD or CHF were included herein and evaluated together. In the 2003-2004 NHANES cycle, 134 participants (Agemean = 65.8 yrs; 67.8% male; 84.5% white) had CAD or CHF; among these 134 with either CAD or CHF, 100 had CAD and 64 had CHF. Although less accurate than hospital records and other forms of objective measurement, self-report of physician diagnosis of morbidity has demonstrated evidence of validity. For example, as shown by

ACCEPTED MANUSCRIPT Bergmann et al.,7 and when compared to hospitalized confirmed diagnosis, sensitivity (true

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positivity) of self-reported heart disease was 84% among American adults.

Free-living physical activity was assessed during all waking hours using the ActiGraph 7164

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accelerometer. SAS (version 9.2) was used to reduce accelerometry data to those with ≥ 4 days

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of ≥ 10 hr/day of monitored data and integrate it into 1 minute time intervals. Nonwear time was

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identified as ≥ 60 consecutive minutes of zero activity counts, with allowance for 1-2 minutes of activity counts between 0 and 100. Activity counts/min ≥ 100 was used as the threshold to

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determine time spent at physical activity across the valid days (i.e., days with at least 10+ hrs of monitoring).8,9 The average physical activity level across these valid days was calculated for

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each participant. This activity count/min cut-point of 100 allows for the quantification of time

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spent engaging in any ambulatory-based movements (i.e., non-sedentary behaviors).8 The

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weighted mean physical activity was 302.9 min/day (SE = 6.6).

Peripheral arterial disease was assessed by examination of the ABI. Detailed procedures of the ABI examination can be found elsewhere.10 While participants rested in supine position, two systolic blood pressure measurements were made in the right arm (brachial artery) and both ankles (posterior tibial arteries). The right ABI was calculated by dividing the highest systolic blood pressure in the right ankle by the highest blood pressure in the arm; similarly, the left ABI was calculated by dividing the highest systolic blood pressure in the left ankle by the highest blood pressure in the arm.11 The lower of the ABI readings were used in the present analysis.12 ABI as an indicator of PAD has been validated against gold-standard angiographically that has a sensitivity and specificity, respectively, of 95% and nearly 100%.13 There appears to be a U-

ACCEPTED MANUSCRIPT shaped relationship between ABI and cardiovascular disease morbidity and mortality.14 An ABI < 1 results in an elevated risk for cardiovascular morbidity and mortality (i.e., greater arterial

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occlusion); between 1 and 1.4 is considered normal, suggesting no evidence of PAD; and above 1.4 (suggesting poorly compressible vessels) is an independent risk factor for cardiovascular

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ABI (1-1.4) and abnormal ABI (< 1 or > 1.4).16

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disease morbidity and mortality.14,15 Here, participants were classified into two groups: normal

In a multivariable logistic regression analysis accounting for the complex survey design

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employed in NHANES, for every 60 min/day increase in physical activity (i.e., non-sedentary activities), CAD/CHF patients had a 19% reduced odds of having an abnormal ABI (OR = 0.81;

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95% CI: 0.67-0.99; P=0.04). This model was adjusted for age, gender, race-ethnicity, measured body mass index, C-reactive protein, serum cotinine, medication use (diabetes, blood pressure,

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cholesterol or anticoagulant medications) and comorbid illness (0, 1, 2, or 3+ of the following conditions: arthritis, stroke, cancer, heart attack, COPD, hypertension and diabetes). When adding duration of CAD/CHF as a covariate, results were unchanged (OR = 0.79; 95% CI: 0.640.97; P=0.03).

Major strengths of this study include the objective measure of physical activity and objective measure of ABI. The findings of this study should be interpreted in the context of the study’s limitations, which includes, for example, the cross-sectional study design and subjective assessment of CAD/CHF. As a result, future prospective work is needed to better inform the temporal sequence of this studied topic. If confirmed by future prospective work using a larger

ACCEPTED MANUSCRIPT homogenous sample, then this may provide useful insights into the potential relationship between physical activity and PAD among those with CAD/CHF.

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Acknowledgements – No funding was used to prepare this manuscript and no conflicts are disclosed.

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