Publications by authors named "Victor Aboyans"

230 Publications

Mortality, Cardiovascular and Limb Events in Patients With Symptomatic Lower Extremity Artery Disease and Diabetes.

Angiology 2021 Nov 26:33197211050144. Epub 2021 Nov 26.

Department of Vascular Medicine, 36760Toulouse University Hospital, Toulouse, France.

The aim of this study was to compare the prognosis of patients according to diabetes status, during a 1-year follow-up after hospital admission for lower extremity artery disease, in the prospective COPART (COhorte de Patients ARTériopathes) registry. Inclusion criteria were intermittent claudication, ischemic rest pain, tissue loss, or acute limb ischemia, with radiological and hemodynamic confirmation. Among 2494 patients, 1235 (49.5%) had diabetes. Incidence rates for major adverse cardiovascular events (MACE) were 18.0/100 person-years (95% confidence interval [CI], 15.4-21.0) for the diabetes group and 11.1/100 person-years (95% CI, 9.2-13.4) for the non-diabetes group. Incidence rates of all-cause mortality were 29.8/100 person-years (95% CI, 26.5-33.4) for the diabetes group and 19.7/100 person-years (95% CI, 17.2-22.7) for the non-diabetes group. Incidence rates of major limb amputation were 24.2/100 person-years (95% CI, 21.1-27.8) for the diabetes group and 11.6/100 person-years (95% CI, 9.6-14.0) for the non-diabetes group. Diabetes was associated with MACE, adjusted hazard ratio 1.60 (95% CI, 1.16-2.22), and all-cause mortality, unadjusted HR 1.49 (95% CI, 1.24-1.78). In the multivariate analysis, diabetes was no longer associated with major amputation, adjusted HR 1.15 (95% CI, .87-1.51). Patients hospitalized for LEAD with diabetes had a higher risk of MACE than those without diabetes.
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http://dx.doi.org/10.1177/00033197211050144DOI Listing
November 2021

The EUCLIDian perspective of global peripheral artery disease (PAD).

Vasc Med 2021 Oct 19:1358863X211051425. Epub 2021 Oct 19.

Department of Clinical Research, Philippine Heart Center and University of the Philippines College of Medicine, Quezon City, Metro Manila, Philippines.

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http://dx.doi.org/10.1177/1358863X211051425DOI Listing
October 2021

Dissecting the epidemiology of aortic dissection.

Eur Heart J Acute Cardiovasc Care 2021 Oct;10(7):710-711

Department of Cardiology, Dupuytren University Hospital, 2 Av. Martin Luther King, 87000 Limoges, France.

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http://dx.doi.org/10.1093/ehjacc/zuab065DOI Listing
October 2021

Editor's Choice - External Applicability of the COMPASS and VOYAGER-PAD Trials on Patients with Symptomatic Lower Extremity Artery Disease in France: The COPART Registry.

Eur J Vasc Endovasc Surg 2021 09 28;62(3):439-449. Epub 2021 Jul 28.

Department of Vascular Medicine, Toulouse University Hospital, Toulouse, France; UMR 1031 INSERM, StromaLab, Toulouse III - Paul Sabatier University, Toulouse, France.

Objective: The aim of this study was to examine the external applicability of the COMPASS and the VOYAGER-PAD trials in patients with lower extremity artery disease (LEAD) in the real world.

Methods: This was a multicentre retrospective analysis of prospectively collected COPART data, a French multicentre registry of patients hospitalised for symptomatic LEAD. The proportion of patients eligible for the combination of rivaroxaban 2.5 mg twice daily plus aspirin based on either COMPASS or VOYAGER-PAD criteria is reported. The one year cumulative incidence of outcomes between eligible and non-eligible patients, as well as eligible patients vs. control arms of the COMPASS (LEAD patient subgroup) and the VOYAGER-PAD trials were compared. Analyses were performed using Cox models.

Results: Of 2 259 evaluable patients, only 679 (30.1%) were eligible for a low dose rivaroxaban plus aspirin regimen. Others were not eligible because of the need for anticoagulant (48.5% and 38.9% of patients meeting COMPASS and VOYAGER-PAD exclusion criteria, respectively) or dual antiplatelet therapy use (15.7% and 16.5%, respectively), high bleeding risk (14.4% and 11.6%, respectively), malignancy (26.1% and 21.0%, respectively), history of ischaemic/haemorrhagic stroke (21.1% and 19.8%, respectively), and severe renal failure (13.2% and 10.5%, respectively). COMPASS and VOYAGER-PAD eligible and ineligible patients were at higher risk of ischaemic events than participants in these trials. The one year cumulative incidences were 6.0% (95% CI 4.3 - 8.1) in the COMPASS eligible subset vs. 3.5% (95% CI 2.9 - 4.3) in the COMPASS control arm for major adverse cardiovascular events, and 27.9% (95% CI 19.9 - 38.3) in the VOYAGER-PAD eligible subset vs. 6.0% (95% CI 5.3 - 6.9) in the VOYAGER-PAD control arm for major adverse limb events.

Conclusion: Many patients hospitalised for symptomatic LEAD in France are not eligible for the low dose rivaroxaban plus aspirin combination. In turn, those eligible may potentially have greater absolute benefit because of higher risk than those enrolled in the trials.
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http://dx.doi.org/10.1016/j.ejvs.2021.05.028DOI Listing
September 2021

Lower Extremity Peripheral Artery Disease: Contemporary Epidemiology, Management Gaps, and Future Directions: A Scientific Statement From the American Heart Association.

Circulation 2021 Aug 28;144(9):e171-e191. Epub 2021 Jul 28.

Lower extremity peripheral artery disease (PAD) affects >230 million adults worldwide and is associated with increased risk of various adverse clinical outcomes (other cardiovascular diseases such as coronary heart disease and stroke and leg outcomes such as amputation). Despite its prevalence and clinical importance, PAD has been historically underappreciated by health care professionals and patients. This underappreciation seems multifactorial (eg, limited availability of the first-line diagnostic test, the ankle-brachial index, in clinics; incorrect perceptions that a leg vascular disease is not fatal and that the diagnosis of PAD would not necessarily change clinical practice). In the past several years, a body of evidence has indicated that these perceptions are incorrect. Several studies have consistently demonstrated that many patients with PAD are not receiving evidence-based therapies. Thus, this scientific statement provides an update for health care professionals regarding contemporary epidemiology (eg, prevalence, temporal trends, risk factors, and complications) of PAD, the present status of diagnosis (physiological tests and imaging modalities), and the major gaps in the management of PAD (eg, medications, exercise therapy, and revascularization). The statement also lists key gaps in research, clinical practice, and implementation related to PAD. Orchestrated efforts among different parties (eg, health care providers, researchers, expert organizations, and health care organizations) will be needed to increase the awareness and understanding of PAD and improve the diagnostic approaches, management, and prognosis of PAD.
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http://dx.doi.org/10.1161/CIR.0000000000001005DOI Listing
August 2021

Antithrombotic therapies in aortic and peripheral arterial diseases in 2021: a consensus document from the ESC working group on aorta and peripheral vascular diseases, the ESC working group on thrombosis, and the ESC working group on cardiovascular pharmacotherapy.

Eur Heart J 2021 10;42(39):4013-4024

Cardiothoracic and Vascular Department, Azienda OspedalieroUniversitaria Pisana, Pisa, Italy.

The aim of this collaborative document is to provide an update for clinicians on best antithrombotic strategies in patients with aortic and/or peripheral arterial diseases. Antithrombotic therapy is a pillar of optimal medical treatment for these patients at very high cardiovascular risk. While the number of trials on antithrombotic therapies in patients with aortic or peripheral arterial diseases is substantially smaller than for those with coronary artery disease, recent evidence deserves to be incorporated into clinical practice. In the absence of specific indications for chronic oral anticoagulation due to concomitant cardiovascular disease, a single antiplatelet agent is the basis for long-term antithrombotic treatment in patients with aortic or peripheral arterial diseases. Its association with another antiplatelet agent or low-dose anticoagulants will be discussed, based on patient's ischaemic and bleeding risk as well therapeutic paths (e.g. endovascular therapy). This consensus document aims to provide a guidance for antithrombotic therapy according to arterial disease localizations and clinical presentation. However, it cannot substitute multidisciplinary team discussions, which are particularly important in patients with uncertain ischaemic/bleeding balance. Importantly, since this balance evolves over time in an individual patient, a regular reassessment of the antithrombotic therapy is of paramount importance.
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http://dx.doi.org/10.1093/eurheartj/ehab390DOI Listing
October 2021

Frailty in cardiology: definition, assessment and clinical implications for general cardiology. A consensus document of the Council for Cardiology Practice (CCP), Acute Cardiovascular Care Association (ACCA), Association of Cardiovascular Nursing and Allied Professions (ACNAP), European Association of Preventive Cardiology (EAPC), European Heart Rhythm Association (EHRA), Council on Valvular Heart Diseases (VHD), Council on Hypertension (CHT), Council of Cardio-Oncology (CCO), Working Group (WG) Aorta and Peripheral Vascular Diseases, WG e-Cardiology, WG Thrombosis, of the European Society of Cardiology, European Primary Care Cardiology Society (EPCCS).

Eur J Prev Cardiol 2021 Jul 16. Epub 2021 Jul 16.

Internal Medicine, Department of Medicine and Surgery, University of Insubria, ASST-settelaghi, Via Guicciardini 5, 21100 Varese, Italy.

Abstract: Frailty is a health condition leading to many adverse clinical outcomes. The relationship between frailty and advanced age, multimorbidity and disability has a significant impact on healthcare systems. Frailty increases cardiovascular (CV) morbidity and mortality both in patients with or without known CV disease. Though the recognition of this additional risk factor has become increasingly clinically relevant in CV diseases, uncertainty remains about operative definitions, screening, assessment, and management of frailty. Since the burdens of frailty components and domains may vary in the various CV diseases and clinical settings, the relevance of specific frailty-related aspects may be different. Understanding these issues may allow general cardiologists a clearer focus on frailty in CV diseases and thereby make more tailored clinical decisions and therapeutic choices in outpatients. Guidance on identification and management of frailty are sparse and an international consensus document on frailty in general cardiology is lacking. Moreover, new options linked with eHealth are going to better define and manage frailty. This consensus document on definition, assessment, clinical implications, and management of frailty provides an input to integrate strategies pre- and post-acute CV events with a comprehensive view including out of hospital, office-based diagnostic and therapeutic choices, and based on a multidisciplinary team approach (general cardiologists, nurses, and general practitioners).
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http://dx.doi.org/10.1093/eurjpc/zwaa167DOI Listing
July 2021

Second consensus document on diagnosis and management of acute deep vein thrombosis: updated document elaborated by the ESC Working Group on aorta and peripheral vascular diseases and the ESC Working Group on pulmonary circulation and right ventricular function.

Eur J Prev Cardiol 2021 Jul 13. Epub 2021 Jul 13.

Department of Cardiology, Dupuytren University Hospital and Inserm 1094, Tropical Neuroepidemiology, School of Medicine, 2 avenue martin Luther-King 87042 Limoges, France.

This consensus document is proposed to clinicians to provide the whole spectrum of deep vein thrombosis management as an update to the 2017 consensus document. New data guiding clinicians in indicating extended anticoagulation, management of patients with cancer, and prevention and management of post-thrombotic syndrome are presented. More data on benefit and safety of non-vitamin K antagonists oral anticoagulants are highlighted, along with the arrival of new antidotes for severe bleeding management.
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http://dx.doi.org/10.1093/eurjpc/zwab088DOI Listing
July 2021

Ultrasound Imaging of the Abdominal Aorta: A Comprehensive Review.

J Am Soc Echocardiogr 2021 Nov 2;34(11):1119-1136. Epub 2021 Jul 2.

Department of Cardiology, Dupuytren-2 University Hospital, and Inserm 1094 & IRD, Limoges University, Limoges, France.

Ultrasound is the imaging modality of choice for the initial evaluation of disorders that involve the abdominal aorta (AA). The diagnostic value of ultrasound resides in its ability to allow assessment of the anatomy and structure of the AA using two- dimensional, three-dimensional, and contrast-enhanced imaging. Moreover, ultrasound permits evaluation of the physiologic and hemodynamic consequences of abnormalities through Doppler interrogation of blood flow, thus enabling the identification and quantification of disorders within the AA and beyond its boundaries. The approach to ultrasound imaging of the AA varies, depending on the purpose of the study and whether it is performed in a radiology or vascular laboratory or in an echocardiography laboratory. The aim of this review is to demonstrate the usefulness of ultrasound imaging for the detection and evaluation of disorders that involve the AA, detail the abnormalities that are detected or further assessed, and outline its value for echocardiographers, sonographers, and radiologists.
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http://dx.doi.org/10.1016/j.echo.2021.06.012DOI Listing
November 2021

Risk of Thromboembolism in Non-Valvular Atrial Fibrillation With or Without Clinical Hyperthyroidism.

Glob Heart 2021 06 17;16(1):45. Epub 2021 Jun 17.

Division of Cardiology and Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, TW.

Background: Patients with hyperthyroidism have higher risk of atrial fibrillation (AF). However, the risk of thromboembolic event in patients with hyperthyroidism-related AF is controversial.

Objectives: The aim of the study was to examine the risk of thromboembolic events in AF patients with/without hyperthyroidism.

Methods: The national retrospective cohort study enrolled AF population was derived from the Taiwan National Health Insurance Research Database. The comparison between the AF patients with clinical hyperthyroidism (HT-AF group) and AF patients without hyperthyroidism (non-thyroid AF group) was made in a propensity score matched cohort and in a real-world setting, of which, the CHADS-VASc level was treated as a stratum variable. The outcomes were ischemic stroke and systemic thromboembolism.

Results: There were 3,880 patients in HT AF group and 178,711 in non-thyroid AF group. After propensity score analysis, the incidence of thromboembolism event and ischemic stroke were lower in HT AF patients than non-thyroid AF patients (1.6 versus 2.2 events per 100 person-years; HR, 0.73; 95% CI, 0.64-0.82 and 1.4 versus 1.8 events per 100 person-years; HR, 0.74; 95% CI, 0.64-0.84, respectively) in the 4.3 ± 3.2 year follow up period. The differences persistently existed in those receiving anticoagulants or not. In AF patients without anticoagulants, the incidence densities of ischemic stroke/systemic thromboembolism were significantly lower in HT AF group than those in non-thyroid AF group at CHADS-VASc scores ≤ 4 (HR, 0.41; 95% CI, 0.35-0.48, p < 0.001), while the differences disappeared in case of score ≥ 5 (HR, 0.80; 95% CI, 0.63-1.02, p = 0.071).

Conclusion: Patients with HT AF had lower incidence of thromboembolic events as compared to non-thyroid AF patients. The threshold of CHADS-VASc score for anticoagulation in AF patients with clinical hyperthyroidism should be further evaluated.

Highlights: The incidence of thromboembolic event was different between hyperthyroidism-related atrial fibrillation (HT-AF) and non-thyroid AF patients.Hyperthyroidism did not confer additional risk of thromboembolic event at CHADS-VASc of ≤ 4.The benefit of anticoagulation strategy in patients with hyperthyroidism-related AF should be further evaluated, especially at low CHADS-VASc score.
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http://dx.doi.org/10.5334/gh.871DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8212838PMC
June 2021

Low-dose rivaroxaban plus aspirin in patients with polypharmacy and multimorbidity: an analysis from the COMPASS trial.

Eur Heart J Cardiovasc Pharmacother 2021 Jun 30. Epub 2021 Jun 30.

Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.

Background: In patients with coronary or peripheral arterial disease, adding low dose rivaroxaban to aspirin reduces cardiovascular events and mortality. Polypharmacy and multimorbidity are frequent in such patients.

Aims: To analyze whether the benefits and risks of rivaroxaban plus aspirin varies in patients with comorbidities and receiving multiple drugs.

Methods And Results: We describe ischemic events (cardiovascular death, stroke, or myocardial infarction) and major bleeding in participants from the randomised, double-blind COMPASS study by number of cardiovascular medications and concomitant medical conditions. We compared event rates and hazard ratios (HR) for rivaroxaban plus aspirin versus aspirin alone by the number of medications and concomitant conditions, and tested for interaction between polypharmacy or multimorbidity and the antithrombotic regimen.The risk of ischemic events was higher in patients with more concomitant drugs (HR 1.7, 95%CI 1.5-2.1 for >4 vs 0-2) and with more comorbidities (HR 2.3, 1.8-2.1 for >3 vs 0-1). Multimorbidity, but not polypharmacy, was associated with a higher risk of major bleeding. The relative efficacy, safety, and net clinical benefit of rivaroxaban were not affected by the number of drugs or comorbidities. Patients taking more concomitant medications derived the largest absolute reduction in the net clinical outcome with added rivaroxaban (1.1% vs 0.4% reduction with >4 vs 0-2 cardiovascular drugs, NNT 91 vs 250).

Conclusion: Adding low-dose rivaroxaban to aspirin resulted in benefits irrespective of the number of concomitant drugs or comorbidities. Multiple comorbidities and/or polypharmacy should not dissuade the addition of rivaroxaban to aspirin in otherwise eligible patients.
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http://dx.doi.org/10.1093/ehjcvp/pvab050DOI Listing
June 2021

Secondary prevention after an acute cardiovascular event: far from targets and large room for improvement.

Eur J Prev Cardiol 2021 May 31. Epub 2021 May 31.

Department of Cardiology, Dupuytren University Hospital, Limoges, France.

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http://dx.doi.org/10.1093/eurjpc/zwab085DOI Listing
May 2021

Cardiovascular consequences of discontinuing low-dose rivaroxaban in people with chronic coronary or peripheral artery disease.

Heart 2021 07 21;107(14):1130-1137. Epub 2021 May 21.

Population Health Research Institute, Hamilton Health Sciences/McMaster University, Hamilton, Ontario, Canada.

Objective: In patients with chronic coronary or peripheral artery disease enrolled in the Cardiovascular Outcomes for People Using Anticoagulation Strategies trial, randomised antithrombotic treatments were stopped after a median follow-up of 23 months because of benefits of the combination of rivaroxaban 2.5 mg two times per day and aspirin 100 mg once daily compared with aspirin 100 mg once daily. We assessed the effect of switching to non-study aspirin at the time of early stopping.

Methods: Incident composite of myocardial infarction, stroke or cardiovascular death was estimated per 100 person-years (py) during randomised treatment (n=18 278) and after study treatment discontinuation to non-study aspirin (n=14 068).

Results: During randomised treatment, the combination compared with aspirin reduced the composite (2.2 vs 2.9/100 py, HR: 0.76, 95% CI 0.66 to 0.86), stroke (0.5 vs 0.8/100 py, HR: 0.58, 95% CI 0.44 to 0.76) and cardiovascular death (0.9 vs 1.2/100 py, HR: 0.78, 95% CI 0.64 to 0.96). During 1.02 years after early stopping, participants originally randomised to the combination compared with those randomised to aspirin had similar rates of the composite (2.1 vs 2.0/100 py, HR: 1.08, 95% CI 0.84 to 1.39) and cardiovascular death (1.0 vs 0.8/100 py, HR: 1.26, 95% CI 0.85 to 1.86) but higher stroke rate (0.7 vs 0.4/100 py, HR: 1.74, 95% CI 1.05 to 2.87) including a significant increase in ischaemic stroke during the first 6 months after switching to non-study aspirin.

Conclusion: Discontinuing study rivaroxaban and aspirin to non-study aspirin was associated with the loss of cardiovascular benefits and a stroke excess.

Trial Registration Number: NCT01776424.
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http://dx.doi.org/10.1136/heartjnl-2020-318758DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8257559PMC
July 2021

Vascular ultrasound for cardiovascular risk stratification in asymptomatic patients with type-2 diabetes.

Prim Care Diabetes 2021 08 23;15(4):726-732. Epub 2021 Apr 23.

INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France; Department of Cardiology, Dupuytren University Hospital, Limoges, France. Electronic address:

Aims: To identify new independent vascular markers to predict cardiovascular events in patients with type-2 diabetes (T2D), and their incremental value compared to the Swedish National Diabetes Register (NDR) risk score.

Methods: A retrospective cohort study was conducted on 1332 asymptomatic patients with T2D, free from prior CV event, assessed for a cardiovascular work-up, including Duplex ultrasonography to detect plaque on carotid and femoral arteries. The extent of atherosclerosis was rated as atherosclerosis burden score (ABS). Patients were followed up to 5 years and the occurrence of cardiovascular events recorded.

Results: A total of 82 patients (6.2%) experienced a cardiovascular event, including 34 (2.6%) myocardial infarction, 18 (1.4%) cardiac revascularisation and 17 (1.3%) stroke. The independent determinants of these events were male sex (HR = 1.81 [1.13-2.88], p = 0.013) and ABS ≥ 2 (HR = 1.98 [1.21-3.25], p = 0.007). The NDR risk score performed poorly to predict cardiovascular events (area under the curve = 0.56 [0.49-0.63], p = 0.11), whereas screening for atherosclerotic plaques provided significant incremental prognostic value over the NDR score (model χ2 increase: +231%, p = 0.002).

Conclusion: Duplex ultrasonography to screen for atherosclerotic plaques improve the estimation of cardiovascular prognosis on top of clinical data and could be routinely used to improve cardiovascular risk stratification.
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http://dx.doi.org/10.1016/j.pcd.2021.04.006DOI Listing
August 2021

Progress in aorta and peripheral cardiovascular disease research.

Cardiovasc Res 2021 07;117(9):2045-2053

Department of Cardiology, Dupuytren-2 University Hospital, and Inserm 1094 & IRD, Limoges University, Limoges, France.

Although coronavirus disease 2019 seems to be the leading topic in research number of outstanding studies have been published in the field of aorta and peripheral vascular diseases likely affecting our clinical practice in the near future. This review article highlights key research on vascular diseases published in 2020. Some studies have shed light in the pathophysiology of aortic aneurysm and dissection suggesting a potential role for kinase inhibitors as new therapeutic options. A first proteogenomic study on fibromuscular dysplasia (FMD) revealed a promising novel disease gene and provided proof-of-concept for a protein/lipid-based FMD blood test. The role of NADPH oxidases in vascular physiology, and particularly endothelial cell differentiation, is highlighted with potential for cell therapy development. Imaging of vulnerable plaque has been an intense field of research. Features of plaque vulnerability on magnetic resonance imaging as an under-recognized cause of stroke are discussed. Major clinical trials on lower extremity peripheral artery disease have shown added benefit of dual antithrombotic (aspirin plus rivaroxaban) treatment.
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http://dx.doi.org/10.1093/cvr/cvab144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8600478PMC
July 2021

HIV clinical stages and lower extremity arterial disease among HIV infected outpatients in Burundi.

Sci Rep 2021 04 15;11(1):8296. Epub 2021 Apr 15.

CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, INSERM, Univ. Limoges, Limoges, France.

Chronic disease of people living with human immunodeficiency virus (HIV) infection are now approaching those of the general population. Previous, in vitro studies shown that HIV causes arterial injuries resulting in inflammation and atherosclerosis but direct relationship between HIV infection clinical stages and lower extremity arterial disease (LEAD) remain controversial. No study assessed, with an accurate method, both the prevalence of LEAD and the influence of HIV severity on LEAD in HIV outpatients in Central Africa. A cross-sectional study was conducted among 300 HIV-infected outpatients, aged ≥ 40 years in Bujumbura, Burundi. All patients underwent ankle-brachial index (ABI) measurement and LEAD was diagnosed by ABI ≤ 0.9. The prevalence of LEAD was 17.3% (CI 95% 13.2-22.1). The mean age was 49.6 ± 7.1 years. On multivariable analysis, factors associated with LEAD were hypertension (OR = 2.42; 95% CI 1.10-5.80), and stage IV HIV clinical infection (OR = 4.92, 95% CI 1.19-20.36). This is the first study performed on a large HIV population in Central Africa, reporting high LEAD prevalence. It underlines the influence of HIV infection on peripheral atherosclerosis at latest clinical stages and the need for LEAD screening in HIV-infected patients.
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http://dx.doi.org/10.1038/s41598-021-87862-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8050048PMC
April 2021

The Role for Combined Antithrombotic Therapy With Platelet and Coagulation Inhibition After Lower Extremity Revascularization.

JACC Cardiovasc Interv 2021 04;14(7):796-802

Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA. Electronic address:

Evidence for antithrombotic treatment following lower extremity revascularization (LER) for peripheral artery disease (PAD) is limited, leading to weak and conflicting guideline recommendations and heterogeneous practice patterns. This variability in post-LER antithrombotic treatment raises quality-of-care issues that have long been under-studied. This Viewpoint reviews the most updated guidelines, currently-available evidence, and contemporary data about practice patterns and practitioner opinions in this area. Particular attention is paid to distinctions between antiplatelet therapy, anticoagulant therapy, and combination therapy in light of the recent VOYAGER-PAD (Vascular Outcomes Study of ASA [acetylsalicylic acid] Along with Rivaroxaban in Endovascular or Surgical Limb Revascularization for PAD) trial. The implications of VOYAGER-PAD pertaining to various subgroups of patients undergoing LER are explored. Overall, this Viewpoint argues for consideration of post-LER therapy targeted at both platelet function and the coagulation cascade, though further LER-specific analyses, including expected VOYAGER-PAD sub-analyses, are needed.
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http://dx.doi.org/10.1016/j.jcin.2021.01.035DOI Listing
April 2021

Arm Based on LEg blood pressures (ABLE-BP): can systolic leg blood pressure measurements predict systolic brachial blood pressure? Protocol for an individual participant data meta-analysis from the INTERPRESS-IPD Collaboration.

BMJ Open 2021 03 19;11(3):e040481. Epub 2021 Mar 19.

Primary Care Research Group, University of Exeter, Exeter, UK

Introduction: Blood pressure (BP) is normally measured on the upper arm, and guidelines for the diagnosis and treatment of high BP are based on such measurements. Leg BP measurement can be an alternative when brachial BP measurement is impractical, due to injury or disability. Limited data exist to guide interpretation of leg BP values for hypertension management; study-level systematic review findings suggest that systolic BP (SBP) is 17 mm Hg higher in the leg than the arm. However, uncertainty remains about the applicability of this figure in clinical practice due to substantial heterogeneity.

Aims: To examine the relationship between arm and leg SBP, develop and validate a multivariable model predicting arm SBP from leg SBP and investigate the prognostic association between leg SBP and cardiovascular disease and mortality.

Methods And Analysis: Individual participant data (IPD) meta-analyses using arm and leg SBP measurements for 33 710 individuals from 14 studies within the Inter-arm blood pressure difference IPD (INTERPRESS-IPD) Collaboration. We will explore cross-sectional relationships between arm and leg SBP using hierarchical linear regression with participants nested by study, in multivariable models. Prognostic models will be derived for all-cause and cardiovascular mortality and cardiovascular events.

Ethics And Dissemination: Data originate from studies with prior ethical approval and consent, and data sharing agreements are in place-no further approvals are required to undertake the secondary analyses proposed in this protocol. Findings will be published in peer-reviewed journal articles and presented at conferences. A comprehensive dissemination strategy is in place, integrated with patient and public involvement.

Prospero Registration Number: CRD42015031227.
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http://dx.doi.org/10.1136/bmjopen-2020-040481DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986760PMC
March 2021

Management of carotid stenosis for primary and secondary prevention of stroke: state-of-the-art 2020: a critical review.

Eur Heart J Suppl 2020 Nov 6;22(Suppl M):M35-M42. Epub 2020 Dec 6.

Department of Cardiology, Dupuytren University Hospital, INSERM 1094 & IRD, Limoges, France.

Carotid atherosclerotic plaque is encountered frequently in patients at high cardiovascular risk, especially in the elderly. When plaque reaches 50% of carotid lumen, it induces haemodynamically significant carotid stenosis, for which management is currently at a turning point. Improved control of blood pressure, smoking ban campaigns, and the widespread use of statins have reduced the risk of cerebral infarction to <1% per year. However, about 15% of strokes are still secondary to a carotid stenosis, which can potentially be detected by effective imaging techniques. For symptomatic carotid stenosis, current ESC guidelines put a threshold of 70% for formal indication for revascularization. A revascularization should be discussed for symptomatic stenosis over 50% and for asymptomatic carotid stenosis over 60%. This evaluation should be performed by ultrasound as a first-line examination. As a complement, computed tomography angiography (CTA) and/or magnetic resonance angiography are recommended for evaluating the extent and severity of extracranial carotid stenosis. In perspective, new high-risk markers are currently being developed using markers of plaque neovascularization, plaque inflammation, or plaque tissue stiffness. Medical management of patient with carotid stenosis is always warranted and applied to any patient with atheromatous lesions. Best medical therapy is based on cardiovascular risk factors correction, including lifestyle intervention and a pharmacological treatment. It is based on the tri-therapy strategy with antiplatelet, statins, and ACE inhibitors. The indications for carotid endarterectomy (CEA) and carotid artery stenting (CAS) are similar: for symptomatic patients (recent stroke or transient ischaemic attack ) if stenosis >50%; for asymptomatic patients: tight stenosis (>60%) and a perceived high long-term risk of stroke (determined mainly by imaging criteria). Choice of procedure may be influenced by anatomy (high stenosis, difficult CAS or CEA access, incomplete circle of Willis), prior illness or treatment (radiotherapy, other neck surgery), or patient risk (unable to lie flat, poor AHA assessment). In conclusion, neither systematic nor abandoned, the place of carotid revascularization must necessarily be limited to the plaques at highest risk, leaving a large place for optimized medical treatment as first line management. An evaluation of the value of performing endarterectomy on plaques considered to be at high risk is currently underway in the ACTRIS and CREST 2 studies. These studies, along with the next result of ACST-2 trial, will provide us a more precise strategy in case of carotid stenosis.
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http://dx.doi.org/10.1093/eurheartj/suaa162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7916422PMC
November 2020

International public awareness of peripheral artery disease.

Vasa 2021 07 1;50(4):294-300. Epub 2021 Mar 1.

Department of Cardiology, Dupuytren University Hospital, Limoges, France.

: Peripheral artery disease (PAD) of the lower limbs is a common condition with considerable global burden. Some country-specific studies suggest low levels of public awareness. To our knowledge public awareness of PAD has never been assessed simultaneously in several countries worldwide. : This was an international, general public, internet-based quantitative survey assessing vascular health and disease understanding. Questionnaires included 23 closed-ended multiple-choice, Likert scale and binary choice questions. Data were collected from 9,098 survey respondents from nine countries in Europe, North and Latin America during May-June 2018. : Overall, familiarity with PAD was low (57% of respondents were "not at all familiar", and 9% were "moderately" or "very familiar"). Knowledge about PAD health consequences was limited, with 55% of all respondents not being aware of limb consequences of PAD. There were disparities in PAD familiarity levels between countries; highest levels of self-reported awareness were in Germany and Poland where 13% reported to be "very" or "moderately" familiar with PAD, and lowest in Scandinavian countries (5%, 3% and 2% of respondents in Norway, Sweden and Denmark, respectively). There were disparities in awareness according to age. Respondents aged 25-34 were most familiar with PAD, with 12% stating that they were "moderately" or "very" familiar with the condition, whereas those aged 18-24 were the least familiar with PAD (7% "moderately" or "very" familiar with PAD). In the 45-54, 55-64 and 65+ age groups, 9% said they were "moderately" or "very" familiar with the term. There was no important gender-based difference in PAD familiarity. : On an international level, public self-reported PAD awareness is low, even though PAD is a common condition with considerable burden. Campaigns to increase PAD awareness are needed to reduce delays in diagnosis and to motivate people to control PAD risk factors.
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http://dx.doi.org/10.1024/0301-1526/a000945DOI Listing
July 2021

Type-2 diabetes patients at high risk for cardiovascular events: time to challenge the 'metformin-always first' paradigm.

Eur J Prev Cardiol 2021 03;28(1):66-68

Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Pl, Glasgow G12 8TA, UK.

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http://dx.doi.org/10.1093/eurjpc/zwaa157DOI Listing
March 2021

Thromboembolic events in atrial fibrillation: Different level of risk and pattern between peripheral artery disease and coronary artery disease.

Arch Cardiovasc Dis 2021 Mar 29;114(3):176-186. Epub 2021 Jan 29.

Division of Cardiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123, Ta Pei Road, Niao Sung District, 83301 Kaohsiung City, Taiwan. Electronic address:

Background: The existence of vascular disease in patients with atrial fibrillation (AF) is associated with an increased risk of thromboembolic events. It is unclear whether coronary artery disease (CAD) and/or peripheral artery disease (PAD) have similar presentations and complication rates.

Aim: To investigate thromboembolic events among patients with AF who have CAD, PAD or polyvascular disease.

Methods: Patients with a new diagnosis of AF without anticoagulation (n=306,386) were identified from the National Health Insurance Research Database in Taiwan (2001-2013). Ischaemic stroke (IS), systemic thromboembolism (STE) and their combination (IS/STE) were compared in four groups (No-CAD/PAD, CAD-only, PAD-only, CAD+PAD), and secondarily in patients with only CAD versus only PAD. Last, we compared propensity score-matched patients with only CAD or PAD with those with CAD and PAD.

Results: There were 185,169 patients without CAD or PAD, 8113 patients with only PAD, 105,715 patients with only CAD, and 7389 patients with CAD and PAD eligible for analysis (mean±SD follow-up 3.2±3.2 years). The incidences of STE and IS/STE differed in the four groups, with the highest in the CAD+PAD group and the lowest in the No-CAD/PAD group. The proportions of IS and STE also varied, with higher proportions of STE in patients with PAD, but higher proportions of IS in patients with CAD. After propensity score matching, the PAD-only group had significantly higher incidences of STE and IS/STE than the CAD-only group, across all levels of CHADS-VASc score. Patients with CAD and PAD had a significantly higher incidence of STE and IS/STE than propensity score-matched patients with CAD or PAD.

Conclusions: PAD or CAD in patients with AF did not contribute equally to the risk prediction and presentation of IS and STE. Patients with polyvascular disease should be considered at higher risk than those with either condition.
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http://dx.doi.org/10.1016/j.acvd.2020.11.004DOI Listing
March 2021

The mortality rates in registries of patients with STEMI are highly affected by inclusion criteria and population characteristics.

Acta Cardiol 2021 Jul 22;76(5):504-512. Epub 2021 Jan 22.

CHU Limoges, Hôpital Dupuytren, Limoges, France.

Background: Different mortality rates are reported in registries of patients with ST-segment elevation myocardial infarction (STEMI), but comparisons between registries are challenging.

Aims: To determine whether the higher mortality rate in our regional French registry (SCALIM) is related to different inclusion criteria and demographic characteristics.

Methods: The SCALIM registry included all patients with STEMI within the first 24 h in the region of Limousin, France (06/2011-01/2015). To compare mortality rates with other contemporary registries in France and European neighbouring countries, the others' inclusion criteria were applied to the SCALIM registry.

Results: Among 1501 patients included, in-hospital and 1-month mortality were 8.2% and 8.8% respectively, significantly higher than many other registries. The use of inclusion criteria from EMUST (France), MINAP (UK) or LOMBARDIMA (Italy) markedly decreased the number of enrolled patients by 64%, 36%, and 21%, respectively. When those inclusion criteria were applied to the SCALIM registry, difference in in-hospital and 1-month mortality rates between other registries and ours remained significant. In the multivariate analysis, age, initial acute pulmonary oedema (Killip class ≥2), complication occurring before percutaneous coronary intervention, absence of transfer to an interventional cardiology centre for primary angioplasty and lack of reperfusion therapy within 12 h were associated with higher risk of 1-month mortality (all  < 0.05). Age (65 versus 63.3 years,  < 0.001) was higher and reperfusion rate (84.2 versus 74.7%,  < 0.001) was significantly lower in SCALIM than FAST-MI, the national French registry on STEMI patients. Interestingly, the 3% of patients included in SCALIM who would be excluded from FAST-MI registry had 91% mortality at one month.

Conclusion: Higher mortality rate in our regional SCALIM registry is in part due to differences in inclusion criteria and demographic data. Consensus should be made to harmonise inclusion criteria in STEMI registries for the sake of comparability.
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http://dx.doi.org/10.1080/00015385.2020.1848970DOI Listing
July 2021

Cardiovascular Health and Near Visual Impairment Among Older Adults in the Republic of Congo: A Population-Based Study.

J Gerontol A Biol Sci Med Sci 2021 04;76(5):842-850

INSERM, Univ. Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France.

Background: Visual impairment (VI) and determinants of poor cardiovascular health are very common in Sub-Saharan Africa. However, we do not know whether these determinants are associated with VI among older adults in this region. This study aimed at investigating the association between the determinants of poor cardiovascular health and near VI among older adults living in Congo.

Methods: Participants were Congolese adults aged 65 or older included in Epidemiology of Dementia in Central Africa-Follow-up population-based cohort. Near VI was defined as visual acuity less than 20/40 measured at 30 cm. Associations between determinants of poor cardiovascular health collected at baseline and near visual acuity measured at first follow-up were investigated using multivariable logistic regression models.

Results: Among the 549 participants included, 378 (68.8%; 95% confidence interval [CI]: 64.9%-72.7%]) had near VI. Of the determinants of poor cardiovascular health explored, we found that having high body mass index of at least 25 kg/m2 (odds ratio [OR] = 2.15; 95% CI: 1.25-3.68), diabetes (OR = 2.12; 95% CI: 1.06-4.25) and hypertension (OR = 1.65; 95% CI: 1.02-2.64) were independently associated with near VI.

Conclusions: Several determinants of poor cardiovascular health were associated with near VI in this population. This study suggests that promoting good cardiovascular health could represent a target for VI prevention among older adults.
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http://dx.doi.org/10.1093/gerona/glaa304DOI Listing
April 2021

Tc-99m HMDP bone scintigraphy for cardiac amyloidosis diagnosis: A false positive case.

J Nucl Cardiol 2021 Jan 3. Epub 2021 Jan 3.

Department of Nuclear Medicine, CHU Dupuytren, 2 rue Martin Luther King, 87000, Limoges, France.

A 68-year-old man with heart failure (left ventricular ejection fraction = 30%) and normal coronary angiography underwent bone scintigraphy for suspected transthyretin-related cardiac amyloidosis (CA).1 He received 532 MBq (14.3 mCi) Tc-99m hydroxy-methyl-diphosphonate (HMDP) and data were acquired 2 hours after injection. On anterior and posterior whole-body scans (Figure 1 A and B), diffuse cardiac, hepatic, and soft-tissue uptake of the radiotracer was seen, in association with low skeletal uptake. It was established that the patient had recently been hospitalized for heart failure exacerbation and had received an intravenous iron injection, which is a recommended treatment for heart failure.2 In consultation with our hospital's cardiology team, it was decided to repeat the bone scan at a time when the patient had received no recent iron infusion. Two months after the first bone scan, the patient received 556 MBq (15 mCi) of 99m-Tc HMDP, and no cardiac, hepatic, or soft-tissue uptake was detected (Figure 1C and D).
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http://dx.doi.org/10.1007/s12350-020-02451-3DOI Listing
January 2021

Associations Between Systolic Interarm Differences in Blood Pressure and Cardiovascular Disease Outcomes and Mortality: Individual Participant Data Meta-Analysis, Development and Validation of a Prognostic Algorithm: The INTERPRESS-IPD Collaboration.

Hypertension 2021 02 21;77(2):650-661. Epub 2020 Dec 21.

NIHR Exeter Clinical Research Facility, Royal Devon and Exeter Hospital and University of Exeter College of Medicine & Health, England (A.C.S.).

Systolic interarm differences in blood pressure have been associated with all-cause mortality and cardiovascular disease. We undertook individual participant data meta-analyses to (1) quantify independent associations of systolic interarm difference with mortality and cardiovascular events; (2) develop and validate prognostic models incorporating interarm difference, and (3) determine whether interarm difference remains associated with risk after adjustment for common cardiovascular risk scores. We searched for studies recording bilateral blood pressure and outcomes, established agreements with collaborating authors, and created a single international dataset: the Inter-arm Blood Pressure Difference - Individual Participant Data (INTERPRESS-IPD) Collaboration. Data were merged from 24 studies (53 827 participants). Systolic interarm difference was associated with all-cause and cardiovascular mortality: continuous hazard ratios 1.05 (95% CI, 1.02-1.08) and 1.06 (95% CI, 1.02-1.11), respectively, per 5 mm Hg systolic interarm difference. Hazard ratios for all-cause mortality increased with interarm difference magnitude from a ≥5 mm Hg threshold (hazard ratio, 1.07 [95% CI, 1.01-1.14]). Systolic interarm differences per 5 mm Hg were associated with cardiovascular events in people without preexisting disease, after adjustment for Atherosclerotic Cardiovascular Disease (hazard ratio, 1.04 [95% CI, 1.00-1.08]), Framingham (hazard ratio, 1.04 [95% CI, 1.01-1.08]), or QRISK cardiovascular disease risk algorithm version 2 (QRISK2) (hazard ratio, 1.12 [95% CI, 1.06-1.18]) cardiovascular risk scores. Our findings confirm that systolic interarm difference is associated with increased all-cause mortality, cardiovascular mortality, and cardiovascular events. Blood pressure should be measured in both arms during cardiovascular assessment. A systolic interarm difference of 10 mm Hg is proposed as the upper limit of normal. Registration: URL: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42015031227.
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.120.15997DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803446PMC
February 2021

Association of pulse wave velocity and pressure wave reflection with the ankle-brachial pressure index in Japanese men not suffering from peripheral artery disease.

Atherosclerosis 2021 01 29;317:29-35. Epub 2020 Nov 29.

Department of Cardiology, Tokyo Medical University, Tokyo, Japan.

Background And Aims: We examined the cross-sectional and longitudinal association of arterial stiffness and pressure wave reflection with the ankle-brachial pressure index (ABI) in middle-aged Japanese subjects free of peripheral artery disease (PAD).

Methods: ABI, brachial-ankle pulse wave velocity (baPWV) and radial augmentation index (rAI) were measured annually during the 9-year observation period in 3066 men (42 ± 9 years old) with ABI ≥1.00 at baseline of the study period, and not taking any antihypertensive medication.

Results: In the cross-sectional assessments, mediation analysis demonstrated that baPWV showed both direct and indirect (via the rAI) associations with ABI, and rAI showed both direct and indirect (via the heart-arm difference of systolic blood pressure) associations with the ankle-arm difference of systolic blood pressure, both at study baseline and end of study period. Mixed model linear regression analysis of the repeated-measurement data obtained over the 9-year observation period demonstrated that annual increase of baPWV (estimate = 0.73 × 10, p < 0.01) and rAI (estimate = 0.33 × 10, <0.01) was associated with ABI. When baPWV and rAI were entered into the same model, only baPWV showed a significant longitudinal association with ABI.

Conclusion: In middle-aged Japanese men free of PAD, arterial stiffness may contribute to ABI directly and via pressure wave reflection. Pressure wave reflection may contribute to ABI directly and, at least in part, via attenuation of peripheral pulse pressure amplification.
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http://dx.doi.org/10.1016/j.atherosclerosis.2020.11.031DOI Listing
January 2021

The ESC Working Group on Aorta & Peripheral Vascular Diseases.

Eur Heart J 2020 11;41(44):4221-4223

Department of Angiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland.

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http://dx.doi.org/10.1093/eurheartj/ehaa620DOI Listing
November 2020
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