Evaluation of lipid profile in the peripheral arterial disease
(Portuguese
PDF version)
Paulo Kauffman *
*
Ph.D. Assistant Professor, Vascular Surgery, Department of Surgery,
Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP,
Brazil.
J
Vasc Br 2005;4(2):120-1
The peripheral
obstructive arterial disease (PAD) has been progressively growing in
importance in clinical practice, due to an increased life expectancy.
Its prevalence depends on the diagnostic criteria used, being significantly
higher when the ankle-brachial pressure index is used than when estimated
only based on intermittent claudication.
The etiology
for almost all patients is the arteriosclerosis, a disease which has
a systemic character, with high morbidity and mortality rates, mainly
when the coronary or cerebral arteries are affected.
The association
of PAD with coronary and/or cerebrovascular disease is frequent. In
the classic study by Cleveland Clinic, the arteriosclerotic impairment
of the coronary arteries was found in 90% of hospitalized patients with
peripheral arterial disease, asymptomatic from the cardiac point of
view, routinely submitted to coronary angiography, considering that
28% of them had tri-arterial disease with a surgical indication.1
Regarding the cerebrovascular disease, it was observed that approximately
20% of patients with PAD, who were assessed by the duplex scan, already
presented carotid artery stenosis greater than 50%, and around 15% greater
than 75%.2
The survival
of patients with PAD is inversely proportional to the level of ischemia
in the limb, being twice lower in claudicants and three to four times
lower in patients with critical ischemia, comparing to the population
at the same age group with no peripheral arterial disease.3
Since in
most cases it is easily diagnosed clinically, even in its early stages,
the PAD has become a marker of the systemic arteriosclerotic disease.
Risk factors
implied in the PAD are the same reported for the coronary and carotid
arteriosclerosis, but the importance order of these factors is different
for the peripheral arteriosclerosis. Under these circumstances, smoking
represents the major risk factor, both as a predisposing and aggravating
factor in its progression,4 besides being
a risk factor strongly associated with aortic aneurysms.5
Dyslipidemia, on its turn, is a known major factor for the coronary
artery disease, but the same unanimity does not occur for the peripheral
arterial disease. Particularly for degenerative arterial aneurysms,
the relation with the arteriosclerotic disease is controversial. In
these aneurysms, enzymatic factors, which allow the elastin and collagen
fragmentation in the elastic artery wall, seem to be more important
than occasional parietal lipid alterations. However, some authors have
reported an association of these aneurysms with hypercholesterolemia
and hypertriglyceridemia, the latter being strongly related to death
by aortic aneurysm rupture.6,7
In the
study published in this issue of the Jornal Vascular Brasileiro,
by Brandão et al.,8 the evaluation of lipid
profile in patients with peripheral arterial disease revealed a significant
reduction in the levels of HDL cholesterol, comparing to the control
group, a finding which has already been made by Yoshida et al. at the
Faculdade de Medicina de Botucatu.9
Increased levels of LDL cholesterol in patients with obstructive disease,
when compared to patients with aneurysmatic disease, show a higher risk
of cardiovascular events in those cases, mainly because they present
a lower protective effect of the HDL cholesterol in association. It
is also suggestive that this association of factors represents a risk
factor for the peripheral arteriosclerosis.
It is surprising
in the study by Brandão et al.8 the low
frequency of the association of smoking with PAD and with the aneurysmatic
arterial disease, since, as previously mentioned, smoking is considered
a major risk factor for both diseases.
The use
of cholesterol and triglyceride reducers, particularly vastatins, launched
in the market in the 1980's, has proven to be useful for the treatment
of the arteriosclerotic disease, not only by reducing the levels of
LDL cholesterol in the blood, but also by having protective effects,
such as an improvement in the endothelial function, reduction in the
inflammation, etc. The stabilization of the atheroma plaque results
in beneficial effects in several organic territories, including in the
peripheral circulation. Vastatins significantly reduce morbidity and
mortality which have a cardiac cause in patients with peripheral arterial
disease, as showed by Durazzo et al., using the atorvastatin in the
perioperative of peripheral arterial surgeries, independently from preoperative
lipemic levels.10
The frequent
association of dyslipidemia with peripheral arterial disease and the
beneficial effects of its repair make the study of the lipid profile
obligatory for all patients with arteriopathy.
In conclusion,
the angiologist and the vascular surgeon may and should diagnose and
globally treat their patients, offering them the opportunity to live
longer with a better quality of life.
1.
Hertzer NR, Beven EG, Young JR, et al. Coronary artery disease in peripheral
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Alexandrova NA, Gibson WC, Norris JW, Maggisano R. Carotid artery stenosis
in peripheral vascular disease. J Vasc Surg 1996;23:645-9.
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Criqui MH, Langer RD, Fronek A, et al. Mortality over a period of 10
years in patients with peripheral arterial disease. N Eng J Med 1992;326:381-6.
4.
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des membres inferieures. Drugs 1998;56 (Suppl. 3):1.
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Lederle FA, Johnson GR, Wilson SE, et al. Prevalence and associations
of abdominal aortic aneurysm detected through screening. Aneurysm detection
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Intern Med 1997;126:441-9.
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Suarez BK. Honolulu heart study. Review of genetic analyses. Prog Cli
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Brandão AC, Trindade DM, Pinhel MA. Avaliação do
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as risk factors for patients with peripheral arterial disease. J Vasc
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Durazzo AES, Machado FS, Ikeoka DT, et al. Reduction in cardiovascular
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