Elsevier

Atherosclerosis

Volume 152, Issue 1, 1 September 2000, Pages 167-174
Atherosclerosis

Femoral atherosclerosis in an older British population: prevalence and risk factors

https://doi.org/10.1016/S0021-9150(99)00447-5Get rights and content

Abstract

Most estimates of the prevalence of peripheral atherosclerosis have been based on intermittent claudication or lower limb blood flow. The aim of this study was therefore to determine the prevalence of underlying femoral plaque, and to determine its association with other cardiovascular disease and risk factors. Presence of plaque was identified using ultrasound in a random sample of men (n=417) and women (n=367) aged 56–77 years. Coexistent cardiovascular disease, exercise and smoking were determined by questionnaire, blood pressure was recorded, and serum cholesterol and plasma fibrinogen were determined. Of the 784 subjects that were scanned, 502 (64%) demonstrated atherosclerotic plaque. Disease prevalence increased significantly with age (P<0.0001), and was more common in men (67.1 vs. 59.4%, P<0.05). Subjects with femoral plaque had a significantly greater odds of previous ischaemic heart disease (OR 2.2, 95% CI 1.3, 3.7) and angina (OR 1.7, 95% CI 1.03, 2.7), but not of stroke or leg pain on exercise. Current and ex-smoking, raised serum total cholesterol and plasma fibrinogen levels, but not blood pressure, were associated with an increased risk of femoral plaque, independent of age and sex. Frequent exercise and a high HDL cholesterol were significantly associated with lower risk. In conclusion, therefore, atherosclerotic disease of the femoral artery affects almost two-thirds of the population in late middle age. It is associated with an increased prevalence of ischaemic heart disease and angina, but whether detecting at risk individuals using ultrasound offers advantages over simpler and less expensive risk factor scoring requires evaluation in trials.

Introduction

Lower limb arterial disease is an important cause of morbidity in the general population, particularly in elderly people [1]. It is associated with a significantly increased risk of death, primarily from coronary heart disease [2], [3]. The most common symptom associated with lower limb disease is intermittent claudication, a characteristic pain in the muscles of the calf that appears on exercise and is relieved by rest. Population surveys suggest the prevalence of claudication increases with age, and affects ∼4.5% of middle-aged men in the United Kingdom [1]. Risk factors for intermittent claudication are similar to those for coronary heart disease, including raised systolic blood pressure, elevated serum cholesterol and cigarette smoking [1], [4]. Smoking, however, appears to be more important in the aetiology of lower limb disease than heart disease [5], [6], although reasons for this are not clear.

More recent studies have attempted to determine the prevalence of asymptomatic peripheral arterial disease using indirect tests of blood flow, such as the ankle brachial systolic pressure ratio (ABPI). Using this technique, ∼15–20% of a middle-aged population have significant disease indicated by an ABPI ≤0.9 [7]. Patients with a reduced ABPI also have an increased risk of coronary events [8], [9], but show a slightly weaker association with conventional risk factors than patients with intermittent claudication [7].

Modern ultrasound techniques now permit direct assessment of arterial thickening, enabling the prevalence of atherosclerotic plaque to be determined more accurately [10], [11]. Studies of disease in the carotid artery suggest that plaque affects 25% [12] to 57% [13] of middle-aged men, but the prevalence of atherosclerotic plaque in the lower limb using this technique has not been reported. The aim of this study was to determine the prevalence of plaque in the common femoral artery using ultrasound, in a population sample drawn from the British Regional Heart Study, and to determine the association between plaque, cardiovascular disease and risk factors.

Section snippets

Study population

The study population was recruited from Dewsbury and Maidstone, two towns selected from the British Regional Heart Study (BRHS). The baseline response rates were 79% in Dewsbury and 72% in Maidstone. These towns had wide differences in the prevalence of coronary heart disease, high in Dewsbury and low in Maidstone [14], and were therefore selected for further investigation using ultrasound.

A total of 513 men and 545 women were invited by letter to attend a clinic for ultrasound examination. All

Response rates

Response rates were slightly higher for men than women: 481 men completed a questionnaire (93.8%) and 417 attended for an ultrasound examination (81.3%), compared with 441 women (80.9%) completing a questionnaire and 367 (67.3%) attending for ultrasound. There were no significant differences between the response rates in Dewsbury and Maidstone.

Prevalence of femoral plaque and coexistent cardiovascular disease

Of the 784 subjects who were scanned, 502 (64.0%) had evidence of atherosclerotic plaque in one of their femoral arteries (Table 1). In Dewsbury, 68.9%

Prevalence of femoral plaque and coexistent cardiovascular disease

This paper is the first report of the prevalence of femoral plaque identified by ultrasound in the general population. Almost two-thirds of the subjects who were scanned showed evidence of femoral plaque. This is almost three times higher than the proportion expected to show evidence of disease on testing with the ankle brachial pressure index [7], and therefore suggests that ultrasound is able to detect much less severe disease. Most epidemiological studies of intermittent claudication

Conclusions

Atherosclerosis of the femoral artery is very common in the general population, affecting almost two-thirds of men and women in late middle age. The proportion of people with femoral plaques who might also be recognised by their associated symptoms is relatively small. As ultrasound detected femoral plaques are associated with risk factors, prevalent disease and predictive risk scores, it is likely that those people with femoral plaques will have a high risk of clinical cardiovascular events.

Acknowledgements

We thank the Stroke Association for funding this study and the Department of Health and the British Heart Foundation for programme grant funding of the British Regional Heart Study. We also thank the CDER Trust for funding the ultrasound equipment. We are grateful to the two general practices who collaborated in the field work, to our field team (Stella Barlow RGN, Annalise Hamilton RGN and Lucy Lennon BSc) who carried out the field work and all the participants of the British Regional Heart

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