Femoral atherosclerosis in an older British population: prevalence and risk factors
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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2022, Journal of the American College of CardiologyCitation Excerpt :In the PESA (Progression of Early Subclinical Atherosclerosis) study, femoral plaque burden (3D volume) had a stronger association with traditional risk factors than carotid plaque burden.16 In a subgroup of 784 randomly selected individuals from the British Regional Heart study, our team demonstrated that those with plaques at the common femoral bifurcations had a significantly higher prevalence of ischemic heart disease (odds ratio [OR]: 2.2; 95% CI: 1.3-3.7) and angina (OR: 1.7; 95% CI: 1.03-2.7) but not stroke or leg pain on exercise.12 That the presence of femoral plaques is potentially a stronger indicator of cardiovascular risk has been demonstrated in a recent cross-sectional study involving 1,423 men, aged 40-59 years, who had carotid and femoral ultrasonography plus noncontrast coronary computed tomography.
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2022, AtherosclerosisCitation Excerpt :Atherosclerosis was present in ∼40% of patients classified to be at low long-term risk and ∼60% of those at intermediate risk. Femoral plaques had a stronger association with prevalent coronary events than carotid plaques [24]. Global plaque burden defined as the sum of all plaque volumes in both carotid and both common femoral bifurcation were obtained in a cross-sectional study of the PESA (Progression of Early Subclinical Atherosclerosis) cohort.