The epidemiology of subclavian stenosis and its association with markers of subclinical atherosclerosis: The Multi-Ethnic Study of Atherosclerosis (MESA)
Introduction
The term peripheral arterial disease (PAD) is usually associated with the presence of atherosclerotic occlusive lesions affecting the lower limb arteries. It is frequently associated with atherosclerosis in other vascular beds, and predicts subsequent cardiovascular (CVD) events [1], [2], [3]. Although ischemic symptoms are much less frequent in the upper compared to the lower limbs, atherosclerosis also affects the upper limbs, especially the subclavian (and innominate) arteries, and may likewise be a marker of diffuse atherosclerosis and increased risk for cardiovascular events [4], [5]. The simplest method to detect subclavian stenosis (SS) is to compare the systolic blood pressures in the left and right brachial arteries [4], [5]. Using angiography [4], a threshold difference of at least 15 mmHg between both arms appears to be an optimal cut-point for defining SS, and has been found to be associated with CVD risk factors and other cardiovascular comorbidities [5].
Data on the epidemiology of SS in the general population are scarce [5], [6], [7]. Moreover, to our knowledge no data on ethnic-specific prevalence of SS has previously been reported. The Multi-Ethnic Study of Atherosclerosis (MESA) provides a unique opportunity to describe the epidemiology of SS in an ethnically diverse cohort and to investigate its relationships with both CVD risk factors and subclinical CVD. We hypothesized that SS is positively associated with risk factors for CVD while also being significantly associated with a higher prevalence of subclinical CVD in other major vascular beds.
Section snippets
Subjects
MESA investigates the prevalence, correlates, and progression of subclinical CVD in a multi-ethnic, population-based sample of 6814 men and women aged 45–84 years, free of clinical cardiovascular diagnoses at baseline [8]. Participants were enrolled and initially examined from 2000 to 2002 at six U.S. field centers: Baltimore City and Baltimore County, MD; Chicago, IL; Forsyth County, NC; Los Angeles County, CA; Northern Manhattan and the Bronx, NY; and St. Paul, MN. The study included 53%
Results
We excluded 71 (1%) study participants who had missing data on brachial systolic blood pressure, leaving 6743 subjects for the analysis. The distribution is presented in Fig. 1. The mean SBPD of the study population was −0.63 ± 7.17 mmHg. In 48.1% of participants, the left arm SBP was higher than the right one; the opposite occurred in 38.7%. Both arms’ SBPs were exactly equal in 13.2%. Overall, 307 participants (4.5%) had SS (left side, 41.7%; right side, 58.3%). Total SS prevalence was higher in
Discussion
The results of this study support the hypothesis that subclavian stenosis is independently associated with PAD (ABI ≤ 0.90), carotid intima-media thickness (highest vs. other quartiles) and coronary artery calcium score (>100). Additionally, SS was found to be significantly more frequent among women than men, and in non-Hispanic whites and African Americans than in Hispanics and Chinese Americans. Significant fully adjusted risk factor associations were limited to pulse pressure and C-reactive
Conclusion
Subclavian stenosis was common in our cohort, especially in non-Hispanic whites and African Americans. In our study, an elevated pulse pressure and C-reactive protein were found to be positively and significantly associated with SS, independently of other risk factors. Other cardiovascular risk factors were shown to be related to SS, although not significantly so, including smoking, diabetes, hypertension, BMI, and dyslipidemia. Subclavian stenosis appears to be associated with subclinical CVD
Acknowledgements
This research was supported by contracts N01-HC-95159 through N01-HC-95165 and N01-HC-95169 from the National Heart, Lung, and Blood Institute. The authors thank the other investigators, the staff, and the participants of the MESA study for their valuable contributions. A full list of participating MESA investigators and institutions can be found at http://www.mesa-nhlbi.org.
References (30)
- et al.
Subclavian stenosis: the prevalence, risk factors and association with other cardiovascular diseases
J Am Coll Cardiol
(2004) - et al.
The vital prognosis of subclavian stenosis
J Am Coll Cardiol
(2007) - et al.
Comparison of Dinamap Pro-100 and mercury sphygmomanometer blood pressure measurements in a population study
Am J Hypertens
(2006) - et al.
Cholestrol measures to identify and treat individuals at risk of coronary heart disease
Am J Prev Med
(2003) - et al.
Intrinsic contribution of gender and ethnicity to normal ankle-brachial index values: the Multi-Ethnic Study of Atherosclerosis (MESA)
J Vasc Surg
(2007) - et al.
Can we improve the cardiovascular risk prediction beyond risk equations in the physician's office?
J Clin Epidemiol
(2006) - et al.
Aortic arch angiography prior to carotid endarterectomy. Is its continued use justified?
Eur J Vasc Endovasc Surg
(1997) - et al.
Mortality over a period of 10 years in patients with peripheral arterial disease
N Engl J Med
(1992) - et al.
ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing;TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation
Circulation
(2006) - Norgren L, Hiatt WR, Dormandy JA, et al., on behalf of the TASC II working group. Inter-society consensus for the...
Screening for subclavian stenosis in patients who are candidates for coronary bypass surgery
Cathet Cardiovasc Intervent
Patient characteristics and factors associated with inter-arm difference of blood pressure measurements in a general population in Ohasama, Japan
J Hypertens
Multi-ethnic study of atherosclerosis: objectives and design
Am J Epidemiol
The arterial system in human hypertension
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