Atherosclerosis is a multifactorial disease, with
hypertension (HT), hyperlipidaemia (HPL), diabetes mellitus
(DM), smoking and other vascular risk factors.
Atherosclerosis is a chronic disease which begins in
childhood. It progresses asymptomatically in adulthood and
finally manifests itself clinically at a certain point. The same
pathological process in atherosclerosis can have a similar
impact on all vessels in the body, leading to coronary artery
disease (CAD), cerebrovascular disease (CVD), and
peripheral arterial disease (PAD).1
PAD is observed in 12-14% of the general
population. It often co-exists with CAD and CVD,
particularly in older people. Most patients with PAD
ultimately die as a result of a cardiac or cerebrovascular
event. Modifiable risk factors for PAD have been reported
to be smoking, HPL, HT, DM, and metabolic syndrome
(MS). PAD is more common in males and older people.2
The risk factors for CAD and PAD are similar. The risk
factors for CAD have been reported to be a family history
of CAD, HT, decreased levels of HDL-cholesterol, elevated
levels of LDL-cholesterol, DM and smoking.3
Vol. 62, No. 7, July 2012644
Relationship of the angiographic extent of peripheral arterial
disease with coronary artery involvement
Omer Satiroglu,1Sinan Altan Kocaman,2Zakir Karadag,3Ahmet Temiz,4Mustafa Çetin,5Aytun Canga,5Turan Erdogan,7
Mehmet Bostan,8Yuksel Cicek,9Emre Durakoglugil,10Mutlu Vural,11Engin Bozkurt12
Cardiology Department, Rize University School of Medicine, Rize,1,7-10,12Cardiology Department, Education and Research Hospital, Rize,2-6
Cardiology Department, John F. Kennedy Hospital, Istanbul,11Turkey.
Corresponding Author: Ömer Satiroglu. E-mail: firstname.lastname@example.org
Objective: To determine the co-incidence of coronary artery disease (CAD) in patients investigated for peripheral
arterial disease (PAD), and to establish the relationship between the risk factors in the two groups of patients.
Methods: The prospective study, done from January 2005 and April 2009, at the Cardiology Clinic of Rize
Education and Research Hospital, Rize and John F. Kennedy Hospital, Istanbul, Turkey, had a cohort of 307
patients who had been diagnosed with peripheral artery disease either clinically or by ultrasonography for the
arteries of the lower extremities and had undergone coronary angiography and peripheral angiography in the
same or different sessions. The patients were evaluated in terms of age, gender and atherosclerotic risk factors.
Relationship of the extent of peripheral arterial disease with coronary artery involvement was investigated.
Results: Of the 307 patients, 251 (81.8%) were male, and the mean age was 62.1±9.5 years. In the study
population, 178 (58.0%) patients were diagnosed as hypertensive, 84 (27.4%) patients were diabetic, 18 (5.9%)
patients had a family history of coronary artery disease, 111 (36.2%) were smokers, 149 (48.5%) were
hypercholesterolemic, and 20 (6.5%) had cerebrovascular/carotid disease. In 92.3% of patients with peripheral
arterial disease, various levels of coronary stenosis (P=0.007) was noticed. Hypertension was a risk factor for both
coronary and peripheral artery diseases (p=0.012 and 0.027, respectively). Univariate logistic regression analysis
demonstrated that the presence of peripheral artery disease was related to the coronary variety (Odds ratio [OR]:
6, 95% CI: 1.4-25.5, P=0.016) and severe cases (diffused atherosclerotic stenosis and complete occlusion in all
segments) significantly indicated the presence of some coronary pathology (OR: 8, 95%CI: 1.7-37.4, P=0.008).
This relationship maintained its significance after adjustment for age, gender, hypercholesterolaemia, smoking,
hypertension, diabetes, family history, and the presence of cerebrovascular/carotid disease (p=0.010).
Conclusions: Peripheral coronary artery diseases had similar risk factors. The extent of peripheral arterial
disease observed during peripheral lower extremity angiography was significantly associated with the presence
and severity of coronary artery disease. Particular attention should be focused on the possibility of coronary
artery disease in patients with established and extensive peripheral arterial disease. Non-invasive, as well as
invasive tests, should be performed to decrease morbidity and mortality risk of such patients.
Keywords: Peripheral arterial disease, Coronary artery disease, Peripheral angiography, Coronary angiography,
Arteries of the lower extremity, Risk factors. (JPMA 62: 644; 2012)
Despite its comparatively young population, Turkey
has a high prevalence of atherosclerotic disease and
associated mortality. A number of studies investigating the
risk factors for CAD have reported that though total
cholesterol levels were lower than those observed in Western
Europe, Turkey has a huge population of smokers, that carry
risk factors like DM, HT and a high incidence of metabolic
syndrome. Besides, obesity, particularly in females, has also
The current study was conducted to determine the
coincidence of CAD in patients investigated for PAD, and to
establish the relationship between the risk factors in the two
groups of patients.
Patients and Methods
The patients who had been diagnosed with PAD by
either clinical examination or Doppler ultrasonography for
the arteries of the lower extremities and underwent coronary
angiography and peripheral angiography in the same or in
another session between January 2005 and April 2009 were
prospectively enrolled in current study. The study was
conducted in the Cardiology Clinic of the Rize Education and
Research Hospital, Rize and John F. Kennedy Hospital,
The patients were evaluated in terms of age, gender
and atherosclerotic risk factors. Medical histories, records of
physical examination and the cardiovascular risk factors of all
patients were also assessed. Of the major cardiovascular risk
factors, the presence of family history of premature CAD in
first-degree relatives, presence of CAD or diagnosed
myocardial infarction in males <55years and females <65
years), HT (systolic blood pressure >140 mmHg and diastolic
blood pressure > 90 mmHg in at least two distinct readings,
or previously receiving anti-hypertensive medications), DM
(fasting blood glucose >126 mg/dl, or previously receiving
anti-diabetic medications), HPL (fasting blood total
cholesterol >200 mg/dl, or fasting blood low-density
lipoprotein levels > 130 mg/dl or previously receiving anti-
hyperlipidemic medications) and smoking habits were
recorded. Total cholesterol and LDL levels of the morning
blood samples, obtained from the patients after a 12-hour
fasting a day before coronary angiography procedure, was
measured with standard enzymatic colorimetric methods.
LDL levels were calculated using the Friedewald formula.
Informed consent was obtained from all patients. The
study was performed in accordance with the principles stated
in the Helsinki Declaration and was approved by the Ethics
Committee. Patients were excluded if they had renal failure,
decompensated heart failure, acute coronary syndrome, heart
valve disease, cardiomyopathy or Buerger disease.
Peripheral angiography of the lower extremity was
performed, assisted by a radiologist, either in the same
session with coronary angiography or in a separate session.
Iodine-containing radiopaque media of 270-300 mOsmol was
administered via the distal abdominal aorta using a pigtail
catheter or via the right or left common iliac arteries
selectively by using the right coronary artery catheter to
examine the right-left common iliac artery, iliac externa, iliac
interna, main femoral, superficial femoral, deep femoral,
popliteal, tibioperoneal truncus, anterior tibial, and posterior
tibial arteries, and up to the distal peroneal artery. Coronary
angiography was performed by standard right-left diagnostic
and pigtail ventriculography catheters via the femoral artery
with a 6-French sheath. A stenosis of > 50% was considered
to be severe stenosis, while below that level it was regarded
as non-critical (plaques not leading to significant stenosis) for
coronary and peripheral arteries. Patients with
cerebrovascular (CV) findings who were also observed with
severe or non-critical atherosclerotic lesions on Doppler
ultrasonography or carotid angiography were grouped as
patients with CV/carotid artery disease.
Descriptive statistics were expressed as the mean and
standard deviation for numerical variables, and frequency and
percentage for categorical variables. The difference between
the groups for categorical variables was evaluated by the chi-
square test (χ2-test) and Student's t test for numerical
variables. Relationship of the extent of PAD with coronary
artery involvement was investigated by univariate and
multivariate analyses. Logistic regression analyses were used
to identify the relation of peripheral pathology with coronary
pathology. A P value of <0.05 was regarded as statistically
significant. The Statistical Program for Social Sciences
(SPSS) version 15, Inc., Chicago, IL, USA) was used for all
In our cohort of 307 patients, 251 (81.8%) patients
were male and the mean age was 62.1±9.5 years. Of the total,
178 (58.0%) were diagnosed as hypertensive, 84 (27.4%)
patients were diabetic, 18 (5.9%) had a family history of
CAD, 111 (36.2%) were smokers, 149 (48.5%) were
hypercholesterolemic, and 20 (6.5%) patients had
Peripheral angiography results demonstrated that
2.9% patients had normal arteries, while 15.3% had non-
critical plaques; 19.5% had proximal critical single stenosis,
12.4% had distal stenoses, and 49.8% had complete occlusion
or diffused atherosclerotic stenoses in all segments. Coronary
angiography revealed that 8.5% of the patients had normal
coronary arteries, while 20.2% had non-critical plaques,
21.5% had single-vessel disease, 16.9% had double-vessel
disease, 29.6% had multi-vessel disease, and 3.3% had left
main coronary disease (Table-1).
645J Pak Med Assoc
The patient characteristics and risk factors with
respect to CAD and PAD were noted (Table-2). Hypertension
was a risk factor for both CAD and PAD (p=0.012 and
p=0.027, respectively). Differences with respect to gender,
smoking, cholesterol, DM, familial history, and the presence
of CV/carotid disease were not found to be significant.
Patients were also assessed for the severity of disease
as established on peripheral and coronary angiography
(Table-3). In 92.3% of the patients with PAD, there was an
established presence of CAD at various levels (p=0.007).
Over 50% of the patients with multiple-vessel disease or left
main coronary disease on coronary angiography were in the
group having diffused atherosclerotic stenosis and complete
occlusion in all segments according to the peripheral
Univariate logistic regression analysis demonstrated
that the presence of PAD was related to CAD (Odds ratio
[OR]: 6, 95%CI: 1.4-25.5, p=0.016) and the severe PAD
(diffused atherosclerotic stenosis and complete occlusion in
all segments) significantly indicates the presence of some
coronary pathology (OR: 8, 95%CI: 1.7-37.4, p=0.008)
(Table-4). This relationship maintained its significance after
adjustment for age, gender, hypercholesterolaemia, smoking,
hypertension, DM, family history of CAD, and the presence
of CV/carotid disease (p=0.010) (Table-5).
Vol. 62, No. 7, July 2012646
Table-1: Patient characteristics and evaluation of coronary and
peripheral arteries by angiography.
Mean Age (years)62.1±9.5
Gender, n (%)
Female 56 (18.2)
Male 251 (81.8)
Hypertension, n (%)178 (58.0)
Diabetes mellitus, n (%)84 (27.4)
Family history of CAD, n (%)18 (5.9)
Smoking, n (%)111 (36.2)
Hypercholesterolemia, n (%)149 (48.5)
CV/Carotid disease, n (%)20 (6.5)
Coronary and peripheral angiography
Coronary angiography, n (%)
C0: Normal coronary artery 26 (8.5)
C1: Non-critical plaque62 (20.2)
C2: Single-vessel disease66 (21.5)
C3: Double-vessel disease52 (16.9)
C4: Multiple-vessel disease91 (29.6)
C5: Left main coronary disease10 (3.3)
Peripheral Angiography, n (%)
P0: Normal arteries 9 (2.9)
P1: Non-critical plaques47 (15.3)
P2: Proximal critical single stenosis60 (19.5)
P3: Distal stenoses (popliteal artery distal)38 (12.4)
P4: Multiple severe stenoses in all segments
(graft restenosis, diffuse stenosis, complete occlusion)153 (49.8)
CAD: Coronary artery disease, CV: Cerebrovascular.
Table-2: The relationship of the presence of coronary and peripheral pathology with risk factors.
Coronary pathologyPeripheral pathology
(-) n (%)(+) n (%)P value (-) n (%)(+) n (%)P value
Mean Age (years)58.4±10.262.4±9.4 0.04157.9±7.162.2±9.60.182
Gender (Male)18 (69.2) 233 (82.9)0.084 6 (66.6) 245 (82.2)0.234
Smoking 7 (26.9)104 (37.0)0.306 6 (33.3) 152 (36.2)0.858
Hypertension9 (34.6)169 (60.1)0.0122 (22.2)190 (59.1)0.027
Hypercholesterolaemia12 (46.2)137 (48.8) 0.8003 (33.3) 146 (48.9)0.354
Diabetes mellitus4 (15.4)80 (28.5)0.1524 (44.4)80 (26.9)0.243
Family history of CAD0 (0.0)18 (6.4)0.1831 (11.1)17 (5.7)0.496
CV/carotid disease0 (0.0) 20 (7.1)0.159 0 (0.0) 20 (6.7)0.422
Coronary pathology (-): Normal coronary artery (C0). Coronary pathology (+): Other coronary angiographic findings (C1, C2, C3, C4 and C5). Peripheral pathology (-): Normal
peripheral arteries (P0). Peripheral pathology (+): Other Peripheral angiographic findings (P1, P2, P3 and P4). CAD, Coronary artery disease; CV, Cerebrovascular.
Table-3: Reciprocal relationship of peripheral and coronary angiographic findings.
Coronary angiography, n (%)Peripheral Angiography, n (%)
P0 P1 P2 P3 P4
C03 (11.5)5 (19.2)6 (23.1)3 (11.5)9 (34.6)
C1 1 (1.6) 9 (14.5)19 (30.6)7 (11.3)26 (41.9)
C22 (3.0)14 (21.2)13 (19.7)8 (12.1)29 (43.9)
C31 (1.9)4 (7.7)10 (19.2)9 (17.3)28 (53.8)
C42 (2.2)14 (15.4)9 (9.9)11 (12.1)55 (60.4)
C50 (0.0)1 (10.0)3 (30.0)0 (0.0)6 (60.0)
C0: Normal coronary artery, C1: Non-critical plaque, C2: Single-vessel disease, C3: Double-vessel disease, C4: Multiple-vessel disease, C5: Left main coronary disease; P0: Normal
peripheral arteries, P1: Non-critical plaques, P2: Proximal critical single stenosis, P3: Distal stenoses, P4: Stenoses or complete occlusion in all segments.
Our study results demonstrated that PAD and CAD
had similar risk factors. The extent of PAD observed during
peripheral lower extremity angiography was significantly
associated with the presence and severity of CAD.
Peripheral arterial disease had a prevalence of >10%
in males >60 years of age. As the disease progresses, the true
prevalence of PAD may be even higher than the registered
prevalence, but for the fact that it can remain asymptomatic
or with atypical symptoms.
The ankle brachial blood pressure index (ABI),
defined as the systolic blood pressure measured at the ankle
divided by the systolic blood pressure measured in the arm
during supine rest, is the most widely used quantitative
measure to determine the presence and severity of PAD. An
abnormal ABI value of < 0.90 is generally considered to be
the best reference standard of identifying PAD, whereas
normal values range between 0.9 to 1.3.5A study analysing
6172 participants who were randomly selected from the
general population and in whom procedures had been carried
out earlier, reported the prevalence of subjects with an ABI
score of <0.9 to be 4.5%. The same study established age,
current smoking status, CAD, uncontrolled HT, as well as
intermittent claudication in males and DM in women to be
associated with low ABI.6
Peripheral arterial disease and CAD are different
clinical manifestations of atherosclerosis and have common
risk factors. PAD risk factors are similar to those for CAD
and CVD. However, PAD is strongly correlated with DM
and smoking. Other risk factors have been reported to be age
(> 45 years in males, > 55 years in females), HT and HPL.7
Other risk factors that have to be carefully observed were
reported to be Lp(a), elevated lipoprotein, homocysteine,
LDL-cholesterol, and acute phase protein (CRP and amyloid
A protein) levels, as well as coagulation and fibrinolytic
factors (tissue plasminogen activator, plasminogen activator
inhibitor 1 and fibrinogen).8
A study conducted in 952 patients at high risk for
CVD established that 86.2% of the patients had symptomatic
atherosclerosis, and reported that at least 2 risk factors were
present in the asymptomatic patients. Of the patients with
CAD, 42% had PAD. No significant differences were
observed between CAD and PAD patients with respect to risk
profiles.9A previous study in which 33629 patients with PAD
were evaluated, established that 29% (9474) of the patients
had DM.10Similarly, in our study, 27.4% of the patients with
PAD had DM.
A recent research conducted in 3047 hypertensive
patients has shown that older age, female gender, elevated
triglycerides levels, low HDL level, DM, and a history of
smoking is associated with a low ABI. Survival rates were
noted to be significantly lower in the low ABI group
compared with those of the normal ABI group. Low ABI was
established to be an independent risk factor for all-cause and
Of the patients in our study, 58% had hypertension,
which was established as a risk factor for both CAD and
PAD. Therefore, patients with hypertension should carefully
be monitored for PAD, and be scanned by ABI measurement
to ensure an early diagnosis.
A previous study was conducted in patients
undergoing intracoronary stent implantation (n=7696).12Two
subgroups were formed of patients with or without PAD
(n=1397, n=6299, respectively). The subgroup with PAD had
older age and higher rate of HT, DM, HPL and a history of
smoking compared with patients without PAD. The presence
of PAD was also shown to be a major risk factor in terms of
poor procedural success and high rate of in-hospital
complications. The group was also observed with a higher
rate of adverse cardiovascular events on follow-up. Of the
patients with concomitant PAD, 79% had HT, 33% DM, 76%
HPL, and 70% had a history of smoking. In a manner
consistent with the findings of this study, of all the patients in
our study, 58% had HT, 27.4% DM, 48.5% HPL and 36.2%
647 J Pak Med Assoc
Table-4: Univariate relationship of the angiographic extent of PAD
with the presence of CAD.
Variables OR 95%CIP value
Mean Age (years) 1.047 1.001-1.094 0.044
Gender (Male)2.157 0.887-5.2480.09
Smoking,+ 1.595 0.649-3.922 0.309
Hypercholesterolemia, + 1.110.496-2.484 0.8
Diabetes mellitus, + 2.1890.731-6.553 0.161
PAD, + 5.9781.403-25.479 0.016
P1 4.20.793-22.255 0.092
P2 4.50.888-22.793 0.069
CAD: Coronary artery disease; PAD, Peripheral arterial disease.
Table-5: Multivariate relationship between the extent of PAD and
VariablesBetaStandard ErrorP value*
Hypertension,+ 0.597 0.158 <0.001
Extent of PAD (0-4) 0.161 0.062 0.010
*Linear regression analysis with stepwise method was used for multivariate analysis
of independent variables including age, gender, HT, DM, smoking,
hypercholesterolemia and family history of CAD.
After exclusion of irrelevant variables from model, linear analyses with enter method
were performed with remaining significant variables.
Dependen variable: extent of coronary artery disease
CAD, coronary artery disease; PAD, Peripheral arterial disease.
had a history of smoking.
In another study, the prognosis of patients with PAD
concomitant with or without CAD was investigated.13It
consisted of 483 patients with PAD without CAD, and 479
patients with both PAD and CAD. The mean was 67.3±8.9
years for both groups of which 72.3% was male. Of the
patients, 80.18% were either current smokers or had a history
of smoking, and 49.6% had abdominal obesity. The
PAD+CAD group was compared with PAD-only group over
a 2-year follow-up period and no significant differences were
observed in terms of total mortality (4.6% vs. 5.5%),
cardiovascular mortality (3.7% vs. 3.9%), or non-fatal
myocardial infarction (1.9% vs. 2.7%). However, difference
between the two groups for non-fatal stroke (4.4% vs. 2.0%,
p<0.05) was significant.13
A number of studies have been conducted to
investigate the comorbidity of PAD and CAD. These studies
suggest that all patients with PAD should be regarded as
having CAD until proven otherwise.5The results of our study
also support the assertion, as 92.3% of the patients with PAD
had an established presence of CAD at various levels.
Different studies have reported CAD as a comorbid
condition in 10-30% of all PAD patients.14-16In a previous
study conducted in patients hospitalised by CAD, PAD
prevalence was reported to be 40%. It was established that
one-half of those patients had not been diagnosed with PAD
previously. It was recommended that patients presenting with
CAD should be examined for PAD as well.17
When proper care is not provided, PAD patients may
experience ischaemia leading to amputation, which has a
significant effect on morbidity and mortality. A study
conducted in patients with CAD without known PAD who
underwent coronary angiography and/or an intervention
established an incidence of 15% for PAD.18The study
compared the patients with and without PAD in terms of risk
factors. The patients with PAD were older and it was more
common in females. Hypertension, DM and CV event
prevalence were also established to be higher. Of the 745
patients whose CAD diagnosis was confirmed by coronary
angiography, the ones with PAD had higher prevalence for
left main and multi-vessel CAD, as well as a history of
coronary artery bypass surgery.
In our study, the extent and severity of PAD was
significantly correlated with the presence and severity of
CAD. It was also demonstrated that diffused atherosclerotic
stenosis and complete occlusion in all segments in the
peripheral arteries were significant risk factors for coronary
pathology. Therefore, close monitoring for CAD in patients
with severe PAD is of critical importance to decrease vascular
morbidity and mortality. A better understanding of the risk
factors will make it possible to take precautions against the
modifiable risk factors, and will facilitate early diagnosis and
implementation of effective therapy.
PAD and CAD have similar risk factors. The extent
and severity of PAD was significantly associated with the
presence and severity of CAD. Screening for PAD and CAD
in patients with relevant risk factors must ensure early
diagnosis for an improved prognosis. Particular attention
should be focused on the possibility of CAD in patients with
established and extensive PAD. CAD should be investigated
in patients with PAD even when cardiac symptoms, such as
chest pain, are not present, and non-invasive tests, as well as
invasive tests, when deemed necessary, should be performed
to decrease morbidity and mortality risk.
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