Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 125-128

The prevalence of and risk factors for peripheral arterial occlusive disease in human immunodeficiency virus-infected omani patients: The first study in GCC


1 Division of Surgery, Vascular Surgery Unit, Sultan Qaboos University Hospital, Muscat, Oman
2 Vascular Surgery Unit, Division of Surgery, Sultan Qaboos University Hospital, Muscat, Oman
3 Infectious Diseases Unit, Sultan Qaboos University Hospital, Muscat, Oman

Date of Submission05-Nov-2019
Date of Acceptance04-Feb-2020
Date of Web Publication17-Jun-2020

Correspondence Address:
Dr. Ahmed Al-Aufi
Division of Surgery, Vascular Surgery Unit, Sultan Qaboos University Hospital, Muscat
Oman
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_91_19

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  Abstract 


Aim: To assess the prevalence of peripheral arterial occlusive disease (PAOD) in human immunodeficiency virus (HIV)-infected Omani patients and to assess the potential risk factors in this group. Methodology: This was a single-center, cross-sectional study. All patients attending the infectious disease clinic between July 2017 and March 2018 were included in the study; their peripheral pulses were examined and pre- and postexercise ankle–brachial pressure index (ABPI) was measured. Normal ABPI was considered as being in the range of 1.0 ± 0.1, and a reduction of >15% postexercise ABPI was considered as a cutoff limit to define PAOD. The Edinburgh Claudication Questionnaire was answered by all patients, and CD4 count, viral load, albumin and Vitamin D (25-OH) levels, and glycated hemoglobin (HbA1c) were measured. The data were analyzed using IBM SPSS Statistics version 22. Results: Eighty-eight patients who were retroviral positive were enrolled in the study. Fifty-three (60.2%) patients were male and 35 (39.8%) were female, with a mean age of 43 years (24–71). The dorsalis pedis artery pulsation was absent bilaterally in 3 (3.4%) patients. None of the patients had a history of claudication; 1 (1.1%) had an abnormal ABPI; 17 (19.2%) had a reduction of >15% postexercise ABPI; 7 (8%) had CD4 count <200; 4 (4.5%) had detectable viral load; albumin level was <25 g/L in 5 (5.8%); 15 (17%) had Vitamin D (25-OH) <50 nmol/L; and 4 (4.5%) had an abnormal HbA1c. Conclusions: The prevalence of PAOD in HIV-infected patients is higher compared to the general population as was evident from an abnormal postexercise ABPI. Risk factors that stood out while not having a significant P- value were low values of CD4 counts and Vitamin –D levels.

Keywords: Ankle–brachial pressure index, arterial, asymptomatic arterial disease, CD4, laudication, Gulf Cooperation Council, human immunodeficiency virus, immunodeficiency, Oman, peripheral arterial occlusive disease, prevalence, vascular


How to cite this article:
Al-Aufi A, Al-Wahaibi K, Stephen E, Balkhair A, Abdelhedy I, Al-Maawali H. The prevalence of and risk factors for peripheral arterial occlusive disease in human immunodeficiency virus-infected omani patients: The first study in GCC. Indian J Vasc Endovasc Surg 2020;7:125-8

How to cite this URL:
Al-Aufi A, Al-Wahaibi K, Stephen E, Balkhair A, Abdelhedy I, Al-Maawali H. The prevalence of and risk factors for peripheral arterial occlusive disease in human immunodeficiency virus-infected omani patients: The first study in GCC. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Sep 30];7:125-8. Available from: http://www.indjvascsurg.org/text.asp?2020/7/2/125/286916




  Introduction Top


The American Heart Association and American College of Cardiology guidelines define peripheral arterial occlusive disease (PAOD) as a resting ankle–brachial pressure index (ABPI) of <0.9 or if there was absolute decrease of >0.15 postexercise.[1],[2]

PAOD is a focal manifestation of atherosclerosis and is a predictor of cardiovascular outcomes.[1] The prevalence of PAOD in a healthy population was extracted from international data and taken as 1%–3%. Majority of the population with PAOD is asymptomatic.[2] Therefore, early diagnosis of PAOD may provide an opportunity for physicians to identify and prevent cardiovascular events in high-risk patients.

The effective usage of antiretroviral therapy in patients with human immunodeficiency virus (HIV) infection has led to improved life expectancy[3],[4],[5] and has therefore led to the development of other comorbidities such as cardiovascular disease and PAOD. Previous studies among the Caucasian population have suggested a higher prevalence of PAOD in HIV-infected patients.[4],[5],[6],[7] However, this was not reported to be the case from a study in India.[8] Evidence from Oman is lacking in both English and Arabic literature on this subject.

The mechanism through which this risk is increased is not well understood. Reports suggested that the HIV inflicts direct damage to the endothelium. Other theories include side effects of retroviral therapy.[4],[6]

Aim

To estimate the prevalence of PAOD in people with HIV infection and to determine the associated risk factors.


  Methodology Top


This was a cross-sectional clinical study. The study was conducted in a tertiary care center in Oman, after approval by the ethics and research committee of the institution from June 2017 to March 2018. The vascular clinical nurse specialist was the sole person present in the clinic of the infectious disease department to guide patients in filling the Edinburgh Claudication Questionnaire and to measure their ABPI and vital signs, after informed consent was taken by the first author.[9] Patients were then asked to perform 20 observed squats and then the ABPI was remeasured.

List of comorbidities, laboratory tests, and medication list were then gathered from the electronic patient record and were documented. A total of 88 patients were included and all patients completed the exercise test successfully. The data were then entered into an SPSS data sheet and were analyzed.

An ABPI of > 0.9 or more than 15% absolute reduction between pre- and postexercise ABPI was considered as a cutoff limit for the definition of PAOD. CD4 counts of <200 were considered as low.

Detectable viral load was presumed as a risk factor; serum albumin level of <25 g/l, Vitamin D (25-OH) levels <50 nmol/l, and glycated hemoglobin (HbA1c) of >5.9 were considered as significant.

All patients attending the infectious disease clinic during the study period were included, except patients who could not perform the exercise test due to any reason. The data were entered into to a spreadsheet and were analyzed using IBM® SPSS Statistics version 22 (New York, USA).


  Results Top


Ninety-three patients were seen in the infectious diseases clinic during the study period. Of these, 88 patients were included as 5 were unable to perform squats.

Fifty-three (60.2%) patients were male and 35 (39.8%) were female [Figure 1]. The mean age for males was 43.5 years with an age range between 26 and 71 years, whereas the mean age for females was 43.6 years ranging between 24 and 65 years.
Figure 1: Gender distribution

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The mean duration of HIV infection was 10.1 years, with maximum of 28 and minimum of 1 year. Forty-eight (48%) patients had HIV infection for ≥10 years [Figure 2].
Figure 2: Duration of human immunodeficiency virus infection

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The posterior tibial artery pulse was palpable in all patients, with the dorsalis pedis artery pulsation absent bilaterally in 3 (3.4%) patients. None of the patients had a history of claudication; 1 (1.1%) had an abnormal resting ABPI; 17 (19.2%) had a reduction of >15% postexercise ABPI, which was statistically significant (P< 0.0001); 13 (72.2%) were male and 5 (27.8%) were female; 7 (8%) had CD4 count <200; 4 (4.5%) had detectable viral load; albumin level was <25 g/L in 5 (5.8%); 15 (17%) had Vitamin D (25-OH) <50 nmol/L; and 4 (4.5%) had an abnormal HbA1c.

Diabetes was recorded in 19 (21.6%) patients, which is similar to the national prevalence in the general Omani population.[10] Fifteen (17%) of the patients had hypertension and 9 (10.2%) were current smokers. Hyperlipidemia was detected in 40 (46%) patients. CD4 count of <200 was observed in 7 (8%) patients. No significant correlation was found between peripheral artery disease and any of the studied risk factors including diabetes, hypertension, dyslipidemia, duration of HIV infection, CD4 count, and smoking.


  Discussion Top


HIV infection was correlated with the occurrence of multiple systemic diseases and also is recognized as a risk factor for health problems.[10],[11] PAOD is no different as previous studies suggest.[6] The theories that were postulated to explain increased prevalence were the direct endothelial damage because of the HIV virus and side effects of medications used to treat the HIV infection resulting in the development of atherosclerosis and as a final consequence of PAOD.[11],[12],[13]

We designed this study to look whether this increased prevalence holds true for the Omani population, and if the prevalence is high, look into the possible risk factors.

After collecting history and examining 88 patients with HIV infection, we noted that the prevalence of PAOD is 19.2%. This percentage is of people who had an Ankle-Brachial Pressure Index (ABPI) of <0.9 at rest and/or who dropped their ABI by >15% after exercise.[14],[15],[16] Although this percentage might come close to the percentages suggested by other studies, looking into its clinical significance might render it insignificant. This is evidenced by the fact that no significant correlation is found between HIV infection and the suggested risk factors and that 16 out of 17 patients with PAOD continued to have ABPI of 0.9 or higher after exercise stress.

Only one patient had a resting ABI of <0.9 and 17 patients had a drop of >15% of their resting ABPI. Despite the 15% drop in the ABPI, these patients still had normal ABPIs, i.e., >0.9 at the end of the exercise. The drop was statistically significant (P< 0.005) and proves the efficacy of the exercise test, but it is of minimal clinical value. The clinical values of this higher prevalence were doubted when we looked into possible risk factors for the increased percentage. There was no significant correlation between PAOD on the one side and age, diabetes, duration of HIV infection, CD4 count, serum albumin, HbA1c, and Vitamin D level on the other side.


  Conclusions Top


The population of Oman is around 5 million and the pattern of disease has changed over the last 50 years with noncommunicable disease taking precedence over communicable disease.[17] Infections such as HIV are also on the rise and this brings up an array of HIV-related complications. Data from the Western populations indicated that the risk of development of PAOD in HIV-infected patients is higher as compared to the age-matched normal patients. Data from Oman and the Gulf Community Collaboration are, however, lacking. We designed this study to have an idea whether a similar correlation to that of Caucasian population exists between HIV infection and PAOD in Omani people.

The prevalence of PAOD in HIV-infected people was 19.2% in our study compared to the general population of 3%. Although this higher prevalence is of doubtful clinical significance, given the fact that all of the patients in the study are asymptomatic and also that majority of people comprising this increased prevalence had a statistically significant drop of ABI postexercise, their ABI remained normal.

A larger patient population needs to be studied in order to categorically state that the presence of HIV does not increase the risk of PAOD. With this suggestion implemented, it will be more plausible to look into diseasespecific risk factors and may form the background for further research in the future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Topakian R, Nanz S, Rohrbacher B, Koppensteiner R, Aichner FT; OECROSS Study Group. High prevalence of peripheral arterial disease in patients with acute ischaemic stroke. Cerebrovasc Dis 2010;29:248-54.  Back to cited text no. 1
    
2.
Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, 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;113:e463-654.  Back to cited text no. 2
    
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Manfredi R. HIV infection and advanced age emerging epidemiological, clinical, and management issues. Ageing Res Rev 2004;3:31-54.  Back to cited text no. 3
    
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Qaqa AY, DeBari VA, Isbitan A, Mohammad N, Sison R, Slim J, et al. The role of postexercise measurements in the diagnosis of peripheral arterial disease in HIV-infected patients. Angiology 2011;62:10-4.  Back to cited text no. 4
    
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Olalla J, Salas D, de la Torre J, Del Arco A, Prada JL, Martos F, et al. Ankle-brachial index in HIV infection. AIDS Res Ther 2009;6:6.  Back to cited text no. 5
    
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van Sighem AI, Gras LA, Reiss P, Brinkman K, de Wolf F; ATHENA national observational cohort study. Life expectancy of recently diagnosed asymptomatic HIV-infected patients approaches that of uninfected individuals. AIDS 2010;24:1527-35.  Back to cited text no. 6
    
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Monsuez JJ, Charniot JC, Escaut L, Teicher E, Wyplosz B, Couzigou C, et al. HIV-associated vascular diseases: Structural and functional changes, clinical implications. Int J Cardiol 2009;133:293-306.  Back to cited text no. 7
    
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Suraj S, Stephen E, Sen I, Rodger A, Nayak S, Varghese GM, et al. Prevalence and risk factors of peripheral arterial occlusive disease in adult Indian HIV positive patients– The PAODH study. Indian J Appl Res 2016;6:30-33.  Back to cited text no. 8
    
9.
Leng GC, Fowkes FG. The Edinburgh Claudication Questionnaire: an improved version of the WHO/Rose Questionnaire for use in epidemiological surveys. J Clin Epidemiol 1992;45:1101-9.  Back to cited text no. 9
    
10.
Al-Lawati JA, Panduranga P, Al-Shaikh HA, Morsi M, Mohsin N, Khandekar RB, et al. Epidemiology of Diabetes Mellitus in Oman: Results from two decades of research. Sultan Qaboos Univ Med J 2015;15:e226-33.  Back to cited text no. 10
    
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Periard D, Cavassini M, Taffé P, Chevalley M, Senn L, Chapuis-Taillard C, et al. High prevalence of peripheral arterial disease in HIV-infected persons. Clin Infect Dis 2008;46:761-7.  Back to cited text no. 11
    
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Gupta N, Bajaj S, Shah P, Parikh R, Gupta I, Dhillon W, et al. The prevalence of peripheral arterial disease in HIV patients. J Vasc Med Surg 2013;1:118.  Back to cited text no. 12
    
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Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: Systematic analysis of population health data. Lancet 2006;367:1747-57.  Back to cited text no. 13
    
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Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ; Comparative Risk Assessment Collaborating Group. Selected major risk factors and global and regional burden of disease. Lancet 2002;360:1347-60.  Back to cited text no. 14
    
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Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment Panel III). JAMA 2001;285:2486-97.  Back to cited text no. 15
    
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Carter SA. Response of ankle systolic pressure to leg exercise in mild or questionable arterial disease. N Engl J Med 1972;287:578-82.  Back to cited text no. 16
    
17.
Available from: http://www.worldometer.com/search: Oman population. [Last accessed on 2018 Feb 22].  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2]



 

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