Prognostic importance of lower extremity arterial disease in patients undergoing coronary revascularization in the bypass angioplasty revascularization investigation (BARI)

OBJECTIVES The purpose of this study was to evaluate the prevalence and prognostic importance of lower extremity arterial disease (LEAD) in patients with multivessel coronary artery disease. BACKGROUND The presence of clinically evident LEAD increases the risk of death in patients with known coronary artery disease. Because studies have lacked noninvasive measures of subclinical LEAD, the true prognostic importance of lower extremity atherosclerosis in this population has probably been underestimated. METHODS Ankle blood pressures were measured in 405 consecutive patients with angiographically documented multivessel coronary disease from seven Bypass Angioplasty Revascularization Investigation (BARI) sites and parallel study site within 3 years of enrollment. Lower extremity arterial disease was defined as an ankle/arm systolic blood pressure ratio of 0.90 or less. RESULTS Among patients studied, 69 (17%) had LEAD. These patients were more likely to be current smokers, treated for diabetes, older and present with unstable angin compared with patients without LEAD. Among patients who underwent coronary arterial bypass grafting, major complications occurred in 2.8% of those without LEAD compared with 20.7% of those with LEAD (p = 0.002). Five-year mortality rates were similar for symptomatic LEAD (14%) and asymptomatic LEAD (14%). Patients without LEAD had 3% mortality. After adjusting for baseline differences, the relative risk of death was 4.9 times greater for patients with LEAD compared with those without (95% confidence interval [CI]: 1.8, 13.4, p < 0.01). CONCLUSIONS Patients with LEAD have significantly higher risk of death than patients without LEAD, regardless of the presence of symptoms. An abnormal ankle/arm index is strong predictor of mortality and can be used to further stratify risk among patients with multivessel coronary artery disease.