Journal of Vascular Surgery
Volume 51, Issue 3 , Pages 610-615, March 2010

Gender and ethnic differences in arterial compliance in patients with intermittent claudication

  • Andrew W. Gardner, PhD

      Affiliations

    • CMRI Diabetes and Metabolic Research Program, Harold Hamm Oklahoma Diabetes Center, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
    • Corresponding Author InformationReprint requests: Andrew W. Gardner, PhD, Hobbs-Recknagel Professor, General Clinical Research Center, University of Oklahoma Health Sciences Center, 1122 N.E. 13th Street, Suite 150, Oklahoma City, OK 73117
    • ,
  • Polly S. Montgomery, MS

      Affiliations

    • CMRI Diabetes and Metabolic Research Program, Harold Hamm Oklahoma Diabetes Center, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
    • ,
  • Steve M. Blevins, MD

      Affiliations

    • General Internal Medicine Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
    • ,
  • Donald E. Parker, PhD

      Affiliations

    • Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla

Received 5 August 2009; accepted 30 September 2009.

Article Outline

Objective

To assess the gender and ethnic differences in arterial compliance in patients with intermittent claudication.

Methods

A total of 114 patients participated, including 38 Caucasian men, 32 Caucasian women, 16 African American men, and 28 African American women. Patients were assessed on large artery elasticity index (LAEI), small artery elasticity index (SAEI), age, weight, body mass index, ankle-brachial index (ABI), smoking status, and metabolic syndrome components.

Results

Group differences were found for LAEI (P = .042), SAEI (P = .019), body mass index (P = .020), prevalence of elevated fasting glucose (P = .001), and prevalence of abdominal obesity (P = .025). Significant covariates for LAEI included age (P = .0002) and elevated triglycerides (P = .0719). LAEI (units = 10 mL × mm Hg) adjusted for age and triglycerides was 39% lower (P = .0005) in African Americans (11.4 ± .90; mean ± SE) than in Caucasians (15.8 ± 0.72), whereas no significant difference (P = .7904) existed between men (13.8 ± 0.81) and women (13.5 ± 0.79). Significant covariates for SAEI included age (P = .0001), abdominal obesity (P = .0030), and elevated blood pressure (P = .0067). SAEI (units = 100 mL × mm Hg) adjusted for age, abdominal obesity, and elevated blood pressure was 32% lower (P = .0007) in African-Americans (2.8 ± 0.3) than in Caucasians 4.1 ± 0.2), and was 18% lower (P = .0442) in women (3.1 ± 0.2) than in men (3.8 ± 0.2).

Conclusion

African American patients with intermittent claudication have more impaired macrovascular and microvascular function than Caucasian patients, and women have more impaired microvascular function than men. These ethnic and gender differences in arterial compliance are evident even though ABI was similar among groups, suggesting that arterial compliance provides unique information to quantify vascular impairment in patients with intermittent claudication.

 

Intermittent claudication is a symptom of peripheral arterial disease (PAD), and is associated with elevated rates of mortality1, 2, 3, 4 and morbidity.5 Intermittent claudication afflicts 5% of the US population older than 55 years of age6 and occurs during ambulation when the peripheral circulation is inadequate to meet the metabolic demand of the active leg musculature.

Gender and ethnic differences exist in the prevalence and manifestation of PAD. The prevalence of PAD is less in women at younger ages, but is similar to that of men at older ages.7 Women are more likely to have asymptomatic PAD,8 and less likely to report classic symptoms of intermittent claudication than men at all age groups.9, 10 Women with intermittent claudication have shorter walking distances to the onset of claudication pain, and to maximal claudication pain during standardized treadmill exercise than men.11, 12 With regards to ethnicity, African Americans have more than a twofold greater risk of developing PAD,13 which may not be explained by a greater burden of atherosclerotic risk factors such as diabetes, hypertension, and obesity.13, 14 African Americans have greater ambulatory dysfunction, as measured by self-paced walking tasks, than compared with Caucasians.15

Although differences in vascular function may contribute to gender and ethnic differences in symptomatology, limited data is available. Arterial compliance is a clinically important outcome measure because it is associated with functional and structural characteristics of the vasculature16, 17 and is a predictor of cardiovascular events.18 PAD patients have reduced arterial compliance of the large and small arteries compared with age-matched controls,19, 20 indicating that PAD patients have impaired arterial compliance of both the macrovasculature and microvasculature. However, the characteristics associated with arterial compliance in PAD patients are not well described. Therefore, the purpose of this study was to assess the gender and ethnic differences in arterial compliance in PAD patients with intermittent claudication.

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Methods 

Subjects 

Recruitment 

Patients participated in this study at the General Clinical Research Center (GCRC) at the University of Oklahoma Health Sciences Center (HSC). Patients were recruited by referrals from the HSC vascular clinic, as well as by newspaper advertisements. The procedures used in this study were approved by the Institutional Review Board at the University of Oklahoma HSC. Written informed consent was obtained from each patient prior to investigation.

Screening 

Patients with intermittent claudication secondary to vascular insufficiency were included in this study if they met the following criteria: (1) a history of intermittent claudication, (2) ambulation during a graded treadmill test limited by intermittent claudication,21 and (3) an ankle-brachial index (ABI) ≤0.90 at rest22 or an ABI ≤0.73 after exercise.23 Patients were excluded from this study for the following conditions: (1) absence of PAD (ABI >0.90 at rest and ABI >0.73 after exercise), (2) inability to obtain an ABI measure due to noncompressible vessels, (3) asymptomatic PAD determined from the medical history and verified during the graded treadmill test, (4) use of medications indicated for the treatment of intermittent claudication (cilostazol and pentoxifylline) initiated within three months prior to investigation, (5) exercise tolerance limited by factors other than leg pain (eg, severe coronary artery disease, dyspnea, poorly controlled blood pressure), and (6) active cancer, renal disease, or liver disease.

Measurements 

Medical history, physical examination, and anthropometry 

Patients arrived at the GCRC in the morning fasted, but were permitted to take their usual morning medication regimen. Demographic information, height, weight, body mass index (BMI), waist and hip circumferences,24 cardiovascular risk factors, comorbid conditions, claudication history, blood samples, and a list of current medications were obtained from a medical history and physical examination at the beginning of the study.

Metabolic syndrome 

Patients were evaluated for each component of metabolic syndrome according to the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III.25 Metabolic syndrome is defined as having three or more of the following components: (1) abdominal obesity (waist circumference >102 cm in men and >88 cm in women), (2) elevated triglycerides (≥150 mg/dL), (3) reduced HDL cholesterol (<40 mg/dL in men and <50 mg/dL in women), (4) elevated blood pressure (≥130/85 mm Hg), and (5) elevated fasting glucose (≥110 mg/dL) as well as those with diabetes. In addition, treatment with medications for dyslipidemia, hypertension, and diabetes were used to define presence of metabolic syndrome components. All of the women were post-menopausal, and none were on hormonal therapy. Although several definitions of metabolic syndrome exist, the NCEP ATP III definition was used in this investigation because it was specifically established on a population from the United States.

ABI 

After 10 minutes of supine rest, the ankle and brachial systolic blood pressures were obtained as previously described.26 Briefly, ankle systolic pressure was measured by Doppler technique in the posterior tibial and dorsalis pedis arteries of both legs. The higher of the two arterial pressures from the symptomatic leg was recorded as the resting ankle systolic pressure. Similarly, brachial blood pressure was taken from both arms, and the arm yielding the higher systolic pressure was recorded as the brachial systolic pressure. The ABI was then calculated as ankle systolic pressure/brachial systolic pressure. The test-retest intraclass reliability coefficient for the measurement of ABI in our laboratory is R = 0.96 for ABI.21

Diastolic pulse contour analysis (PCA) 

Arterial compliance measurements were obtained in the morning following an overnight fast of at least 8 hours, and prior to engaging in any strenuous physical activity. The large artery elasticity index (LAEI) and small artery elasticity index (SAEI) were obtained by an HDI/Pulsewave CR-2000 Cardiovascular Profiling System (Hypertension Diagnostic, Inc, Eagan, Minn) following 5 to 10 minutes of rest in the supine position as previously described.27, 28, 29, 30 To convert values to whole numbers, the units for LAEI (mL × mm Hg−1) were multiplied by 10 and the units for SAEI (mL × mm Hg−1) were multiplied by 100. An appropriately sized blood pressure cuff was placed around the subject's left upper-arm, and a rigid plastic wrist stabilizer was placed on the subject's right wrist to minimize wrist movement and stabilize the radial artery during the measurement. An Arterial Pulsewave Sensor was placed on the skin directly over the radial artery at the point of the strongest pulse, while the arm rested in a supine position. The noninvasive acoustic sensor was adjusted to the highest relative signal strength, and arterial waveforms were recorded for 30 seconds and the diastolic portion was digitized at 200 samples per second to determine large artery and small artery elasticity indices.31 Both LAEI and SAEI are measures of arterial compliance throughout the entire arterial tree. LAEI is determined from the decay in diastolic pressure, and SAEI is determined from the decay in arterial waves reflected from resistance vessels and the microvasculature.29 Measurements were averaged over three continuous 30-second trials. The test-retest intraclass reliability coefficient is R = 0.87 for large artery compliance and R = 0.83 for small artery compliance.28

Statistical analysis 

Measurement variables were summarized by presenting means and standard deviations within each of the four races by gender groups. Equality of the four means for each variable was tested using a one way analysis of variance (ANOVA) procedure. The Kruskal-Wallis procedure was used for the ranking scale metabolic syndrome components variable. Dichotomous variables were summarized by presenting percent “yes” within groups and equality of proportions tested using 2 by 4 χ2.

For the two primary response variables, LAEI and SAEI, an analysis of covariance (ANCOVA) was used to test for possible gender, ethnic, and their interaction effects. For each of these responses, selection of appropriate covariates from all the other variables was made by first using a stepwise forward selection method to obtain best linear model constrained to include gender and ethnicity, then using as covariates those variable contained in the set of selected variables for which all covariates were significant at the 0.1 level in the ANCOVA. The 0.1 inclusion criteria was chosen as a conservative measure to guard against omitting pertinent variables while still avoiding over parameterization of model. Since age was the most prominent covariate selected, the association of other variables with primary responses was examined by obtaining partial correlations after adjustment for age, ethnicity, and gender.

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Results 

The clinical characteristics of the Caucasian and African American men and women are displayed in Table I. A total of 114 patients participated, including 38 Caucasian men, 32 Caucasian women, 16 African American men, and 28 African-American women. Overall group differences were found for BMI (P = .020), prevalence of elevated fasting glucose (P = .001), medication usage for diabetes (P = .001), prevalence of abdominal obesity (P = .025), LAEI (P = .042), and SAEI (P = .019). Women had higher values for BMI and abdominal obesity than men, and African Americans had higher prevalence of elevated fasting glucose, greater usage of diabetes medication, and lower LAEI and SAEI than Caucasians. All of the remaining variables were similar among groups (P > .05), including ABI (P = .894).

Table I. Clinical characteristics of peripheral arterial disease patients with intermittent claudication
VariablesCaucasian men (N = 38)African-American men (N = 16)Caucasian women (N = 32)African-American women (N = 28)P value
Age (years)68(12)60(7)67(12)64(9).098
Weight (kg)84.6(16.3)93.7(25.0)77.9(17.9)85.9(18.7).050
Body mass index (kg/m2)27.4(4.4)30.9(8.0)29.7(6.7)32.3(6.9).020
Ankle-brachial index0.72(0.21)0.78(0.20)0.74(0.27)0.73(0.29).894
Current smoking (% yes)24503441.247
Elevated fasting glucose (% yes)26562364.001
Elevated blood pressure (% yes)811007793.101
Elevated triglycerides (% yes)76757464.748
Reduced HDL cholesterol (% yes)87818782.915
Abdominal obesity (% yes)35386168.025
Metabolic syndrome components (n)3.0(1.2)3.5(1.2)3.2(1.2)3.7(1.4).119
Metabolic syndrome (% yes)70817479.807
Obesity (%)32444761.132
Medication for blood pressure (% yes)74886986.298
Medication for dyslipidemia (% yes)63567261.700
Medication for diabetes (% yes)26501661.001
Medication for peripheral artery disease (% yes)71817264.696
Large artery elasticity index (mL × mm Hg−1) × 1015.7(5.8)12.6(3.9)15.2(9.1)11.5(4.3).042
Small artery elasticity index (mL × mm Hg−1) × 1004.3(2.3)3.0(1.8)3.7(2.2)2.8(1.3).019

Values are means (SD) and percentages.

The association between clinical characteristics and arterial compliance adjusted for age, gender, and ethnicity are shown in Table II. SAEI was negatively correlated with current smoking (P < .05) and elevated blood pressure (P < .05), and positively associated with weight (P < .01), BMI (P < .05), abdominal obesity (P < .05), and obesity (P < .05). The significant covariates in the ANCOVA model for SAEI (Table III) included age (P = .0001), abdominal obesity (P = .0030), and elevated blood pressure (P = .0067). The significant covariates for LAEI included age (P = .0002) and elevated triglycerides (P = .0719). Use of medications to control blood pressure, cholesterol, diabetes, and PAD were not significant covariates in the ANCOVA models for SAEI and LAEI.

Table II. Association between clinical characteristics and measures of arterial compliance in 110 peripheral arterial disease patients with intermittent claudication
VariablesLarge artery elasticity indexSmall artery elasticity index
Weight0.1520.251b
Body mass index0.1140.220a
Ankle-brachial index0.0440.156
Current smoking−0.044−0.214a
Elevated fasting glucose−0.0600.014
Elevated blood pressure0.007−0.191a
Elevated triglycerides0.1760.023
Reduced HDL cholesterol0.1540.141
Abdominal obesity0.0220.213a
Metabolic syndrome0.1460.042
Obesity0.1400.210a

Values are Pearson partial correlation coefficients adjusted for gender, ethnicity, and age.

aP < 0.05,

bP < 0.01.

Table III. Regression coefficient summary for covariates used in ANCOV models for large artery elasticity index (LAEI) and small artery elasticity index (SAEI) of peripheral arterial disease patients with intermittent claudication
VariablesPredictorsRegression coefficient95% CIR2P value
LAEIAge−0.2000 per year−0.3027to−0.09720.1110.0002
Elevated triglycerides2.3188 condition present−0.2097to4.84740.0246.0719
SAEIAge−0.0649 per year−0.0965to−0.03330.0961.0001
Abdominal obesity1.0519 condition present0.3657to1.73800.0535.0030
Elevated blood pressure−1.3708 condition present−2.3535to−0.38820.0443.0067

The LAEI of the Caucasian and African American men and women adjusted for age and triglycerides is shown in Table IV. LAEI was 39% lower in African Americans than in Caucasians (P = .0005), whereas no difference existed between men and women (P = .7904). The SAEI adjusted for age, abdominal obesity, and elevated blood pressure is shown in Table V. SAEI was 32% lower in African Americans than in Caucasians (P = .0007), and was 18% lower in women than in men (P = .0442).

Table IV. Large artery elasticity index (LAEI) of peripheral arterial disease patients with intermittent claudication
EthnicityMaleFemaleEthnic meansP value
Caucasian16.2(1.0)15.5(1.1)15.8(0.72)G=.7904
African American11.5(1.5)11.5(1.1)11.4(0.90)E=.0005
Gender means13.8(0.81)13.5(0.79)13.7G×E=.7915

G, Gender effect; E, ethnicity effect; G×E, gender by ethnicity interaction.

Values are means (SE) adjusted for age and elevated triglycerides.

Table V. Small artery elasticity index (SAEI) of peripheral arterial disease patients with intermittent claudication
EthnicityMaleFemaleEthnic meansP value
Caucasian4.6(0.3)3.5(0.3)4.1(0.2)G=.0442
African American3.0(0.4)2.6(0.3)2.8(0.3)E=.0007
Gender means3.8(0.2)3.1(0.2)3.4G×E=.2716

G, Gender effect; E, ethnicity effect; G×E, gender by ethnicity interaction.

Values are means (SE) adjusted for age, abdominal obesity, and elevated blood pressure.

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Discussion 

The primary finding of this investigation was that African American patients had impaired large and small arterial compliance compared with Caucasian patients, even after adjusting for covariates such as age, abdominal obesity, and elevations in blood pressure and triglycerides. This finding supports a previous observation that in young, asymptomatic adults between 18 and 44 years of age, African Americans had lower large and small arterial compliance than Caucasians.32 However, this is the first study to compare ethnic differences in arterial compliance in PAD patients and supports the notion of African-Americans having a greater atherosclerotic burden than Caucasians.13 Thus, less compliant large and small arteries of African Americans may be one factor contributing to their higher risk for PAD,13 and to their shorter 6-minute walk distance, slower velocity while walking 4 meters, and lower summary performance score.15

A second key observation in this report was that women had similar large artery compliance to men, but lower small artery compliance adjusted for age, abdominal obesity, and elevated blood pressure. Thus, the macrovasculature was similar between men and women, both from the standpoint of having similar large artery compliance as well as having similar ABI. However, the lower small artery compliance of women indicates that they have impaired microvasculature function compared with men. This finding supports a recent study from our laboratory that measured calf muscle hemoglobin oxygen saturation (StO2) during treadmill exercise in men and women.12 Calf muscle StO2, a measure of the local circulation, was impaired in women and was predictive of their lower exercise performance. Less compliant small arteries of women with intermittent claudication observed in this investigation may contribute to their impaired calf muscle StO2 and shorter walking distances. The lower small artery compliance in women in our study also is in agreement with the finding that young, asymptomatic adult women have lower small artery compliance than their male counterparts.32

Age was the most significant single covariate for both large and small artery compliance, indicating that age has a deleterious effect on arterial compliance in older patients with PAD and intermittent claudication. This observation is supported by previous studies reporting a decrease in large and small artery compliance in PAD patients with either intermittent claudication or critical limb ischemia,20 in patients solely with intermittent claudication,(19) and in asymptomatic adults.27, 31, 32 The age-related decrease in arterial compliance occurs due to structural changes within the arterial wall, such as increased fragmentation and decreased density of elastin,33 increased concentration of collagen,34 and hypertrophy of vascular smooth muscle.34

Elevated blood pressure was another significant covariate for small artery compliance, indicating that hypertension impairs microvascular function. This finding is supported by previous reports in patients with intermittent claudication19 and in asymptomatic adults.29, 31, 32 The clinical implication is that management to lower blood pressure not only lowers cardiovascular risk of patients with intermittent claudication,7 but it may also increase small artery compliance, a marker of endothelial function,31 and thus improve microcirculation. Abdominal obesity was another covariate of small artery compliance, as those with abdominal obesity had higher compliance. This finding agrees with previous studies20, 31 and suggests that obesity may reflect a state of chronic vasodilatation, perhaps secondary to relative hyperinsulinemia frequently associated with obesity.35 Elevated triglycerides, a component of metabolic syndrome, was a final covariate for arterial compliance, as it was a significant covariate for large artery compliance after adjusting for age.

There are several limitations to this study. The cross-sectional research design of this study does not allow causality to be established when examining the relationship between arterial compliance and covariates, such as age, blood pressure, body fatness, and metabolic syndrome components. Another limitation is that diastolic PCA is a noninvasive technique to determine large and small artery compliance.31, 36, 37 However, this technique has been validated with invasive measures of arterial compliance36 and provides reliable measurement of arterial compliance.28

The present findings are also limited to PAD patients who have intermittent claudication and may not be generalized to patients with less severe or more severe PAD. However, the patients in the current study are typical of patients with intermittent claudication, as there was a high prevalence of cardiovascular risk factors for PAD, including smoking, diabetes, hypertension, dyslipidemia, and obesity. Thus, the findings of the present study are generalizable to the majority of patients with intermittent claudication who typically have numerous comorbid conditions.

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Conclusions 

African-American patients with intermittent claudication have more impaired macrovacular and microvascular function than Caucasian patients and women have more impaired microvascular function than men. These ethnic and gender differences in arterial compliance are evident even though ABI was similar among groups, suggesting that arterial compliance provides unique information to quantify vascular impairment in patients with intermittent claudication. Future investigations should examine whether arterial compliance is associated with symptomatology and exercise performance, and whether it is modifiable with interventions such as exercise and medication therapies.

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Author contributions 


Conception and design: AG, PM

Analysis and interpretation: AG, DP

Data collection: SB

Writing the article: AG, DP

Critical revision of the article: AG, PM, SB, DP

Final approval of the article: AG, PM, SB, DP

Statistical analysis: DP

Obtained funding: AG

Overall responsibility: AG

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References 

  1. Brass EP, Hiatt WR. Review of mortality and cardiovascular event rates in patients enrolled in clinical trials for claudication therapies. Vasc Med. 2006;11:141–145
  2. Criqui MH, Langer RD, Fronek A, Feigelson HS, Klauber MR, McCann TJ, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326:381–386
  3. Dormandy J, Heeck L, Vig S. The natural history of claudication: risk to life and limb. Semin Vasc Surg. 1999;12:123–137
  4. Muluk SC, Muluk VS, Kelley ME, Whittle JC, Tierney JA, Webster MW, et al. Outcome events in patients with claudication: a 15-year study in 2777 patients. J Vasc Surg. 2001;33:251–257
  5. Vogt MT, Wolfson SK, Kuller LH. Lower extremity arterial disease and the aging process: a review. J Clin Epidemiol. 1992;45:529–542
  6. Weitz JI, Byrne J, Clagett GP, Farkouh ME, Porter JM, Sackett DL, et al. Diagnosis and treatment of chronic arterial insufficiency of the lower extremities: a critical review. Circulation. 1996;94:3026–3049
  7. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45(Suppl S):S5–S67
  8. Vogt MT, Cauley JA, Kuller LH, Nevitt MC. Functional status and mobility among elderly women with lower extremity arterial disease: the Study of Osteoporotic Fractures. J Am Geriatr Soc. 1994;42:923–929
  9. Kannel WB, McGee DL. Update on some epidemiologic features of intermittent claudication: the Framingham Study. J Am Geriatr Soc. 1985;33:13–18
  10. McDermott MM, Greenland P, Liu K, Criqui MH, Guralnik JM, Celic L, et al. Sex differences in peripheral arterial disease: leg symptoms and physical functioning. J Am Geriatr Soc. 2003;51:222–228
  11. Gardner AW. Sex differences in claudication pain in subjects with peripheral arterial disease. Med Sci Sports Exerc. 2002;34:1695–1698
  12. Gardner AW, Parker DE, Montgomery PS, Blevins SM, Nael R, Afaq A. Sex differences in calf muscle hemoglobin oxygen saturation in patients with intermittent claudication. J Vasc Surg. 2009;50:77–82
  13. Criqui MH, Vargas V, Denenberg JO, Ho E, Allison M, Langer RD, et al. Ethnicity and peripheral arterial disease: the San Diego Population Study. Circulation. 2005;112:2703–2707
  14. Collins TC, Petersen NJ, Suarez-Almazor M, Ashton CM. Ethnicity and peripheral arterial disease. Mayo Clin Proc. 2005;80:48–54
  15. Rucker-Whitaker C, Greenland P, Liu K, Chan C, Guralnik JM, Criqui MH, et al. Peripheral arterial disease in African Americans: clinical characteristics, leg symptoms, and lower extremity functioning. J Am Geriatr Soc. 2004;52:922–930
  16. Wilson AM, O'Neal D, Nelson CL, Prior DL, Best JD, Jenkins AJ. Comparison of arterial assessments in low and high vascular disease risk groups. Am J Hypertens. 2004;17:285–291
  17. Duprez DA, De Buyzere ML, De Backer TL, Van d V , Clement DL, Cohn JN. Relationship between arterial elasticity indices and carotid artery intima-media thickness. Am J Hypertens. 2000;13:1226–1232
  18. Grey E, Bratteli C, Glasser SP, Alinder C, Finkelstein SM, Lindgren BR, et al. Reduced small artery but not large artery elasticity is an independent risk marker for cardiovascular events. Am J Hypertens. 2003;16:265–269
  19. Duprez DA, De Buyzere MM, De BL, Clement DL, Cohn JN. Small and large artery elasticity indices in peripheral arterial occlusive disease (PAOD). Vasc Med. 2001;6:211–214
  20. Kals J, Kampus P, Kals M, Zilmer K, Kullisaar T, Teesalu R, et al. Impact of oxidative stress on arterial elasticity in patients with atherosclerosis. Am J Hypertens. 2006;19:902–908
  21. Gardner AW, Skinner JS, Cantwell BW, Smith LK. Progressive vs single-stage treadmill tests for evaluation of claudication. Med Sci Sports Exerc. 1991;23:402–408
  22. 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–e654
  23. Hiatt WR, Marshall JA, Baxter J, Sandoval R, Hildebrandt W, Kahn LR, et al. Diagnostic methods for peripheral arterial disease in the San Luis Valley Diabetes Study. J Clin Epidemiol. 1990;43:597–606
  24. Lohman TC, Roche AF, Martorell R. Anthropometric standardization reference manual. Champaign, IL: Human Kinetics Books; 1988;
  25. 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;285:2486–2497
  26. Gardner AW, Killewich LA, Katzel LI, Womack CJ, Montgomery PS, Otis RB, et al. Relationship between free-living daily physical activity and peripheral circulation in patients with intermittent claudication. Angiology. 1999;50:289–297
  27. Fjeldstad AS, Montgomery PS, Gardner AW. Age-related differences in arterial compliance are independent of body mass index. Angiology. 2008;59:454–458
  28. Acree LS, Montgomery PS, Gardner AW. The influence of obesity on arterial compliance in adult men and women. Vasc Med. 2007;12:183–188
  29. Fjeldstad AS, Fjeldstad C, Acree LS, Nickel KJ, Montgomery PS, Comp PC, et al. The relationship between arterial elasticity and metabolic syndrome features. Angiology. 2007;58:5–10
  30. Nickel KJ, Acree LS, Montgomery PS, Gardner AW. Association between lower-extremity function and arterial compliance in older adults. Angiology. 2008;59:203–208
  31. Duprez DA, Somasundaram PE, Sigurdsson G, Hoke L, Florea N, Cohn JN. Relationship between C-reactive protein and arterial stiffness in an asymptomatic population. J Hum Hypertens. 2005;19:515–519
  32. Bhuiyan AR, Li S, Li H, Chen W, Srinivasan SR, Berenson GS. Distribution and correlates of arterial compliance measures in asymptomatic young adults: the Bogalusa Heart Study. Am J Hypertens. 2005;18:684–691
  33. Avolio A, Jones D, Tafazzoli-Shadpour M. Quantification of alterations in structure and function of elastin in the arterial media. Hypertension. 1998;32:170–175
  34. Lakatta EG. Age-associated cardiovascular changes in health: impact on cardiovascular disease in older persons. Heart Fail Rev. 2002;7:29–49
  35. Serne EH, IJzerman RG, Gans RO, Nijveldt R, De VG, Evertz R, et al. Direct evidence for insulin-induced capillary recruitment in skin of healthy subjects during physiological hyperinsulinemia. Diabetes. 2002;51:1515–1522
  36. Cohn JN, Finkelstein S, McVeigh G, Morgan D, LeMay L, Robinson J, et al. Noninvasive pulse wave analysis for the early detection of vascular disease. Hypertension. 1995;26:503–508
  37. Finkelstein SM, Cohn JN. First- and third-order models for determining arterial compliance. J Hypertens Suppl. 1992;10:S11–S14

 This research was supported by grants from the National Institute on Aging (NIA) (R01-AG-24296; AWG), by a Oklahoma Center for the Advancement of Science and Technology grant (HR04-113S; AWG), and by the University of Oklahoma Health Sciences Center General Clinical Research Center grant (M01-RR-14467), sponsored by the National Center for Research Resources from the National Institutes of Health.

 The final peer-reviewed version of this manuscript is subject to the NIH Public Access Policy, and will be submitted to PubMed Central.

 Competition of interest: none.

 The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest.

PII: S0741-5214(09)02097-7

doi:10.1016/j.jvs.2009.09.059

Journal of Vascular Surgery
Volume 51, Issue 3 , Pages 610-615, March 2010

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