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Published on: September 22, 2020
Amputation and cardiac comorbidity: analysis of severity of cardiac risk
Mallikarjuna Nallegowda1, Esther Lee, Murray Brandstater
1Department of Physical Medicine & Rehabilitation, Loma Linda University Medical Center, Loma Linda, CA 92354, USA. drmallik@yahoo.com
Insights
Amputees show significantly higher coronary artery calcification scores (CACS) than predicted by traditional risk factors. Early screening for coronary artery disease (CAD) and targeted interventions are crucial for managing amputee health.
Area of Science:
- Cardiology
- Vascular Medicine
- Epidemiology
Background:
- Cardiovascular disease is a leading cause of mortality.
- Risk stratification tools like the Framingham Risk Score (FRS) are widely used.
- Amputees represent a unique population with potentially underestimated cardiovascular risk.
Purpose of the Study:
- To evaluate the utility of population-based cardiovascular risk scores and coronary artery calcification scores (CACS) in amputees.
- To compare CACS and traditional cardiac risk factors between amputees and matched control groups.
Main Methods:
- Retrospective cohort study of 1300 veterans undergoing cardiac computed tomography.
- Comparison of 76 amputees with age-, gender-, and FRS-matched controls.
- Assessment of CACS and traditional cardiac risk factors, including hypertension, chronic kidney disease, and dyslipidemia.
Main Results:
- Amputees had significantly higher mean CACS (1285 ± 18) compared to controls (540 ± 84 and 481 ± 11), despite many being in low-to-intermediate FRS categories.
- 76% of amputees had CACS >100 and 38% had CACS >1000, indicating substantial coronary artery disease (CAD).
- Nontraumatic amputees had higher CACS than traumatic amputees; CACS were similar across amputation levels, suggesting widespread CAD.
Conclusions:
- Amputees exhibit a significantly greater burden of subclinical atherosclerotic disease than indicated by standard risk scores.
- Early screening for CAD using CACS and aggressive, targeted interventions are vital for improving outcomes in amputees.
- This highlights the need for re-evaluating cardiovascular risk assessment in the amputee population.
Objective:
To evaluate population-based cardiovascular risk scores and coronary artery calcification scores (CACS) in amputees.
Design:
A retrospective cohort study of 1300 veterans in a cardiac computed tomography database.
Setting:
1B Veterans Administration medical center.
Participants:
A total of 76 amputees and similar number of age-, gender-, and Framingham Risk Scores (FRS)-matched control subjects.
Methods:
The amputee population was identified and compared for CACS and traditional cardiac risk factors. Two control groups were used: control group 1, with known risk factors including diabetes mellitus, and control group 2, with all risk factors without diabetes mellitus.
Main Outcome Measures:
Statistical associations between amputee and control group FRS scores, CACS, and other cardiac risk factors were assessed.
Results:
The study included 57 nontraumatic and 19 traumatic amputees with an average age of 62.4 years. Sixty-six amputees were in the low-to-intermediate cardiac risk groups according to FRS. Despite this classification, the mean CACS were significantly higher in amputees (1285 ± 18) than in either of the control groups: control group 1 (540 ± 84) and control group 2 (481 ± 11), P < .001. CACS also were significantly higher in the nontraumatic subject group (1595 ± 12) compared with the traumatic group (356 ± 57; P < .001). Upon categorization of CACS based on probability of coronary artery disease (CAD), 76% of amputees had a CACS >100 and 38% of amputees had a CACS >1000. Interestingly, CACS were almost the same in finger/toe amputations compared with an above-knee amputation, indicating an already ongoing CAD process irrespective of level of amputation. The predominant clinical significant cardiac risk factors in amputees are hypertension (89.5%), P < .005; chronic kidney disease (31.6%), P < .001; dyslipidemia (72.4%), P < .04; and insulin resistance. Total cholesterol, low-density lipoprotein, and high-density lipoprotein levels were nonsignificantly low in all amputees. Triglycerides were particularly higher in traumatic patients compared with nontraumatic patients, with the triglycerides/high-density lipoprotein ratio >7.
Conclusion:
This study demonstrates that amputees have a much greater burden of underlying atherosclerotic disease as detected by CACS than do control subjects matched by Framingham risk stratification. Early screening for CAD and aggressive targeted interventions may be an important part of management to reduce early mortality after amputation.
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