Physical activity and peripheral artery disease: Two prospective cohort studies and a systematic review
Graphical abstract
Introduction
Peripheral artery disease (PAD) affects over 200 million people worldwide and it is the third most common cause of cardiovascular morbidity, after stroke and coronary heart disease [1]. With an increasing prevalence in both high- and low-income countries, PAD incurs considerable costs to patients and healthcare systems alike, in terms of decreased quality of life, loss of healthy life-years and medical and surgical treatment [2,3]. Despite the increasing burden of PAD, the evidence on risk factors specific to this manifestation of cardiovascular disease is scarce, and specific treatment targets are lacking [4].
At present the primary and secondary preventive treatment for PAD is identical to the prevention of coronary and carotid atherosclerotic disease, with reducing cholesterol, hypertension, smoking, and obesity as the main interventional targets [4]. Although different manifestations of cardiovascular disease share many risk factors, the magnitude of the risk incurred by specific exposures varies between disease outcomes. For example, smoking, hypertension and type-2 diabetes have been consistently shown to be associated with an increased risk of coronary artery disease as well as PAD [1,5], but there is evidence that the effects of other risk factors may differ, e.g. with cholesterol being more strongly implicated in coronary heart disease and chronic inflammation in PAD [6]. Whilst addressing the coronary and carotid therapeutic targets is undoubtedly beneficial to patients at risk of PAD or living with this disease, more explicit evidence on the risk factors specific to peripheral artery atherosclerotic disease is needed to inform clinical practice and the development of guidelines aiming to reduce the incidence and improve prognosis of PAD at individual- and population-levels.
One important modifiable risk factor for cardiovascular disease is low level of physical activity [7]. Randomised controlled trials have shown that physical activity interventions, particularly supervised exercise programmes, are also effective secondary preventive measures in patients with intermittent claudication, as they improve patient-relevant outcomes, such as overall walking distance and speed as well as pain-free walking distance in this patient group [8,9]. However, the potential role of self-initiated physical activity in the development of PAD is unclear. A link between physical activity and the incidence of PAD would lend weight to the increasing role of physical activity and exercise as part of primary prevention strategies for atherosclerotic cardiovascular disease in general and PAD in particular. Here we have systematically reviewed and summarised the currently available evidence of association between self-initiated physical activity and PAD.
Section snippets
Systematic searches
We searched PubMed, EMBASE and CINAHL Plus from the inception of each database up to 31 August 2018 for studies comparing physical activity levels in individuals with and without PAD. Briefly, we searched for original studies in humans, indexed with “physical activity” or “exercise” and “peripheral artery occlusive disease” or “peripheral artery disease” as keywords or Medical Subject Heading terms. No limits were set on study design or language of publication. Details of the search terms used
Systematic search
The results of the systematic searches are detailed in Fig. 1. Briefly, we screened 4436 abstracts and selected 35 potentially relevant articles for full-text review. Of these, 18 articles were excluded. The main reasons for exclusion were irrelevant exposure (other than an amount of physical activity per unit of time) or irrelevant outcome (e.g. CVD other than PAD). After all exclusions, and adding one eligible article from the citing reference search, 18 articles reporting on the association
Summary of findings
Physical activity is an important therapeutic target in treating patients with intermittent claudication (an early manifestation of PAD), and encouraging results from clinical trials point to the impact of supervised exercise programmes in improving functional capacity in this group of patients [8,9,11]. The findings of our systematic review provide some indication that self-initiated physical activity is associated with a decreased risk of PAD. However, all the evidence presented here comes
Conflict of interest
The authors declared they do not have anything to disclose regarding conflict of interest with respect to this manuscript.
Financial support
Whitehall II study is supported by grants from the UK Medical Research Council (K013351, R024227), the US National Institutes on Aging (R01AG056477) and the British Heart Foundation (32334). The Finnish Public Sector study is supported by the Finnish Institute of Occupational Health.
Author contributions
KH and JIH designed the study, with input for PAC. KH, JIH, PAC, JP and MK participated in acquisition, analysis and interpretation of data. KH wrote the first draft of the article and all authors participated in revising it critically for important intellectual content. All authors approved the version to be published.
Ethical approval
The Finnish Public Sector Study was approved by the Helsinki and Uusimaa hospital district ethics committee. The Whitehall II study protocol was approved by the University College London Medical School committee on the ethics of human research. All procedures performed in these studies were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed
Acknowledgements
The authors thank all of the participating civil service departments in Whitehall II study and their welfare, personnel, and establishment officers; the British Occupational Health and Safety Agency; the British Council of Civil Service Unions; all participating civil servants in the Whitehall II study; and all members of the Whitehall II study team. The Whitehall II Study team comprises research scientists, statisticians, study coordinators, nurses, data managers, administrative assistants and
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