Jornal Vascular Brasileiro
https://jvascbras.org/article/doi/10.1590/S1677-54492008000200005
Jornal Vascular Brasileiro
Original Article

Estudo comparativo da evolução e sobrevida de pacientes com claudicação intermitente, com ou sem limitação para exercícios, acompanhados em ambulatório específico

Comparative study of evolution and survival of patients with intermittent claudication, with or without limitation for exercises, followed in a specific outpatient setting

Ricardo de Alvarenga Yoshida; Caroline Kazue Matida; Marcone Lima Sobreira; Mariângela Gianini; Regina Moura; Hamilton Almeida Rollo; Winston Bonetti Yoshida; Francisco Humberto de Abreu Maffei

http://dx.doi.org/10.1590/S1677-54492008000200005 J Vasc Bras, vol.7, n2, p.112-122, 2008
PDF Português
PDF English
SciELO
Downloads: 0
Views: 1122

Resumo

CONTEXTO: Os fatores de risco para doença aterosclerótica, que influenciam na evolução natural dessa doença, estão bem estabelecidos, assim como o benefício do programa de exercícios para pacientes claudicantes. Entretanto, faltam informações sobre a relação entres limitações clínicas e fatores de risco, com desempenho do programa de caminhadas e suas implicações na evolução e mortalidade destes pacientes. OBJETIVO: Comparar, ao longo do tempo, a distância de claudicação e sobrevida de pacientes claudicantes em ambulatório específico, com ou sem limitação para exercícios. MÉTODOS: Foi feito um estudo tipo coorte retrospectivo de 185 pacientes e 469 retornos correspondentes, no período de 1999 a 2005, avaliando-se dados demográficos, distância média de claudicação (CI) e óbito. Os dados foram analisados nos programas Epi Info, versão 3.2, e SAS, versão 8.2. RESULTADOS: A idade média foi de 60,9±11,1 anos, sendo 61,1% do sexo masculino e 38,9% do sexo feminino. Oitenta e sete por cento eram brancos, e 13%, não-brancos. Os fatores de risco associados foram: hipertensão (69,7%), tabagismo (44,3%), dislipidemia (32,4%) e diabetes (28,6%). Nos claudicantes para menos de 500 m, a CI inicial em esteira foi de 154,0±107,6 m, e a CI final, de 199,8±120,5 m. Cerca de 45% dos pacientes tinham alguma limitação clínica para realizar o programa de exercícios preconizado, como: angina (26,0%), acidente vascular cerebral (4,3%), artropatia (3,8%), amputação menor ou maior com prótese (2,1%) ou doença pulmonar obstrutiva crônica (1,6%). Cerca de 11,4% dos pacientes tinham infarto do miocárdio prévio, e 5,4% deles usavam cardiotônico. O tempo de seguimento médio foi de 16,0±14,4 meses. A distância média de CI referida pelos pacientes aumentou 100% (de 418,47 m para 817,74 m) ao longo de 2 anos, nos grupos não-limitante (p < 0,001) e não-tabagista (p < 0,001). A sobrevida dos claudicantes foi significativamente menor no grupo com limitação. A análise de regressão logística mostrou que a limitação para realização de exercícios, isoladamente, influenciou significativamente na mortalidade (p < 0,001). CONCLUSÃO: A realização correta e regular dos exercícios e o abandono do fumo melhoram a distância de claudicação, além de reduzir a mortalidade nesses casos, seja por meio de efeitos positivos próprios do exercício, seja por meio de controle dos fatores de risco e de seus efeitos adversos.

Palavras-chave

Claudicação intermitente, aterosclerose, terapia por exercício, fatores de risco

Abstract

BACKGROUND: Risk factors for atherosclerotic disease acting on natural history are well established, as well as the benefits of physical training in the treatment of intermittent claudication (IC). However, current data do not provide enough information about the relationship between clinical limitations and risk factors and the performance of physical training and its implications on the evolution and mortality of these patients. OBJECTIVE: To compare the claudication distance and survival of patients with IC throughout time in a specific outpatient setting, with or without limitation for exercises. METHODS: A retrospective cohort study was performed to review the protocols of 185 patients and 469 returns, from 1999 to 2005, evaluating demographic data, average claudication distance and death. The data were analyzed using the software Epi-Info, version 3.2, and SAS, version 8.2. RESULTS: Mean age was 60.9±11.1 years; 61.1% were males and 38.9% were females; 87% were Caucasians and 13% were non-Caucasians. Associated risk factors were hypertension (69.7%), smoking (44.3%), dyslipidemia (32.4%), and diabetes (28.6%). For the patients with claudicating distance lower than 500 m, mean initial distance was 154.0±107.6 m and final distance was 199.8±120.5 m. About 45% of the patients had some clinical limitation to perform the prescribed exercise program, such as angina (26.0%), stroke (4.3%), osteoarthrosis (3.8%), previous minor or major amputation (2.1%), or chronic obstructive pulmonary disease (1.6%). About 11.4% of the patients had previous myocardial infarction, and 5.4% of them were using cardiotonic drugs. Mean follow-up time was 16.0±14.4 months. Mean claudication distance increased 100% (418.47 to 817.74 m) throughout 2 years in the group without limitation (p < 0.001) and in nonsmokers (p < 0.001). Survival rate of patients with IC was significantly reduced in the group with limitation for exercises. Logistic regression analysis showed that limitation to exercises was the single factor significantly influencing mortality (p < 0.001). CONCLUSION: Proper and regular exercises and quitting smoking improve claudication distance and reduce mortality rates of these patients, whether by the positive effects of exercises or by controlling risk factors and their adverse effects.

Keywords

Intermittent claudication, atherosclerosis, exercise therapy, risk factors

References

Maffei FHA, Lastória S. Aterosclerose obliterante periférica: epidemiologia, fisiopatologia, quadro clínico e diagnóstico. Doenças vasculares periféricas. 2000;2:1007-23.

Criqui MH, Fronek A, Barrett-Connor E, Klauber MR, Gabriel S, Goodman D. The prevalence of peripheral arterial disease in a defined population. Circulation. 1985;71:510-5.

Creager MA. Medical management of peripheral arterial disease. Cardiol Rev. 2001;9:238-45.

Aronow WS. Management of peripheral arterial disease. Cardiol Rev. 2005;13:61-8.

Hiatt WR, Hoag S, Hamman RF. Effect of diagnostic criteria on the prevalence of peripheral arterial disease: The San Luis Valley Diabetes Study. Circulation. 1995;91:1472-9.

Kannel WB, Skinner JJ Jr., Schwartz MJ, Shurtleff D. Intermittent claudication: Incidence in the Framingham Study. Circulation. 1970;41:875-83.

Management of peripheral arterial disease (PAD): TransAtlantic Inter-Society Consensus (TASC). Eur J Vasc Endovasc Surg. 2000;19(^sA):Si-xxviii, S1-250.

Norgren L, Hiatt WR, Dormandy JA. Inter-society consensus for the management of peripheral arterial disease. Int Angiol. 2007;26:81-157.

Brevetti G, Annecchini R, Bucur R. Intermittent claudication: pharmacoeconomic and quality-of-life aspects of treatment. Pharmacoeconomics. 2002;20:169-81.

Schainfeld RM. Management of peripheral arterial disease and intermittent claudication. J Am Board Fam Pract. 2001;14:443-50.

Wullink M, Stoffers HE, Kuipers H. A primary care walking exercise program for patients with intermittent claudication. Med Sci Sports Exerc. 2001;33:1629-34.

Leng GC, Fowler B, Ernst E. Exercise for intermittent claudication. Cochrane Library Syst Rev. 2000:CD000990.

Diretrizes da SBACV (Normas de orientação clínica para prevenção, diagnóstico e tratamento da doença arterial obstrutiva periférica). J Vasc Bras. 2005;4(3^s4):S222-38.

Durazzo AES, Sitrângulo Jr. CJ, Presti C, Silva ES, De Luccia N. Doença arterial obstrutiva periférica: que atenção temos dispensado à abordagem clínica dos pacientes?. J Vasc Bras. 2005;4:255-64.

Rehring TF, Sandhoff BG, Stolcpart RS, Merenich JA, Hollis HW Jr. Atherosclerotic risk factor control in patients with peripheral arterial disease. J Vasc Surg. 2005;41:816-22.

Hiatt WR. Pharmacologic therapy for peripheral arterial disease and claudication. J Vasc Surg. 2002;36:1283-91.

Yoshida WB, Bosco FA, Medeiros FATM, Rollo HA, Dalben IN. Lipídios séricos como fator de risco para pacientes com doença arterial periférica. J Vasc Bras. 2003;2:5-12.

Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ. 1998;317:703-13.

Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. UK Prospective Diabetes Study Group. BMJ. 1998;317:713-20.

Burns P, Lima E, Bradbury AW. What constitutes best medical therapy for peripheral arterial disease?. Eur J Vasc Endovasc Surg. 2002;24:6-12.

Myers KA, King RB, Scott DF, Johnson N, Morris PJ. The effect of smoking on the late patency of arterial reconstructions in the legs. Br J Surg. 1978;65:267-71.

Ungerleider RM, Holman WL, Stanley TE 3rd. Encircling endocardial ventriculotomy for refractory ischemic ventricular tachycardia: I. Electrophysiological effects. J Thorac Cardiovasc Surg. 1982;83:840-9.

Jonason T, Bergström R. Cessation of smoking in patients with intermittent claudication: Effects on the risk of peripheral vascular complications, myocardial infarction and mortality. Acta Med Scand. 1987;221:253-60.

Jonason T, Ringqvist I. Prediction of the effect of training on the walking tolerance in patients with intermittent claudication. Scand J Rehabil Med. 1987;19:47-50.

Maffei FHA, Lastória S. Tratamento clínico da aterosclerose obliterante perférica. Doenças vasculares periféricas. 2000;2:1025-41.

Criqui MH, Langer RD, Fronek A. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326:381-6.

Da Silva A, Widmer LK, Ziegler HW, Nissen C, Schweizer W. The Basle longitudinal study: report on the relation of initial glucose level to baseline ECG abnormalities, peripheral artery disease, and subsequent mortality. J Chronic Dis. 1979;32:797-803.

Fowler B, Jamrozik K, Norman P, Allen Y. Prevalence of peripheral arterial disease: persistence of excess risk in former smokers. Aust N Z J Public Health. 2002;26:219-24.

Criqui MH, Denenberg JO, Langer RD, Fronek A. The epidemiology of peripheral arterial disease: importance of identifying the population at risk. Vasc Med. 1997;2:221-6.

Gardner AW, Montgomery PS, Flinn WR, Katzel LI. The effect of exercise intensity on the response to exercise rehabilitation in patients with intermittent claudication. J Vasc Surg. 2005;42:702-9.

Shephard RJ, Balady GJ. Exercise as cardiovascular therapy. Circulation. 1999;99:963-72.

Fowler B, Jamrozik K, Norman P, Allen Y, Wilkinson E. Improving maximum walking distance in early peripheral arterial disease: randomised controlled trial. Aust J Physiother. 2002;48:269-75.

Gornik HL, Beckman JA. Cardiology patient page: Peripheral arterial disease. Circulation. 2005;111:e169-72.

Wolosker N, Nakano L, Rosoky RA, Puech-Leao P. Evaluation of walking capacity over time in 500 patients with intermittent claudication who underwent clinical treatment. Arch Intern Med. 2003;163:2296-300.

Gardner AW, Katzel LI, Sorkin JD. Improved functional outcomes following exercise rehabilitation in patients with intermittent claudication. J Gerontol A Biol Sci Med Sci. 2000;55:M570-7.

Fowler B. Homocystein: an independent risk factor for cardiovascular and thrombotic diseases. Ther Umsch. 2005;62:641-6.

Alpert JS, Larsen OA, Lassen NA. Exercise and intermittent claudication: Blood flow in the calf muscle during walking studied by the xenon-133 clearance method. Circulation. 1969;39:353-9.

Tan KH, De Cossart L, Edwards PR. Exercise training and peripheral vascular disease. Br J Surg. 2000;87:553-62.

Tan KH, Cotterrell D, Sykes K, Sissons GR, de Cossart L, Edwards PR. Exercise training for claudicants: changes in blood flow, cardiorespiratory status, metabolic functions, blood rheology and lipid profile. Eur J Vasc Endovasc Surg. 2000;20:72-8.

Skinner JS, Strandness DE Jr. Exercise and intermittent claudication: I. Effect of repetition and intensity of exercise. Circulation. 1967;36:15-22.

Skinner JS, Strandness DE Jr. Exercise and intermittent claudication: II. Effect of physical training. Circulation. 1967;36:23-9.

Hiatt WR, Regensteiner JG, Hargarten ME, Wolfel EE, Brass EP. Benefit of exercise conditioning for patients with peripheral arterial disease. Circulation. 1990;81:602-9.

Hiatt WR, Wolfel EE, Meier RH, Regensteiner JG. Superiority of treadmill walking exercise versus strength training for patients with peripheral arterial disease: Implications for the mechanism of the training response. Circulation. 1994;90:1866-74.

De Luccia N. Amputação e reconstrução nas doenças vasculares e no pé diabético. 2006:67-96.

Izquierdo-Porrera AM, Gardner AW, Powell CC, Katzel LI. Effects of exercise rehabilitation on cardiovascular risk factors in older patients with peripheral arterial occlusive disease. J Vasc Surg. 2000;31:670-7.

Miller TD, Balady GJ, Fletcher GF. Exercise and its role in the prevention and rehabilitation of cardiovascular disease. Ann Behav Med. 1997;19:220-9.

Belardinelli R, Georgiou D, Ginzton L, Cianci G, Purcaro A. Effects of moderate exercise training on thallium uptake and contractile response to low-dose dobutamine of dysfunctional myocardium in patients with ischemic cardiomyopathy. Circulation. 1998;97:553-61.

Ehsani AA, Martin WH 3rd, Heath GW, Coyle EF. Cardiac effects of prolonged and intense exercise training in patients with coronary artery disease. Am J Cardiol. 1982;50:246-54.

Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV)"> Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV)">
5ddd6b4a0e88256a531da3e9 jvb Articles
1677-7301 (Electronic)
J Vasc Bras ©2024 All rights reserved.

J Vasc Bras

Share this page
Page Sections