Vascular structure and function and their relationship with health-related quality of life in the MARK study

García-Ortiz et al. BMC Cardiovascular Disorders (2016) 16:95 DOI 10.1186/s12872-016-0272-9 RESEARCH ARTICLE Open Access Vascular structure and function and their relationship with health-related quality of life in the MARK study Luis García-Ortiz1,2*, José I. Recio-Rodríguez1, Sara Mora-Simón1,4, John Guillaumet5, Ruth Martí6,8, Cristina Agudo-Conde1, Emiliano Rodriguez-Sanchez1,3, Jose A. Maderuelo-Fernandez1, Rafel Ramos-Blanes6,7,8, Manuel A. Gómez-Marcos1,3 and the MARK Group Abstract Background: There is limited evidence concerning the relationship between vascular disease and health-related quality of life (HRQL). We investigated the relationship between vascular structure and function with health-related quality of life in a population with intermediate cardiovascular risk. Methods: This study analyzed 303 subjects with ankle-brachial index (ABI) values ranging from 0.9 to 1.4 who were included in the MARK study (age 35 to 74 years; mean:60.5 ± 8.5), of which 50.2 % were women. Measurements included: ABI, brachial-ankle pulse wave velocity (ba-PWV), and cardio-ankle vascular index (CAVI), all measured using the VaSera device. The central augmentation index was adjusted to 75 lpm (AIx_75) using the Mobil-O-Graph device. HRQL was assessed by the Spanish version of the SF-12, version2. The highest obtained CAVI and ba-PWV values and the lowest ABI values were considered for the study. Results: The cohort was composed of21 % smokers, 76 % hypertensive patients, and 24 % diabetic patients. The ABI mean was 1.09 ± 0.07,the ba-PWV mean was 14.64 ± 2.55 m/s with a 12.9 % of subjects higher than 17.5 m/s, AIx_75 26.46 ± 14.05, and CAVI 8.61 ± 1.08 with a 36.6 % of subjects higher than 9. Men scored higher than women in the HRQL measurements for physical (PSC-12; 49.9 vs. 46.9, p = 0.004) and mental (MSC-12) domains (51.2 vs. 47.7, p = 0.003). Age was positively correlated with CAVI (r = 0.547), ba-PWV (r = 0.469), AIx_75 (r = 0.255, p < 0.01), and the MSC-12 (r = 0.147, p < 0.05), but not the PSC-12. In the adjusted multiple linear regression analysis, the positive association of ABI and CAVI with the PSC-12 was maintained. Conclusions: The ABI in the normal range has a positive association with the PSC-12 of HRQL evaluated with the SF-12. The CAVI also showed a positive association with the PSC-12 of HRQL. Trial Registration: ClinicalTrials.gov Identifier: NCT01428934. Keywords: Health-related quality of life, Arterial stiffness, Ankle-brachial index, Brachial ankle pulse wave velocity, Cardio-ankle vascular index, Augmentation index * Correspondence: 1 Primary Care Research Unit, The Alamedilla Health Center. Castilla and León Health Service (SACyL), Biomedical Research Institute of Salamanca (IBSAL), 37003 Salamanca, Spain 2 Biomedical and Diagnostic Sciences Department, University of Salamanca, Salamanca, Spain Full list of author information is available at the end of the article © 2016 García-Ortiz et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. García-Ortiz et al. BMC Cardiovascular Disorders (2016) 16:95 Background Health outcomes reported by patients are becoming more important in research, clinical practice, and health planning [1, 2]. Self-perception of health status and health-related quality of life (HRQL) provide information that complements traditional health indicators based on morbidity and mortality [3]. HRQL is an important outcome in clinical trials, population health assessments, clinical improvement, and documenting for purchasers quality of care. In addition to the more objective clinical measures, many patients consider HRQL equally important. HRQL is conceptualized as a patient's perceptions of the impact of disease and treatment on functioning in a variety of dimensions, including physical, mental, and social domains [4, 5]. One of the most commonly used instruments to measure HRQL is the SF-36 Questionnaire or its SF-12 version [3, 6], that reduces the workload of health workers, the workload for patients, and the time to complete the questionnaire. The assessment of vascular structure and function with different devices allows for the detection of the early stages of atherosclerosis and the degree of arterial stiffness. Fowkes et al. conducted a meta-analysis of 16 population cohort studies that included 480.325 person years of follow up, and found that the ankle–brachial index (ABI) showed an inverse linear relationship between subclinical peripheral arterial disease (PAD) and cardiovascular disease, even at ABI values between 0.91 and 1.00 [7]. The authors also found that the risk of death for different levels of ABI, compared with a reference ABI score of 1.11 to 1.20, formed a reverse Jshaped curve. For levels of ABI below 1.11, the hazard ratios (HRs) increased with decreasing ABI, and for ABI >1.40 the HRs also increased, but this was not the case for ABI scores between 1.11 and 1.40 [7]. However, little is known about the relationship between ABI and activities of daily living functioning at the population level. In some subgroups of subjects with high cardiovascular risk, PAD and severe renal impairment [8–10], there was a positive association between ABI and HRQL, including for patients whose ABI was in the range 0.9 to 1.3. A worse quality of life was also found in subjects with ABI > 1.4 [11]. The subgroup of patients with intermediate cardiovascular risk is the group in which the highest number of cardiovascular events occur, and it is known the association of these with a worse HRQL [12, 13]. However, the potential influence of ABI on HRQL, when considering ABI as a continuous variable, in individuals with intermediate cardiovascular risk and ABI in the normal range [14] has not been analyzed. Knowing this relationship may lead to improvements in a multidimensional therapeutic approach for this very large subjects group at risk for a cardiovascular event. Page 2 of 10 Vascular function, as evaluated by pulse wave velocity (PWV) [15, 16], has been correlated with morbidity and mortality both in patients with cardiovascular disease and in healthy individuals. The cardio-ankle vascular index (CAVI) is a parameter [17] of the overall stiffness of the artery from the aorta's origin to the ankle. It can be used to estimate the risk of atherosclerosis [18]. The relationship between vascular function and HRQL has been little studied, and only in some population subgroups. Bruner et al. [19] (...truncated)