Poorly controlled ambulatory blood pressure in outpatients with peripheral arterial disease

  • Nina Dahle Centre for Clinical Research, Uppsala University, Falun, Sweden; and Primary Health Care Center Britsarvet-Grycksbo, County of Dalarna, Falun, Sweden https://orcid.org/0000-0003-1444-2515
  • Emma Skau Centre for Clinical Research, Uppsala University, Västmanland County Hospital, Västerås, Sweden; and Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden https://orcid.org/0000-0002-5625-1146
  • Jerzy Leppert Centre for Clinical Research, Uppsala University, Västmanland County Hospital, Västerås, Sweden https://orcid.org/0000-0003-1433-0329
  • Johan Ärnlöv Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden; and School of Health and Social Studies, Dalarna University, Falun, Sweden https://orcid.org/0000-0002-6933-4637
  • Pär Hedberg Centre for Clinical Research, Uppsala University, Västmanland County Hospital, Västerås, Sweden; and Department of Clinical Physiology, Västmanland County Hospital, Västerås, Sweden https://orcid.org/0000-0001-5731-966X
Keywords: Carotid artery disease, cardiovascular risk factors, hypertension, smoking, hyperlipidemia, preventive efforts


Background: Patients with peripheral arterial disease (PAD) are generally less intensively managed than patients with coronary heart disease (CHD), despite that their risk of complications is believed to be equivalent. Identification of PAD patients at risk of poorly controlled blood pressure (BP) could lead to improved treatment, thus lowering the risk of cardiovascular (CV) complications. We aimed to describe the prevalence of poorly controlled cardiovascular (CV) risk factors, focusing on BP, in outpatients with PAD diagnosed in a vascular ultrasound laboratory.

Methods: Consecutive outpatients with carotid and/or lower extremity PAD were included (n = 402) and examined with blood sampling, clinical BP, and 24-h ambulatory BP measurements. A poorly controlled clinical BP was defined as ≥140/90 mmHg, ambulatory BP ≥130/80 mmHg, low-density lipoprotein (LDL)-cholesterol level ≥2.5 mmol/L, and glycated hemoglobin (HbA1c) level >53 mmol/mol in those with diabetes.

Results: Most of the patients had poorly controlled clinical (76.6%) and ambulatory BP (51.7%) profiles. Antihypertensive medications were prescribed in 84% of the patients. However, >40% of them used only 0–1 medication, and <25% of them used three or more agents. Clinical BP, a low number of medications, body mass index, and the presence of diabetes independently predicted a poorly controlled ambulatory BP. Nearly one-third of the patients were smokers, and most of the cohort had an LDL-cholesterol level of ≥2.5 mmol/L. An HbA1c level of >53 mmol/mol was present in 55% of diabetic patients.

Conclusion: Poorly controlled clinical and ambulatory systolic BP profiles were common. In addition, suboptimal control of other important CV risk factors was detected. The findings of this study highlight the need for better preventive efforts against CV risk factors in outpatients with PAD.


Download data is not yet available.


  1. Criqui MH, Aboyans V. Epidemiology of peripheral artery disease. Circ Res 2015; 116: 1509–26. doi: 10.1161/CIRCRESAHA.116.303849

  2. Aboyans V, Ricco JB, Bartelink MEL, Bjorck M, Brodmann M, Cohnert T, et al. 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS): document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. Endorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J 2018; 39: 763–816. doi: 10.1093/eurheartj/ehx095

  3. Feringa HH, Van Waning VH, Bax JJ, Elhendy A, Boersma E, Schouten O, et al. Cardioprotective medication is associated with improved survival in patients with peripheral arterial disease. J Am Coll Cardiol 2006; 47: 1182–7. doi: 10.1016/j.jacc.2005.09.074

  4. Shu J, Santulli G. Update on peripheral artery disease: epidemiology and evidence-based facts. Atherosclerosis 2018; 275: 379–81. doi: 10.1016/j.atherosclerosis.2018.05.033

  5. Fowkes FG, Murray GD, Butcher I, Heald CL, Lee RJ, Chambless LE, et al. Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. JAMA 2008; 300: 197–208. doi: 10.1001/jama.300.2.197

  6. Lindholt JS, Sogaard R. Population screening and intervention for vascular disease in Danish men (VIVA): a randomised controlled trial. Lancet (London, England) 2017; 390: 2256–65. doi: 10.1016/S0140-6736(17)32250-X

  7. Hirsch AT, Criqui MH, Treat-Jacobson D, Regensteiner JG, Creager MA, Olin JW, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA 2001; 286: 1317–24. doi: 10.1001/jama.286.11.1317

  8. Sartipy F, Lundin F, Wahlberg E, Sigvant B. Cardiovascular long-term outcome and prophylactic treatment patterns in peripheral arterial disease in a population-based cohort. Eur Heart J Qual Care Clin Outcomes 2019; 5: 310–20. doi: 10.1093/ehjqcco/qcz037

  9. Subherwal S, Patel MR, Kober L, Peterson ED, Bhatt DL, Gislason GH, et al. Peripheral artery disease is a coronary heart disease risk equivalent among both men and women: results from a nationwide study. Eur J Prev Cardiol 2015; 22: 317–25. doi: 10.1177/2047487313519344

  10. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: the task force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens 2018; 36: 1953–2041. doi: 10.1097/HJH.0000000000001940

  11. Wirehn AB, Karlsson HM, Carstensen JM. Estimating disease prevalence using a population-based administrative healthcare database. Scand J Public Health 2007; 35: 424–31. doi: 10.1080/14034940701195230

  12. Carlsson AC, Wandell P, Osby U, Zarrinkoub R, Wettermark B, Ljunggren G. High prevalence of diagnosis of diabetes, depression, anxiety, hypertension, asthma and COPD in the total population of Stockholm, Sweden – a challenge for public health. BMC Public Health 2013; 13: 670. doi: 10.1186/1471-2458-13-670

  13. Ettehad D, Emdin CA, Kiran A, Rahimi K. Blood pressure lowering for cardiovascular disease – authors’ reply. Lancet (London, England) 2016; 388: 126–7. doi: 10.1016/S0140-6736(16)30669-9

  14. Farah R, Zeidan RK, Chahine MN, Asmar R, Chahine R, Salameh P, et al. Predictors of uncontrolled blood pressure in treated hypertensive individuals: first population-based study in Lebanon. J Clin Hypertens (Greenwich) 2016; 18: 871–7. doi: 10.1111/jch.12775

  15. Knight EL, Bohn RL, Wang PS, Glynn RJ, Mogun H, Avorn J. Predictors of uncontrolled hypertension in ambulatory patients. Hypertension 2001; 38: 809–14. doi: 10.1161/hy0901.091681

  16. Mallat SG, Samra SA, Younes F, Sawaya MT. Identifying predictors of blood pressure control in the Lebanese population – a national, multicentric survey – I-Predict. BMC Public Health 2014; 14: 1142. doi: 10.1186/1471-2458-14-1142

  17. Morgado M, Rolo S, Macedo AF, Pereira L, Castelo-Branco M. Predictors of uncontrolled hypertension and antihypertensive medication nonadherence. J Cardiovasc Dis Res 2010; 1: 196–202. doi: 10.4103/0975-3583.74263

  18. Shelley D, Tseng TY, Andrews H, Ravenell J, Wu D, Ferrari P, et al. Predictors of blood pressure control among hypertensives in community health centers. Am J Hypertens 2011; 24: 1318–23. doi: 10.1038/ajh.2011.154

  19. Pickering TG, Shimbo D, Haas D. Ambulatory blood-pressure monitoring. N Engl J Med 2006; 354: 2368–74. doi: 10.1056/NEJMra060433

  20. Redon J, Lurbe E. Ambulatory blood pressure monitoring is ready to replace clinic blood pressure in the diagnosis of hypertension: con side of the argument. Hypertension 2014; 64: 1169–74; discussion 74. doi: 10.1161/HYPERTENSIONAHA.114.03883

  21. Schwan A. Reference values for 24-hour non-invasive ambulatory blood pressure: a population study of men aged fifty. Scand J Prim Health Care 1993; 11: 21–5. doi: 10.3109/02813439308994897

  22. Banegas JR, Ruilope LM, de la Sierra A, de la Cruz JJ, Gorostidi M, Segura J, et al. High prevalence of masked uncontrolled hypertension in people with treated hypertension. Eur Heart J 2014; 35: 3304–12. doi: 10.1093/eurheartj/ehu016

  23. Head GA. Ambulatory blood pressure monitoring is ready to replace clinic blood pressure in the diagnosis of hypertension: pro side of the argument. Hypertension 2014; 64: 1175–81; discussion 81. doi: 10.1161/HYPERTENSIONAHA.114.03882

  24. Banegas JR, Ruilope LM, de la Sierra A, Vinyoles E, Gorostidi M, de la Cruz JJ, et al. Relationship between clinic and ambulatory blood-pressure measurements and mortality. N Engl J Med 2018; 378: 1509–20. doi: 10.1056/NEJMoa1712231

  25. Niiranen TJ, Maki J, Puukka P, Karanko H, Jula AM. Office, home, and ambulatory blood pressures as predictors of cardiovascular risk. Hypertension 2014; 64: 281–6. doi: 10.1161/HYPERTENSIONAHA.114.03292

  26. Hedberg P, Hammar C, Selmeryd J, Viklund J, Leppert J, Hellberg A, et al. Left ventricular systolic dysfunction in outpatients with peripheral atherosclerotic vascular disease: prevalence and association with location of arterial disease. Eur J Heart Fail 2014; 16: 625–32. doi: 10.1002/ejhf.95

  27. Bromfield SG, Booth JN, 3rd, Loop MS, Schwartz JE, Seals SR, Thomas SJ, et al. Evaluating different criteria for defining a complete ambulatory blood pressure monitoring recording: data from the Jackson Heart Study. Blood Press Monit 2018; 23: 103–11. doi: 10.1097/MBP.0000000000000309

  28. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF, 3rd, Feldman HI, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009; 150: 604–12. doi: 10.7326/0003-4819-150-9-200905050-00006

  29. De Backer G, Ambrosioni E, Borch-Johnsen K, Brotons C, Cifkova R, Dallongeville J, et al. European guidelines on cardiovascular disease prevention in clinical practice: third joint task force of European and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of eight societies and by invited experts). Eur Heart J 2003; 24: 1601–10. doi: 10.1016/S0195-668X(03)00347-6

  30. Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2020; 41: 111–88. doi: 10.1093/eurheartj/ehz455

  31. Barna I, Keszei A, Dunai A. Evaluation of meditech ABPM-04 ambulatory blood pressure measuring device according to the British Hypertension Society protocol. Blood Press Monit 1998; 3: 363–8.

  32. O’Brien E, Parati G, Stergiou G, Asmar R, Beilin L, Bilo G, et al. European society of hypertension position paper on ambulatory blood pressure monitoring. J Hypertens 2013; 31: 1731–68. doi: 10.1097/HJH.0b013e328363e964

  33. Skoglund PH, Ostergren J, Svensson P. Ambulatory pulse pressure predicts cardiovascular events in patients with peripheral arterial disease. Blood Press 2012; 21: 227–32. doi: 10.3109/00365599.2012.676755

  34. Itoga NK, Tawfik DS, Lee CK, Maruyama S, Leeper NJ, Chang TI. Association of blood pressure measurements with peripheral artery disease events. Circulation 2018; 138: 1805–14. doi: 10.1161/CIRCULATIONAHA.118.033348

  35. Thomas Manapurathe D, Krishna SM, Dewdney B, Moxon JV, Biros E, Golledge J. Effect of blood pressure lowering medications on leg ischemia in peripheral artery disease patients: a meta-analysis of randomised controlled trials. PLoS One 2017; 12: e0178713. doi: 10.1371/journal.pone.0178713

  36. Sigvant B, Wiberg-Hedman K, Bergqvist D, Rolandsson O, Wahlberg E. Risk factor profiles and use of cardiovascular drug prevention in women and men with peripheral arterial disease. Eur J Cardiovasc Prev Rehabil 2009; 16: 39–46. doi: 10.1097/HJR.0b013e32831c1383

  37. Sigvant B, Hasvold P, Thuresson M, Jernberg T, Janzon M, Nordanstig J. Myocardial infarction and peripheral arterial disease: treatment patterns and long-term outcome in men and women results from a Swedish nationwide study. Eur J Prev Cardiol 2019: 2047487319893046. doi: 10.1177/2047487319893046

  38. Kumbhani DJ, Steg PG, Cannon CP, Eagle KA, Smith SC, Jr., Goto S, et al. Statin therapy and long-term adverse limb outcomes in patients with peripheral artery disease: insights from the REACH registry. Eur Heart J 2014; 35: 2864–72. doi: 10.1093/eurheartj/ehu080

  39. Stock JK. The challenge of peripheral arterial disease: how do we improve outcome? Atherosclerosis 2018; 270: 196–8. doi: 10.1016/j.atherosclerosis.2017.12.031

  40. Sjahid SI, van der Linden PD, Stricker BH. Agreement between the pharmacy medication history and patient interview for cardiovascular drugs: the Rotterdam elderly study. Br J Clin Pharmacol 1998; 45: 591–5. doi: 10.1046/j.1365-2125.1998.00716.x

How to Cite
Dahle N., Skau E., Leppert J., Ärnlöv J., & Hedberg P. (2021). Poorly controlled ambulatory blood pressure in outpatients with peripheral arterial disease. Upsala Journal of Medical Sciences, 126(1). https://doi.org/10.48101/ujms.v126.7609
Original Articles