Association of Lower Extremity Performance With Cardiovascular and All-Cause Mortality in Patients With Peripheral Artery Disease: A Systematic Review and Meta-Analysis

Study Questions:

What is the association between lower extremity performance measures and mortality in patients with peripheral arterial disease (PAD)?


This was a systematic review and meta-analysis. Included studies had an assessment of a lower extremity performance measure and reported an association with either cardiovascular mortality or all-cause mortality.


Ten studies were included in the analysis; nine studies were conducted prospectively and another was performed retrospectively. A range of lower extremity performance measures was examined, and these could be grouped into the following three general categories: lower limb strength, objectively measured walking performance, and the walking impairment questionnaire. Shorter maximum walking distance was associated with increased 5-year cardiovascular (unadjusted relative risk [RR], 2.54; 95% confidence interval [CI], 1.86-3.47; p < 0.00005) and all-cause mortality (unadjusted RR, 2.23; 95% CI, 1.85-2.69; p < 0.00005). Two studies reported strong associations between walking distance and mortality after adjustment for ankle-brachial index (ABI). The association between lower limb strength and outcomes was variable. Poor isometric strength for the following was associated with increased cardiovascular and all-cause mortality: hip extension, knee flexion, knee extension power, and plantar flexion.


Select measures of lower extremity performance, namely shorter walking distance and certain measures of poor isometric strength, are associated with increased cardiovascular and all-cause mortality in patients with PAD.


This is an important study that helps characterize the associations between lower extremity performance and outcomes in PAD patients. There is paucity of data from randomized trials to inform the benefit of such interventions as exercise therapy in patients with PAD. As the association between walking distance and mortality persists after adjusting for ABI, an objective measure of lower extremity performance appears to offer incremental value. Measurement of lower extremity performance should be performed routinely in PAD patients to inform prognosis.

Clinical Topics: Diabetes and Cardiometabolic Disease, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Exercise

Keywords: Walking, Ankle Brachial Index, Exercise Therapy, Peripheral Arterial Disease, Leg, Peripheral Vascular Diseases

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