Atherosclerosis 221 (2012) 527–535 Contents lists available at SciVerse ScienceDirect Atherosclerosis jo ur nal homep age : www.elsevier.com/locate/atherosclerosis Fate of individuals with ischemic amputations in the REACH Registry: Three-year cardiovascular and limb-related outcomes Maria Teresa B. Abola a,∗ , Deepak L. Bhatt b , Sue Duval c , Patrice P. Cacoub e , Iris Baumgartner d , Hong Keo l , Mark A. Creager f , Danielle M. Brennan g , Ph. Gabriel Steg h,i,j , Alan T. Hirsch k , on behalf of the REACH Investigators 1 a Division of Education, Philippine Heart Center, Quezon City, Philippines b VA Boston Healthcare System, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA, United States c Lillehei Clinical Research Unit, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, Minnesota, MN, USA d Division of Angiology, University Hospital, Bern, Switzerland e Department of Internal Medicine, AP HP, Groupe Hospitalier Pitié-Salpétrière, and Université Pierre et Marie Curie, Paris 6, Paris, France f Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States g Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, United States h INSERM U698, Paris, France i Université Paris 7, Paris, France j Hôpital Bichat Claude Bernard, AP-HP, Paris, France k Vascular Medicine Program, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA l Kantonsspital Aarau AG, Division of Angiology, Tellstrasse, 5001 Aarau Switzerland a r t i c l e i n f o Article history: Received 10 July 2011 Received in revised form 16 November 2011 Accepted 2 January 2012 Available online 24 January 2012 Keywords: Atherosclerosis Peripheral artery disease Amputation Health outcomes Amputation Critical limb ischemia Myocardial infarction a b s t r a c t Objective: To evaluate systemic and limb ischemic event rates of PAD patients with prior leg amputation and determine predictors of adverse outcomes. Methods: The REduction of Atherothrombosis for Continued Health (REACH) Registry provided a prospec- tive multinational cohort of 7996 outpatients with PAD enrolled from primary medical clinics in 44 countries in 2003–2004. 1160 patients (14.5%) had a prior leg amputation at any level. Systemic (myocar- dial infarction [MI], stroke, cardiovascular death) and limb (angioplasty, surgery, amputation) ischemic event rates were determined in a 3-year follow-up. Results: PAD patients with leg amputations on entry had a 5-fold higher rate of a subsequent amputation (12.4% vs. 2.4%, P < .001), lower rate of peripheral angioplasty (8.3% vs. 10.7%, P = .005), and similar rates of surgical revascularization procedures compared with PAD patients without amputation. A nearly 2-fold increase in rates of cardiovascular death (14.5% vs. 7.7%, P < .001) and all-cause mortality (21.8% vs. 12.6%, P < .001) and an increase in the composite outcome of MI, stroke, cardiovascular death, or hospitalization (48.7% vs. 40.0%, P < .001) were noted. Recent (≤1 year) amputation was associated with higher rates of worsening PAD, subsequent lower extremity surgical revascularization procedures, re-amputation, non-fatal MI, and the composite outcome, including hospitalization. Adverse systemic and limb ischemic outcomes were similar regardless of amputation level. Conclusions: Individuals with a history of leg amputations have markedly elevated rates of systemic and limb-related outcomes. PAD patients with recent ischemic amputation have the highest risk of adverse events. A history of “minor” ischemic amputation may confer an identical systemic risk as “major” leg amputation. © 2012 Elsevier Ireland Ltd. All rights reserved. ∗ Corresponding author at: Suite 409, 4th floor, Medical Arts Building; Philippine Heart Center, East Avenue, Quezon City, 1100, Philippines. Tel.: +63 29202515; fax: +63 29296373. E-mail address: tesabola@mac.com (M.T.B. Abola). 1 A complete list of the REACH Registry Investigators appears in JAMA 2006;295:180–89. 1. Introduction Peripheral artery disease (PAD) is a common manifestation of atherosclerosis and ischemic amputation is the most devastating limb outcome. While few PAD patients require amputation [1], the incidence rate of major lower extremity amputation is estimated to be approximately 120–500 per million patients per year, occur- ring more commonly in black, elderly, and diabetic cohorts with PAD [2–12]. Only 1–3% of PAD patients will initially present with 0021-9150/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.atherosclerosis.2012.01.002