Prevalence of Peripheral Arterial Disease – Results of the Heinz Nixdorf Recall Study

  • Knut Kröger
  • Andreas Stang
  • Jana Kondratieva
  • Susanne Moebus
  • Eva Beck
  • Axel Schmermund
  • Stefan Möhlenkamp
  • Nico Dragano
  • Johannes Siegrist
  • Karl-Heinz Jöckel
  • Raimund Erbel
  • Heinz Nixdorf Recall Study Group
Cardiovascular Diseases


Background: This report presents population-based estimates of the prevalence of peripheral arterial disease (PAD), chronic critical limb ischemia (CLI), and Moenckeberg’s medial calcinosis (MC) in Germany. Patients and methods: From the year 2000 to 2003, a total of 4,814 subjects aged 45–75 years were included in the study. In 30 of the subjects (0.6%), determination of the ankle brachial index (ABI) was not possible, leaving 4,735 subjects (99.4%) in the data set. PAD was considered present in all subjects with an ABI < 0.9 in one leg, and/or a history of prior treatment for PAD. CLI was considered present if the highest ankle artery pressure measured < 70 mmHg. Prevalence of MC was calculated for ABI cut-off values of 1.3 and 1.5. Findings: The overall prevalence of PAD according to the ABI criteria was 6.4% among men and 5.1% among women. After accounting for history of PAD, the prevalence increased to 8.2% among men and 5.5% among women. Taking the ABI criteria and medical history into account, males had a higher prevalence of PAD, with large increases in males aged 65–69 and 70–75 years. Chronic CLI was rare in the investigated population, and was found in only five older subjects (0.1%). With the criterion of ABI > 1.3, about 13.3% of males and 6.9% of females had MC. In contrast to PAD, the prevalence of MC did not increase with age. With the criterion of ABI > 1.5, MC was present in only 1.1% and 0.5% of men and women, respectively, but only 30 (0.6%) subjects had incompressible ankle arteries with a cuff pressure > 260 mmHg. Conclusion: Prevalences of PAD based only on ABI generally underestimate the true prevalence of PAD in population-based studies. CLI predominantly affects older subjects. In addition, cut-off values for MC must be newly determined.


Ankle brachial index Blood pressure Chronic critical limb ischemia Cohort studies Germany Moenckeberg’s medial calcinosis Peripheral arterial disease 


  1. 1.
    Aronow, WS 1992Prevalence of atherothrombotic brain infarction, coronary artery disease and peripheral arterial disease in elderly Blacks, Hispanics and WhitesAm J Cardiol7012121213CrossRefPubMedGoogle Scholar
  2. 2.
    CAPRIE Steering Committee1996A randomised, blind trial of clopidogrel versus aspirin in patients at risk of ischemic events (CAPRIE)Lancet34813291339CrossRefGoogle Scholar
  3. 3.
    Hooi, JD, Kester, AD, Stoffers, HE, Rinkens, PE, Knottnerus, JA, Ree, JW 2004Asymptomatic peripheral arterial occlusive disease predicted cardiovascular morbidity and mortality in a 7-year follow-up studyJ Clin Epidemiol57294300CrossRefPubMedGoogle Scholar
  4. 4.
    Ouriel, K 2001Peripheral arterial diseaseLancet35812571264CrossRefPubMedGoogle Scholar
  5. 5.
    Dormandy, J, Heeck, L, Vig, S 1999The natural history of claudication: Risk to life and limbSemin Vasc Surg12123137PubMedGoogle Scholar
  6. 6.
    Meijer, WT, Hoes, AW, Rutgers, D, Bots, ML, Hofman, A, Grobbee, DE 1998Peripheral arterial disease in the elderlyArterioscler Thromb Vasc Biol18185192PubMedGoogle Scholar
  7. 7.
    Newman, AB, Siscovick, DS, Manolio, TA,  et al. 1993Ankle-Arm Index as a marker of arteriosclerosis in the Cardiovascular Health StudyCirculation88837845PubMedGoogle Scholar
  8. 8.
    Criqui, MH, Fronek, A, Klauber, MR, Barrett-Connor, E, Gabriel, S 1985The sensitivity, specificity, and predictive value of traditional clinical evaluation of peripheral arterial disease: Results from non-invasive testing in a defined populationCirculation71516522PubMedGoogle Scholar
  9. 9.
    Fowkes, FGR, Housley, E, Cawood, EHH, Macintyre, CCA, Ruckley, CV, Prescott, RJ 1991Edinburgh Artery Study. Prevalence of asymptomatic and symptomatic peripheral arterial disease in the general populationInt J Epidemiol20384392PubMedGoogle Scholar
  10. 10.
    TransAtlantic Inter-Society Working Group2000Management of peripheral arterial diseaseJ Vasc Surg31168169CrossRefGoogle Scholar
  11. 11.
    Dormandy, J, Heeck, L, Vig, S 1999The fate of patients with critical leg ischemiaSemin Vasc Surg12142147PubMedGoogle Scholar
  12. 12.
    Binaghi, F, Fronteddu, PF, Cannas, F,  et al. 1994Prevalence of peripheral arterial occlusive disease and associated risk factors in a sample of Southern Sardinian populationInt Angiol13233245PubMedGoogle Scholar
  13. 13.
    Dormandy, J, Heeck, L, Vig, S 1999Predicting which patients will develop chronic critical leg ischemiaSemin Vasc Surg12138141PubMedGoogle Scholar
  14. 14.
    Lachman, AS, Spray, TL, Kerwin, DM, Shugoll, GI, Roberts, WC 1977Medial calcinosis of Monckeberg. A review of the problem and a description of a patient with involvement of peripheral, visceral and coronary arteriesAm J Med63615622CrossRefPubMedGoogle Scholar
  15. 15.
    Shanahan, CM, Cary, NR, Salisbury, JR, Proudfoot, D, Weissberg, PL, Edmonds, ME 1999Medial localization of mineralization-regulating proteins in association with Monckeberg’s sclerosis: Evidence for smooth muscle cell-mediated vascular calcificationCirculation10021682176PubMedGoogle Scholar
  16. 16.
    Leskinen, Y, Salenius, JP, Lehtimaki, T, Huhtala, H, Saha, H 2002The prevalence of peripheral arterial disease and medial arterial calcification in patients with chronic renal failure: Requirements for diagnosticsAm J Kidney Dis40472479CrossRefPubMedGoogle Scholar
  17. 17.
    Ono, K, Tsuchida, A, Kawai, H,  et al. 2003Ankle-brachial blood pressure index predicts all-cause and cardiovascular mortality in hemodialysis patientsJ Am Soc Nephrol1415911598CrossRefPubMedGoogle Scholar
  18. 18.
    Schmermund A, Möhlenkamp S, Stang A, et al. Assessment of clinically silent atherosclerotic disease and established and novel risk factors for predicting myocardial infarction and cardiac death in healthy middle-aged subjects: Rationale and design of the Heinz Nixdorf Recall Study. Am Heart J 2002; 144: 212–218Google Scholar
  19. 19.
    Stang, A, Ahrens, W, Jöckel, KH 1999Control response proportions in population-based case-control studies in GermanyEpidemiology10181183CrossRefPubMedGoogle Scholar
  20. 20.
    Stang, A, Moebus, S, Dragano, N,  et al. 2005Baseline recruitment and analyses of nonresponse of the Heinz Nixdorf Study: Identifiability of phone numbers as the major determinant of responseEur J Epidemiol20489496CrossRefPubMedGoogle Scholar
  21. 21.
    Hirschl, M, Francesconi, M, Hirschl, MM 1991Moenckeberg media sclerosis: Clinical aspects in diabetic patientsVasa20216221PubMedGoogle Scholar
  22. 22.
    Collins, TC, Petersen, NJ, Suarez-Almazor, M, Ashton, CM 2003The prevalence of peripheral arterial disease in a racially diverse populationArch Intern Med16314691474CrossRefPubMedGoogle Scholar
  23. 23.
    Resnick, HE, Lindsay, RS, McDermott, MM,  et al. 2004Relationship of high and low ankle brachial index to all-cause and cardiovascular disease mortality: The Strong Heart StudyCirculation109733739CrossRefPubMedGoogle Scholar
  24. 24.
    SAS Institute Inc.1990 SAS/STAT User’s Guide, Version 8. SAS Institute, Inc.: Cary, NC. 1990Google Scholar
  25. 25.
    Selvin, E, Erlinger, TP 2004Prevalence of and risk factors for peripheral arterial disease in the United States: Results from the National Health and Nutrition Examination Survey, 1999–2000Circulation110738743CrossRefPubMedGoogle Scholar
  26. 26.
    Gregg, EW, Sorlie, P, Paulose-Ram, R,  et al. 2004Prevalence of lower-extremity disease in the US adult population ≥40 years of age with and without diabetes: 1999–2000 national health and nutrition examination surveyDiabetes Care2715911597PubMedGoogle Scholar
  27. 27.
    Higgins, JP, Higgins, JA 2003Epidemiology of peripheral arterial disease in womenJ Epidemiol13114PubMedGoogle Scholar
  28. 28.
    Newman, AB, Naydeck, BL, Sutton-Tyrrell, K, Polak, JF, Kuller, LH 2001Cardiovascular Health Study Research Group. The role of comorbidity in the assessment of intermittent claudication in older adultsJ Clin Epidemiol54294300CrossRefPubMedGoogle Scholar
  29. 29.
    Hiatt, WR, Hoag, S, Hamman, RF 1995Effect of diagnostic criteria on the prevalence of peripheral arterial disease. The San Luis Valley Diabetes StudyCirculation9114721479PubMedGoogle Scholar
  30. 30.
    Stoffers, HEJH, Rinkens, PELM, Kester, ADM, Kaiser, V, Knottnerus, JA 1996The prevalence of asymptomatic and unrecognized peripheral arterial occlusive diseaseInt J Epidemiol25282290PubMedGoogle Scholar
  31. 31.
    Vogt, MT, Cauley, JA, Kuller, LH, Hulley, SB 1993Prevalence and correlates of lower extremity arterial disease in elderly womenAm J Epidemiol137559568PubMedGoogle Scholar
  32. 32.
    Murabito, JM, D’Agostino, RBD, Silberhatz, H, Wilson, PWF 1997Intermittent claudicationCirculation964449PubMedGoogle Scholar
  33. 33.
    McDermott, MM, Liu, K, Greenland, P,  et al. 2004Functional decline in peripheral arterial disease: Associations with the ankle brachial index and leg symptomsJAMA292453461CrossRefPubMedGoogle Scholar
  34. 34.
    OHare, AM, Glidden, DV, Fox, CS, Hsu, CY 2004High prevalence of peripheral arterial disease in persons with renal insufficiency: Results from the national health and nutrition examination survey 1999–2000Circulation109320323CrossRefGoogle Scholar
  35. 35.
    The Vascular Surgical Society of Great Britain, Ireland1995Critical limb ischaemia: Management and outcome. Report of a National SurveyEur J Vasc Endovasc Surg10108113CrossRefGoogle Scholar
  36. 36.
    Quigley, FG, Faris, IB, Duncan, HJ 1991A comparison of Doppler ankle pressures and skin perfusion pressure in subjects with and without diabetesClin Physiol112125PubMedGoogle Scholar
  37. 37.
    Latza, U, Stang, A, Bergmann, M,  et al. 2004The problem of response in epidemiological studies in Germany (part I)Gesundheitswesen66326336CrossRefPubMedGoogle Scholar
  38. 38.
    Stang, A, Jöckel, KH 2004Low response rate studies may be less biased than high response rate studiesAm J Epidemiol159204210CrossRefPubMedGoogle Scholar
  39. 39.
    Stang, A 2003Nonresponse research – an underdeveloped field in epidemiology (editorial)Eur J Epidemiol18929931CrossRefPubMedGoogle Scholar

Copyright information

© Springer 2006

Authors and Affiliations

  • Knut Kröger
    • 1
  • Andreas Stang
    • 2
  • Jana Kondratieva
    • 3
  • Susanne Moebus
    • 4
  • Eva Beck
    • 4
  • Axel Schmermund
    • 3
  • Stefan Möhlenkamp
    • 3
  • Nico Dragano
    • 5
  • Johannes Siegrist
    • 5
  • Karl-Heinz Jöckel
    • 4
  • Raimund Erbel
    • 3
  • Heinz Nixdorf Recall Study Group
  1. 1.Department of AngiologyUniversity HospitalEssenGermany
  2. 2.Institute for Medical Epidemiology, Biometry and InformaticsUniversity HospitalHalleGermany
  3. 3.West-German Heart CenterUniversity HospitalEssenGermany
  4. 4.Institute for Medical Informatics, Biometry and EpidemiologyUniversity Hospital EssenGermany
  5. 5.Department of Medical SociologyUniversity of DüsseldorfDusseldorfGermany

Personalised recommendations