臺灣博碩士論文加值系統

周邊動脈疾病(peripheral arterial disease, PAD)與動脈粥狀硬化密切相關。在過去的幾十年中，全世界都推薦使用踝肱血壓指數(ankle-brachial pressure index)或稱踝肱指數(Ankle-brachial Index，ABI)來篩檢動脈粥狀硬化高危患者是否存在PAD的可能性。被確定患有PAD的患者可能受益於早期治療和嚴格的風險因子調整。ABI在診斷動脈明顯狹窄患者方面具有非常高的特異性。然而，ABI在動脈狹窄程度較低或有動脈鈣化的患者方面診斷的敏感度還不夠。治療準則建議進一步測量趾臂指數(toe-brachial index, TBI)或將運動心電圖(treadmill exercise test)與ABI相結合，以提高敏感度。光體積變化描記圖(photoplethysmography, PPG)是一種便攜式光學設備，也曾經用於檢測PAD，並被證實有足夠的靈敏度。ABI和PPG以不同的機轉檢測PAD。除了TBI和運動心電圖外，我們的研究主旨想確定ABI與PPG的結合在檢測PAD的診斷價值。
我們利用兩年的時間招募了來自門診部或病房的130名患者。他們分別接受了ABI、PPG 和都卜勒超音波(duplex ultrasonography)檢查暨2年的預後追蹤。我們採用都卜勒超音波檢查來確立PAD的最終診斷，並藉此評估ABI、PPG 和這兩種組合的靈敏度、特異性和準確性。本研究中PPG檢查有2種方法，包括PPGratio和PPGamp。ABI的總體敏感性、特異性和準確性分別為55.9%、98.6%和80.3%；PPGratio為78.4%、87.2%和83.4%；PPGamp為75.7%、92.6%和85.3%；ABI加PPGratio組合為84.8%、86.4%和85.7%；ABI加PPGamp組合分別為81.1%、91.2%和86.9%。與單獨使用ABI或PPG相比，ABI和PPG的組合可以顯著提高診斷PAD的靈敏度及準確性。此外尤其是高風險患者，它還為主要心血管不良事件(MACE)和全因死亡率(all-cause mortality)提供了有價值的診斷見解。

Peripheral arterial disease (PAD) is highly associated with atherosclerosis. It has been recommended worldwide to use the ankle-brachial pressure index, also called ankle-brachial index (ABI) to screen for the possibility of PAD in patients with a high risk of atherosclerosis in the past decades. Patients identified to have PAD may benefit from early treatment and strict risk factors modification. ABI has very high specificity in the diagnosis of PAD in patients with significant arterial stenosis. However, the sensitivity in patients with less severe stenosis or calcified arteries has been insufficient. Further measurement of the toe-brachial index (TBI) or the combination of the treadmill exercise test with ABI has been recommended to improve the sensitivity. Photoplethysmography (PPG), a portable optical device, was also used to detect PAD with adequate sensitivity. ABI and PPG detect PAD in different mechanisms. In addition to TBI and treadmill exercise test, our study was to determine the diagnostic value of ABI combined with photoplethysmography (PPG) in detecting PAD. Within 2 years, we included 130 patients from the outpatient department or ward. They all received ABI, PPG, duplex ultrasonography, and 2-year follow up respectively. Sensitivity, specificity, and accuracy were evaluated in ABI, PPG, and both combinations. The final diagnosis of PAD was confirmed by duplex ultrasonography. There were 2 methods for PPG examination in this study, including PPGratio and PPGamp. The overall sensitivity, specificity, and accuracy were 55.9%, 98.6%, and 80.3% in ABI; 78.4%, 87.2%, and 83.4% in PPGratio; 75.7%, 92.6%, and 85.3% in PPG 84.8%, 86.4%, and 85.7% in ABI plus PPGratio combination; 81.1%, 91.2%, and 86.9% in ABI plus PPGamp combination, respectively. Integrating ABI and PPG significantly enhances sensitivity and accuracy in diagnosing PAD compared to using ABI or PPG individually. This combined approach improves diagnostic precision and provides crucial insights into predicting major adverse cardiovascular events (MACE) and all-cause mortality, particularly beneficial for high-risk patients.

1.1 Definition of Peripheral Arterial Disease 1
1.2 Etiology of Peripheral Arterial Disease 1
1.2.1 Inflammatory Causes 2
1.2.2 Genetic Causes 2
1.2.3 Traumatic Causes 2
1.2.4 Embolism 2
1.2.5 Age 2
1.3 Epidemiology of Peripheral Arterial Disease 3
1.3.1 Risk Factors, incidence, and prevalence of peripheral arterial disease 3
1.3.2 Cross risk of atherothrombotic events of peripheral arterial disease 3
1.3.3 Progression of Peripheral Arterial Disease and Prognosis 4
1.4 Diagnosis of Peripheral Arterial Disease 4
1.4.1 History Taking and Physical Examination 4
1.4.1.1 Changes and Status of Skin 5
1.4.1.2 Color, Hairiness, and Temperature of Legs and Feet 5
1.4.1.3 Muscular Abnormalities 5
1.4.1.4 Pulse Examinations 5
1.4.1.5 Orthopedic Deformities 5
1.4.1.6 Neurological Examinations 6
1.4.2 Ankle-brachial Index 6
1.4.2.1 The importance of Anke-brachial index 6
1.4.2.2 The measurement of Ankle-brachial Index 6
1.4.3 Toe-brachial Index 7
1.4.4 Treadmill Exercise Test 8
1.4.5 Non-invasive Diagnostic Imaging 8
1.4.5.1 Duplex Ultrasonography 8
1.4.5.2 Computed Tomographic Angiography 9
1.4.5.3 Magnetic Resonance Angiography 10
1.4.6 Invasive Diagnostic Imaging 10
1.4.6.1 Arterial angiography (digital subtraction angiography) 10
1.5 The Role of Photoplethysmography in the Diagnosis of Peripheral Arterial Disease 11
1.5.1 Physiological origins of photoplethysmography 11
1.5.2 Signal acquisition of photoplethysmography 12
1.5.3 Photoplethysmography signal processing 13
1.5.4 Presentation of the photoplethysmography signal 14
1.5.5 Literature review of photoplethysmography in the diagnosis of peripheral arterial disease 15
1.6 Motivation and Hypothesis 15
2.1. Experimental Subjects and Paradigm 17
2.2. Experimental Setup 17
2.3 Ankle-brachial Index 20
2.4 Duplex Ultrasonography 20
2.5 Photoplethysmography System and Photoplethysmography-derived Parameters 22
2.6 Morbidity and Mortality follow up 24
2.7 Major Adverse Cardiovascular Events and all-cause Mortality 24
2.8. Statistical Analysis 24
Chapter III Results 26
3.1 Basic Characters of Subjects 26
3.2 Sensitivity, Specificity, and Accuracy in Ankle-brachial Index and Photoplethysmography 28
3.3 Using Combined Models of Ankle-brachial Index and Photoplethysmography-derived Parameters 31
3.4 Univariable and Multivariable Analysis of Peripheral Artery Disease-Associated Variables 32
3.5 Subgroup analysis of Sensitivity and Specificity of Peripheral Artery Disease-Associated Variables 34
3.6 Ankle-brachial Index versus Ankle-brachial Index and Photoplethysmography Combination as a Predictor of Cardiovascular Morbidity and Mortality 35
3.7 Major Adverse Cardiovascular Events and all-cause Mortality 37
Chapter IV Discussion 39
4.1 The Influence of Peripheral Arterial Disease Locations on Ankle-brachial Index Sensitivity 39
4.2 Improvement of Diagnostic Sensitivity with Photoplethysmography in Patients at high atherosclerotic Risk 43
4.3 Potential Implications of Photoplethysmography-Derived Parameters as a Complementary Tool to Ankle-brachial Index 44
4.4 Limitations 45
Chapter V Conclusion and Perspective 46
5.1 Conclusion and Perspective 46
5.1.1 Sensitivity, Specificity, and Accuracy in Photoplethysmography, ankle-brachial Index, and Their Combination 46
5.1.2 The Design and the Etiology of Lower ankle-brachial Index Sensitivity at the below-knee Level 46
5.1.3 Predictive Value in Major Adverse Cardiovascular Events and All-Cause Mortality in Photoplethysmography and ankle-brachial Index Combination and Their Further Outlook. 47
Appendix A 48
Appendix B 49
List of References 50

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