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Relation of Lower-Extremity Amputation to All-Cause and Cardiovascular Disease Mortality in American Indians

The Strong Heart Study

¹ MedStar Research Institute, Hyattsville, Maryland
² School of Nursing, University of Minnesota, Minneapolis, Minnesota
³ Mille Lacs Band of Ojibwe Indians, Diabetes Program, Mille Lacs, Minnesota
⁴ Missouri Breaks Research, Timber Lake, South Dakota
⁵ University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma

Address correspondence and reprint requests to Helaine E. Resnick, PhD, MPH, Department of Epidemiology and Statistics, MedStar Research Institute, 6495 New Hampshire Ave., Suite 201, Hyattsville, MD 20783. E-mail: helaine.e.resnick{at}medstar.net

OBJECTIVE—To compare risk of all-cause and cardiovascular disease (CVD) mortality in people with a lower-extremity amputation (LEA) attributable to diabetes and people without an LEA.

RESEARCH DESIGN AND METHODS—The Strong Heart Study is a study of CVD and its risk factors in 13 American-Indian communities. LEA was ascertained at baseline by direct examination of the legs and feet. Mortality surveillance is complete through 2000.

RESULTS—Of 2,108 participants with diabetes at baseline, 134 participants (6.4%) had an LEA. Abnormal ankle-brachial index (53%), albuminuria (87%), and long diabetes duration (mean 19.8 years) were common among diabetic subjects with LEA. Mean diabetes duration among diabetic participants without LEA and in those with toe and below-the-knee amputations was 11.9, 18.6, and 21.1 years, respectively. During 8.7 (±2.9) years of follow-up, 102 of the participants with LEA (76%) died from all causes and 35 (26%) died from CVD. Of the 1,974 diabetic participants without LEA at baseline, 604 (31%) died from all causes and 206 (10%) died from CVD. The unadjusted hazard ratios (HRs) for all-cause and CVD mortality in diabetic participants with LEA compared with those without were 4.0 and 4.1, respectively. Adjusting for known and suspected confounders, LEA persisted as a predictor of all-cause (HR 2.2, 95% CI 1.7–2.9) and CVD mortality (HR 1.9, 95% CI 1.3–2.9). We observed a significant interaction between baseline LEA and sex on CVD mortality, with female sex conferring added risk of CVD mortality.

CONCLUSIONS—LEA is a potent predictor of all-cause and CVD mortality in diabetic American Indians. The combination of female sex and LEA is associated with greater risk of CVD mortality than either factor alone.

Abbreviations: ABI, ankle brachial index • AKA, above-the-knee amputation • BKA, below-the-knee amputation • CVD, cardiovascular disease • IHS, Indian Health Service • LEA, lower-extremity amputation • SHS, Strong Heart Study • WHO, World Health Organization

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