Fibrinogen and mortality in chronic critical limb ischaemia

Objective. Plasma fibrinogen predicts cardiovascular events in patients with stable peripheral arterial occlusive disease, but its predictive value in patients with chronic critical limb ischaemia, a condition associated with a high risk of death, is unknown. Design. A prospective cohort study. Setting. Determination of fibrinogen and other potential predictors during clinic-based work-up of patients admitted for diagnostic and therapeutic evaluation. Subjects. A total of 108 patients (72 ± 10 years, 78 males) with atherosclerotic occlusive disease and critical limb ischaemia (pain at rest and/or trophic lesions) followed up for a median period of 1.6 years (range: 8 days-5.5 years; 218 patient-years). Main outcome measures. Total mortality. Results. Forty-five deaths (71% cardiovascular) occurred during the follow- up. Baseline fibrinogen was higher in those who died in the early follow-up period (first 6 months), as were white cell count and serum creatinine, while haematocrit was lower. Plasma fibrinogen values correlated positively with white cell count, and negatively with haematocrit; other cardiovascular prognostic factors did not differ. Only plasma fibrinogen predicted survival independently in multivariate age-corrected Cox regression analysis. Relative risk of death doubled for each standard deviation above the mean and increased with each tertile increase in fibrinogen. Conclusions. Fibrinogen predicted death in these elderly arteriopaths with critical limb ischaemia, particularly those who died in the first months following critical ischaemia. Inflammatory stimuli secondary to severely defective tissue oxygenation and possibly sepsis and necrosis, might have stimulated fibrinogen, an acute- phase reactant, thereby compromising organ perfusion through increased blood viscosity and/or promoting thrombosis.