© Borgis - New Medicine 3/2007, s. 74-78
*Iwona Sudoł-Szopińska1, Krzysztof Błachowiak2, Piotr Koziński, MD3
Overview of risk factors of chronic venous disease
1Department of Ergonomy, Central Institute for Labour Protection - National Research Institute, Warsaw, Poland
2Department of General Surgery "B” and Multi-Trauma with Gastroenterological and Endocrinological Surgery Unit, Provincial Hospital, Poznań, Poland
3Department of Medical Radiology, Central Clinic of the Medical Military Institute, Warsaw, Poland
In the European countries venous diseases pose a serious social problem – as many as 35% of the professionally active population, 50% of pensioners, and every second female suffer from this disease. Chronic venous disease (CVD) is one of the most frequently occurring forms of venous diseases, particularly in developed countries; it is thought to concern 1/3 of the population.
Although a correlation between selected risk factors, e.g. age, obesity or deep vein thrombosis, and clinical stage of CVD was found in a number of studies, there is still controversy about the real aetiopathogenesis of CVD. It is still open to discussion whether only hereditary factors are responsible for the development of CVD or, quite to the contrary, environmental factors including lifestyle and type of work performed are at the source of the disease. This paper presents a review of literature on the following risk factors for the development of CVD: obesity, lack of physical activity, dietary habits including constipation, pregnancy, genetic factors as well as prolonged sedentary or upright position while performing work tasks.
Venous diseases constitute a serious social problem. In Europe 35% of the working population, 50% of the retired and every other woman suffer from this condition. Chronic venous disease (CVD) is the most frequent one and according to different authors (Evans et al. 1999) it is present in one third of the population, including 40-60% of women and 15-30% of men. Therefore the social and economic costs of CVD in Western Europe are extremely high, due to the incidence of the disease, costs of its diagnostics and treatment as well as work absence (Nicolaides 2000). Lower leg (shank) ulceration is the greatest medical as well as economical problem in the course of CVD. It is estimated that expenses related to this treatment reach 1-3% of the health service budget (Evans et al. 1999; Jawien 2003). In the UK the cost of treatment for leg ulcers is 400-600 million pounds per year. Research done in Germany in 1980 demonstrated that the costs of treatment for varicose veins, superficial thrombophlebitis and deep vein thrombosis were 660 m euros, whereas in 1990 they reached 1 billion euros. In addition, in the USA (Tsai et al. 2005) the analysis of admission of patients requiring hospitalisation showed that among 100 thousand patients 92 were admitted due to CVD. The average hospitalisation period was 7 days and the average cost of hospitalisation and treatment was 13 900 US dollars.
The symptoms of chronic venous disease include pain, feeling of fatigue, leg heaviness, tingling sensation, itching of the skin of the legs, muscle cramps at night, leg oedema, dilation of small intradermal blood vessels (telangiectasia), dilation and prominence of subcutaneous veins (small – reticular or feeder veins, and large – varicose veins) and dermal changes: discolouration of the skin of the shanks (haemosiderosis – dermite ocre), lipodermatosclerosis, stasis dermatitis (eczema) and lower leg ulcers (Nicolaides 2000; Kalodiki and Nicolaides 2002; Jawien 2003). The CEAP classification, established in 1994 by the Ad Hoc Committee of American Venous Forum, presents a wide spectrum of possible CVD symptoms (Agus et al. 2005). This classification is commonly used by clinical physicians to evaluate the stage of CVD.
A multifactor aetiology of CVD is well documented and consists of two main factors: weakening of the venous wall (flaccidity, loss of elasticity) and impaired functions of the valves (Giannoukas et al. 2002). However, the aetiopathogenesis of the disease still remains unknown (Pistorius 2003; Sansilvestri-Morel et al. 2003). The question whether only genetic factors are responsible for CVD development or, to the contrary, the main reason for the disease is environmental factors including lifestyle and type of work is still controversial. This question is substantiated by statistical data indicating that CVD in the developing countries occurs with higher incidence (on average 50% of women in Western Europe) than in countries where civilisation progress is slowed down (e.g. only 0.1% of women living in the villages of New Guinea).
A great number of different studies have analysed the influence of many factors on the prevalence of CVD, especially the form which is manifested by varicose veins.
Effects of age and sex
The connection between CVD and age is emphasised in the majority of publications. For instance, it is thought that the incidence of varicose veins increases with age. A study performed among school children aged 10-12 indicated that 10% of them had small varicose veins and during the next 4 years the percentage of children with these changes increased to 30% (Nelsen et al. 1991; Mota-Capitao et al. 1995; Fowkes 1996; Jawien 2003).
In a study performed among 1566 citizens of the UK aged 18-44 (Evans 1999) the presence of varicose veins was found in 40% of men and 32% of women (p Ł 0.01). Their incidence increased significantly with age (p Ł 0.001) and for the age group 18-24 years it was 11.5%, whereas for the age group 55-64 years it was 55.7%. In the oldest group, 55-64 years, varicose veins were found more frequently in men (25.2%) than in women (12.3%). In general, in the study group below 35 years CVD was extremely rare in women and there were no cases of CVD in men. In the analysed age group, 18-44 years, CVD was found in 9% of men and 7% of women (p Ł 0.05). Differences regarding sex were not statistically significant for separately analysed individual stages of CVD degree (p> 0.05). In the majority of cases the observed changes were slightly advanced – degree I in the CEAP classification – and included varicose veins in the drainage area of the great and small saphenous veins. A statistically significant difference with regard to the prevalence of pathologic changes in women and men (p Ł 0.01) was observed only regarding this stage of CVD. Less advanced forms of CVD (varicose veins outside the saphenous veins, reticular veins and telangiectasia) were observed with high incidence, namely in 80% of the subjects. In the study group among other symptoms the presence of oedema (in 7.4% of men and with significantly higher frequency in women – 16%) was found and its incidence increased linearly with age. Ulcers were observed only in 10 subjects.
According to the majority of authors CVD is more frequent in women (incidence for women ranging from 0.1% in New Guinea to 60.5% in the Czech Republic, and for men from 5.1% in New Guinea to 56% on the Cook Islands (Fowkes et al. 2001)) although with age the predominance of women vanishes and the incidence of advanced CVD (namely ulcers) is higher in men (Jawien 2003). Therefore, the higher incidence of CVD in women still remains controversial, especially taking into account analyses indicating that the majority of studies showing a higher incidence of CVD in women did not regard a defined age group. Moreover, it is possible that such statistics are connected with the fact that women participate more frequently in epidemiological studies (Kurz et al. 1999; Jawien 2003). The analysis of results of the questionnaire regarding venous complaints (Evans et al. 1999) indicated that only 10% of men and 17% of women admitted that they had been diagnosed with varicose veins in the past, whereas in the clinical study which followed the questionnaire more numerous changes were seen in men. Namely a great number of authors do not confirm the role of a female factor as being significant with regard to the incidence of CVD, and they show similar results or even higher prevalence in men (Beaglehole et al. 1975; Evans et al. 1999). In The Basle Study (Fowkes 2001) varicose veins in men were found in 56% of cases and in women in 55% cases; in The Edinburgh Vein Study (Ewans et al. 1999), varicose veins in men were observed in 39.7% and women in 32.2% (p Ł 0.01), whereas in New Guinea CVD was observed in 0.1% of women and 5.1% of men (Fowkes 1996).
Among environmental factors affecting CVD development, especially varicose veins, the following are mentioned: pregnancy, hormonal changes, dietetic habits, obesity, physical activity, working in a standing or sitting position, tight clothes, atmospheric pressure. A positive correlation was also seen between the presence of varicose veins and chronic constipation with increased rectal tenesmus, weight lifting, presence of inguinal hernia or haemorrhoids (Comu-Thenard et al. 1994).
The most important factors in CVD pathogenesis are: a chronic standing position, obesity, constipation, pregnancy, varicose veins in the family and a history of thrombosis (e.g. almost 30% of fractures lead to lower leg thrombosis and its consequences (Jawien 2003; Jawien et al. 2003). However, it was not proven unambiguously whether any of these factors played a dominant role in CVD pathogenesis (Cesarone et al. 2002). At the same time many factors (such as CVD duration, the value of arterial blood pressure, the number of pregnancies, presence of cardiovascular disease) decrease the statistical significance of CVD when the age of subjects has been taken into account, although there are data presented above that the prevalence of CVD increases with age (Mota-Capitao et al. 1995).
In a study performed in Switzerland – The Basle Study (Fowkes et al. 2001) – with subjects working in the chemical industry, varicose veins were observed in 56% of men and 55% of women. Varicose veins in the small and great saphenous veins were present in 20% of men and 11% of women, whereas reticular veins and/or telangiectasia were seen in 36% of men and 44% of women. Moreover, the study performed in former Czechoslovakia with women working in a supermarket (Stvirtnova et al. 1991) showed the presence of: reticular veins in 15.4%, telangiectasia in 30.7%, varicose veins in the branches of VSM and VSP in 14.4%. In a study performed in Edinburgh (Ewans et al. 1999) reticular veins and telangiectasia in women were observed with similar frequency, namely 18% of cases.
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