Eight to twelve million people in the United States are living with a condition that indicates a fivefold risk of death from heart attack or stroke. Most of those affected have never even heard of their condition, nor do they understand that diagnosing and treating it could save their lives.
Below, Dr. Alan Hirsch of the University of Minnesota, discusses peripheral arterial disease, or PAD, and what can be done for those who have it.
What causes peripheral arterial disease, or PAD?
ALAN HIRSCH, MD: Peripheral arterial disease is caused by blockages to the arteries that supply the legs with blood. It is caused by the same risk factors that cause blockages in other arteries of the body, such as in the heart and brain. These risk factors include smoking, diabetes, high blood pressure and high blood cholesterol.
Who is most at risk?
PAD is more common in individuals as they age, and thus peripheral arterial disease is becoming more common in the United States, as our population ages. Anyone over the age of seventy is at risk, and individuals fifty years of age or older who either smoke or have a history of smoking or who have diabetes mellitus, are also at risk.
What is the increased risk of heart attack or stroke for those with PAD?
A patient that has PAD faces a six- to sevenfold increased risk of heart attack or stroke. This is as high a risk as faced by a patient who has already had a heart attack or stroke.
Is the narrowing, or 'hardening' of the arteries treatable?
This blockage, by itself, is usually considered to be irreversible, but the rate at which it develops can be markedly slowed by a healthy lifestyle. A well-informed and motivated patient can certainly stop smoking, lower their blood cholesterol, control their blood pressure, and ensure that their diabetes is well managed. We know that these treatments can decrease the rate of progression and the incidence of peripheral arterial disease.
What are the symptoms of PAD?
At least half, and perhaps as many as 85% to 90%, of individuals with PAD may not recognize its classical symptoms. Some individuals will have a symptom called claudication, which is a fatigue, discomfort or pain in the muscles of the leg. [Studies show that 5% of men and 2.5% of women 60 years of age or older have symptoms of claudication.]
Claudication can be recognized by patients, which can lead also to the establishment of a diagnosis. One clue that a walking impairment is due to PAD is discomfort within the muscles of the calves or the thighs, or perhaps the buttocks.
Some individuals with PAD suffer a wound in their legs that will not heal, or perhaps gangrene that would otherwise lead to amputation.
But again, it is important to remember that the vast majority of people living with PAD will experience no symptoms at all.
How is PAD diagnosed?
The ankle-brachial index, or ABI, is a measurement performed with an electronic stethoscope and a simple office blood pressure cuff. This test measures the blood pressure at the ankle and at the arm. A blood pressure that is lower in the ankle than the arm implies a blockage in the artery between the heart and the leg. Such a blockage represents peripheral arterial disease.
I believe the ABI is the easiest test to perform that can offer an accurate diagnosis to patient and physician alike regarding the presence of an artery blockage. Some individuals might think that an abnormal ABI is an "early diagnosis." In fact, an abnormal ABI implies there's already damage to the artery, which is significant, and that is why the risk of heart attack and stroke are so high in individuals with PAD.
Once the PAD diagnosis is established, the progress of the disease can easily be followed by subsequent performance of the ABI measurement, either annually or at intervals determined by the physician.
What are some of the considerations in treating a person with PAD?
My first therapeutic objective for an individual with PAD is to decrease their risk of heart attack and stroke. I ask for complete smoking cessation, and that my patients begin an antiplatelet agent, which can decrease the risk of formation of a blood clot in a heart or brain artery, and thus decrease the risk of heart attack and stroke. There are different types of antiplatelet agents on the market, several of which are used in the treatment of PAD, including aspirin and Plavix (clopidogrel).
Additionally, it is critical that a patient normalize their blood cholesterol, their blood sugar level and blood pressure as part of treatment. These factors can promote a decreased risk of heart attack and stroke.
There are many treatment options for people with claudication. One of the most effective is a supervised exercise regimen of perhaps three walks or more per week, under the guidance of a therapist, exercise physiologist or nurse. This can markedly improve claudication. There are medications available to alleviate the leg pain, and for some individuals with severely blocked arteries, balloon angioplasty or limb bypass surgery are viable treatment options to improve blood flow in the legs.
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