Peripheral Artery Disease (PAD): The Atherosclerosis No One Talks AboutYou May Have it and Not Know it. Do you get pain, unusual fatigue or cramping in your leg muscles that limits the distance you can walk before you get out of breath? Is it more severe when you walk fast, up an incline or up stairs? Does the pain get gradually worse the longer you walk causing you to have to sit down until it goes away? Do you have other risk factors for atherosclerosis such as being a past or current smoker, diabetes, high cholesterol, high blood pressure, or a family history of heart problems? If you answered yes to these questions you may have classic symptoms and risk factors of a condition called peripheral artery disease (PAD). PAD occurs when arteries supplying blood and oxygen to the legs become blocked. The lack of blood flow caused by these blockages induces leg pain (claudication) with walking that is relieved by rest. This leg pain is similar to chest pain (angina) when the heart does not receive enough blood and oxygen. PAD is a Major Health Concern. PAD affects 8 to 12 million Americans and continues to rise. PAD is common in both men and women and increases in prevalence with age, such that 5% of Americans over 50 and 15-20% of Americans over 65 are affected by the disease. The two biggest risk factors for PAD are smoking and diabetes. This is a true public health problem because PAD is associated with a significant decrease in a patient's ability to maintain social activities, occupational duties or even daily chores. In addition, it is associated with other forms of atherosclerosis, such as heart disease and stroke. Persons with PAD double their risk of dying of a cardiovascular event. This is because the same blockages found in the legs are often located in the coronary arteries in the heart as well. Why Have I Not Been Screened for PAD? Although PAD has been around for a long time, only recently has is it begun to gain the attention it deserves. Long under-diagnosed in the medical community, and therefore viewed as less significant than heart disease, PAD is now recognized to have an incidence nearly equal to that of heart disease. Unfortunately, PAD has been far less tested for by doctors and less studied than coronary artery disease. Many patients may not know they have PAD until it manifests itself in a severe form. The most severe form of PAD is critical limb ischemia (CLI) which causes pain at rest and may lead to amputation. It is likely that as attention for PAD increases through national programs such as the PAD Coalition and the National Institutes of Health's awareness program there will be a concomitant rise in diagnoses necessitating more effort to screen for the disease and offer the best treatment strategies for patients with PAD. Testing for PAD is very simple, painless and inexpensive. Your doctor can perform a test called an ankle brachial index (ABI) that measures pressures in your arms and legs and is over 90% accurate. If you have the symptoms described, ever smoked or have diabetes you are recommended to be screened for PAD. If you have known heart disease it is also beneficial to be screened for PAD. As with any illness, the sooner it is discovered, the best chance of treatment you have. Treatment Options for PAD Patients. Okay, you have PAD. Now what? Despite its prevalence and cardiovascular risk implications, only 25% of PAD patients are undergoing treatment. Treatment options to increase walking capacity for intermittent claudication (IC) are limited. Pharmacological therapies include drugs called statins, blood thinners and vasodilators. Other treatment strategies include risk factor management by smoking cessation and treatment of hypertension, diabetes, and cholesterol. Based on the most recent available evidence, adherence to a supervised exercise program is considered an effective treatment for PAD. Trials have shown supervised exercise training to be as good a treatment, if not better, than medications and may prevent the need for a surgical procedure. However, the literature suggests that exercise must be performed under medical supervision to be effective. Unfortunately, many PAD patients are unable to participate in a supervised exercise program due to economic considerations, and lack of proximity to an exercise rehabilitation program. For these reasons, revascularization procedures are among the most important and most widely utilized treatments for PAD. Revascularization for PAD. Although revascularization for PAD can be performed surgically or percutaneously, the latter approach has become widely utilized for its less invasive nature and substantially shorter recovery time. Percutaneous revascularization procedures for PAD include angioplasty with or without stent placement and are performed when lifestyle modifications (including exercise) have failed; medications have been maximized without improvement; claudication occurs at rest; tissue preservation becomes necessary; or activities of daily living are no longer possible. Revascularization (either angioplasty or bypass) has been shown to improve both pain-free walking time (by over 200%) and maximal walking time (by almost 100%) in PAD patients. However, studies have shown that the beneficial effects of revascularization may be limited. For example, studies have demonstrated a benefit of angioplasty at 3 months that did not persist out to 12 months, and other studies have failed to show short-term relief of claudication symptoms despite a technically successful angioplasty procedure. Of even greater concern was the finding that 2 years after angioplasty walking capacity was no better than that of patients who did not undergo revascularization. However, most of this data has come from angioplasties that have not used a stent. A stent is a wire like mesh tube used as "scaffolding" to provide support and prevent the artery from closing. It is likely that stenting yields better outcomes than angioplasty alone. Also, success rates can be very dependent on the location and size of the diseased blood vessel. It is important to discuss all options with your doctor. Public Awareness and Education. If you are (were) a smoker, have diabetes or have the symptoms described above for PAD, it is a good idea to ask your doctor to screen you for PAD. The more you know about an illness, the better you can talk to your doctor, make wise decisions and prevent it from getting worse. Therefore, if you or someone you know has PAD, it is also a good idea to learn more about the disease. There are many websites that can provide some information. Your doctor may have brochures on PAD. Surprisingly, there few books written for the public on this disease. Due to this lack of available PAD information in a book format, Shell Beach Publishing has recently introduced a book entitled, "Your Complete and Easy Guide to Understanding Peripheral Artery Disease." The book has been written to give information in a friendly and easily understood format. It discusses many of the topics, in greater detail, that have been mentioned in this article. It can be ordered by going to www.padawareness.com. To order additional copies of this book or contact us go to www.padbook.com
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