Peripheral Arterial Disease
Peripheral Arterial Disease
Rose Marie Robertson, MD, FAHA, FACC, FESC (Chief Science Officer and Past President of the Board of American Heart Association) gives expert video advice on: How is peripheral arterial disease tested and diagnosed?; How is peripheral arterial disease treated? and more...
What is "peripheral arterial disease" or "PAD"?
Peripheral arterial disease, or PAD, is athresclerosis affecting blood vessels other than their heart, and that is blood vessels anywhere in the body. Most commonly, peripheral arterial disease, or athresclerosis, is seen in the blood vessels that affect the legs, but it can also be seen in blood vessels affecting the kidney, affecting the brain, and really in fact affecting any organ; even the intestines, for example. The same athresclerotic deposits that can cause heart attacks can also restrict blood flow to these organs, and can cause the same sort of symptoms. So patients will often find that they suffer from the same sort of pain in the muscles of their legs that patients with angina suffer from in the muscle of their heart. So athresclerosis: Restricting blood flow anywhere in the body.
What are the risk factors for developing peripheral arterial disease?
The risk factors for developing peripheral arterial disease are the same as those for developing coronary artery disease. Smoking has a particularly potent effect on increasing the risk of peripheral arterial disease in the blood vessels in the leg, but in fact high blood pressure, high cholesterol levels, diabetes, being overweight or obese, being physically inactive, all of those can affect blood vessels throughout the body increasing the risk of peripheral arterial disease just as they can affect the blood vessels that supply the heart muscle itself and the brain.
What are the symptoms of peripheral arterial disease?
The symptoms of PAD depend on which blood vessel is being affected most at the moment. So, a common symptom has to do with narrowing of the blood vessels to the legs. People often feel what we call clotication; this is simply pain in the legs when the muscles in the legs are working. So as people walk, they'll find that the muscles in their legs cramp and become quite painful to the point that they actually have to stop walking. They're unable to continue to walk through it. Patients who note clotication, who note this pain in the legs, calves, thighs or the buttocks when they walk, may actually notice other changes if they look carefully at their legs. They may notice that the hair doesn't grow so well, that there's a change in nail growth. Occasionally, they may notice that one leg is actually cooler than another. Sometimes people don't report those symptoms because they think that they're just simply a sign of aging or something that comes on and is due to some other cause. In fact, these are serious signs not only because of the risk to the actual limb itself, the fact that you can lose a limb, but because these symptoms suggest that there are problems in blood vessels in other parts of the body. People with clotication are also at increased risk of heart attack and stroke. So treatment is urgent, treatment really needs to get started, and ignoring these symptoms is a very risky thing to do.
What is "claudication"?
Claudication refers to the symptoms that people have that are due to peripheral arterial disease or atherosclerosis in the blood vessels supplying the legs and buttocks. Claudication means the discomfort that you have in those muscles when you exercise. The discomfort can be felt in various ways by different people; it can be a sense of fatigue or heaviness, often cramping, or sometimes actually pain in the leg, calf, thigh, or in the buttocks when you're exercising. So, when you're walking down the hall or down the street, pain and discomfort will gradually develop, and within a pretty short period of time and a pretty short distance, you find that you really just can't walk anymore, you have to stop and rest. The reason you can't is that the blood flow is not adequate for what the muscle needs at that moment.
How does my blood sugar level effect my chances of getting PAD?
Since diabetes is an important risk factor for peripheral arterial disease, having an elevated blood sugar level certainly affects the chance of getting peripheral arterial disease and having it progress. If you have diabetes, or even a slightly abnormal plasma glucose, it's important for that to be controlled so that full-fledged diabetes doesn't develop, and so that if there is diabetes, it's controlled as well as possible.
How is peripheral arterial disease tested and diagnosed?
If you tell your physician about pain in the legs when you walk -- pain that comes on at a particular time and then goes away when you rest that really prevents you from walking on, pain that we would call claudication -- that simple fact and the history is often all we need to make a diagnosis of peripheral arterial disease or PAD. But to be certain it's there, the physician will examine the legs, will feel the pulses throughout the legs, will often listen with a stethoscope over the blood vessels to listen for noise that turbulent blood flow makes. Then we'll do what's called an ankle-brachial index test where the blood pressure is taken not just in the arm but also in the leg. The blood pressure is taken with a special device called a Doppler so that the blood pressure can be measured very carefully and we can compare the blood pressure in the arms and legs. We would expect that the blood pressure will be nearly equal or in fact greater in the legs. If there is lower blood flow in the legs, that indicates a significant problem with blood flow that is generally caused by atherosclerosis. Atherosclerosis tends to affect blood flow to the legs more than to the arms, so often falling blood flow is seen there first.
How is peripheral arterial disease treated?
Treatments for peripheral arterial disease can vary depending on where the narrowing is located, how severe it is, and what the patient's other problems are. Certainly they will include addressing all the other risk factors for peripheral arterial disease, for atherosclerosis, to prevent problems elsewhere. All of these medications such as aspirin or other medications that effect blood thinning; beta blockers, ACE inhibitors, a whole sequence of medications, are known to have an important preventive effect for the things that can accompany peripheral arterial disease like heart attack and stroke. It will be important that people have their blood pressure and their cholesterol levels both monitored and controlled, brought back to normal, and that this be done continuously over a period of time, hoping that it will have an effect to improve blood flow to the legs but also hoping that it will prevent other more serious problems. If narrowings persist (as they often do) and if blood flow is still inadequate, there are a number of procedures that can be done; some in a surgical way, and some using angioplasty to open up arteries so that more blood flow can be provided to the legs, the limb can be salvaged and symptoms can often be made to go away.
Why does peripheral arterial disease often go untreated?
Peripheral arterial disease or PAD may often go untreated because people don't think that those symptoms are worth telling their doctor about. They think that they're the kind of cramps that one can sometimes have at night that just go away if you get up and walk around the bed. But the kinds of cramps and pain and discomfort you have in the legs when you exercise, the kind that goes away fwhen you rest and comes back again when you start to walk further, that kind of pain caused by a lack of blood flow really does indicate a serious underlying process and if patients don't recognize that it can progress to a severe degree before they actually ever see a physician about it. It also can come on quite gradually so that the change is seen a little bit harder to notice than if they came on suddenly all at once.