Peripheral Arterial Disease: Difference between revisions

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== Introduction ==
== Introduction ==
[[File:Peripheral Arterial Disease.gif|right|frameless|435x435px]]Peripheral artery disease is a common type of cardiovascular disease, which affects 236 million people across the world. It happens when the arteries in the legs and feet become clogged with fatty plaques through a process known as atherosclerosis.
[[File:Peripheral Arterial Disease.gif|right|frameless|435x435px]]Peripheral artery disease is a common type of [[Cardiovascular Disease|cardiovascular disease]], which affects 236 million people across the world. It happens when the arteries in the legs and feet become clogged with fatty plaques through a process known as [[atherosclerosis]].


While some people with this disease experience no symptoms, the most classic symptoms are pain, cramps, numbness, weakness or tingling that occurs in the legs during walking – known as intermittent claudication. These problems affect around 30% of people with peripheral artery disease. Intermittent claudication is more common in adults over 50, men and people who smoke.
While some people with this disease experience no symptoms, the most classic symptoms are [[Pain Assessment|pain]], cramps, numbness, weakness or tingling that occurs in the legs during walking – known as intermittent claudication. These problems affect around 30% of people with peripheral artery disease. Intermittent claudication is more common in adults over 50, men and people who smoke.<ref>The Conversation [https://theconversation.com/walking-can-relieve-leg-pain-in-people-with-peripheral-artery-disease-151240 Walking can relieve leg pain in people with peripheral artery disease] Available: https://theconversation.com/walking-can-relieve-leg-pain-in-people-with-peripheral-artery-disease-151240<nowiki/>(accessed 6.6.2021)</ref>


Currently, peripheral artery disease treatments focus on managing symptoms and preventing the arteries from becoming more clogged, which will reduce the risk of heart disease and stroke. Medications may also be prescribed to reduce cholesterol or treat high blood pressure, which are both risk factors for developing peripheral artery disease.<ref>The Conversation [https://theconversation.com/walking-can-relieve-leg-pain-in-people-with-peripheral-artery-disease-151240 Walking can relieve leg pain in people with peripheral artery disease] Available: https://theconversation.com/walking-can-relieve-leg-pain-in-people-with-peripheral-artery-disease-151240<nowiki/>(accessed 6.6.2021)</ref>
The management of PAD varies depending on the disease severity and symptom status. Treatment options for PAD include lifestyle changes, cardiovascular risk factor reduction, pharmacotherapy, endovascular intervention, and [[Surgery and General Anaesthetic|surgery]].<ref name=":1">Zemaitis MR, Boll JM, Dreyer MA. [https://www.ncbi.nlm.nih.gov/books/NBK430745/ Peripheral arterial disease.] StatPearls [Internet]. 2020 Jul 6.Available :https://www.ncbi.nlm.nih.gov/books/NBK430745/ (accessed 6.6.2021)</ref>


== Epidemiology  ==
== Epidemiology  ==
Prevalence: 12-14%,  20% of the over 70s in Western populations<ref>Radiopedia [https://www.ncbi.nlm.nih.gov/books/NBK430745/ PAD] Available:https://www.ncbi.nlm.nih.gov/books/NBK430745/ (accessed 6.6.2021)</ref>.


Peripheral artery disease affects around 13% of the Western population who are more than 15 years old.<ref name=":0">Crawford F, Welch K, Andras A, Chappell FM. Ankle brachial index for the diagnosis of lower limb peripheral arterial disease. <abbr>Cochrane Database Syst  Rev</abbr>2016;9:CD010680.pmid:27623758</ref> In the United Kingdom, an estimated 500-1000 new cases of PAD are diagnosed per million each year<ref name="Patient">Patient. Peripheral arterial disease. http://www.patient.co.uk/doctor/peripheral-arterial-disease (accessed 9 May 2015)</ref><ref name="Peach">Peach, G, Griffin, M, Jones, KG, Thompson MM, Hinchliffe, RJ. Diagnosis and management of peripheral arterial disease. BMJ 2012; 345: 1-8.  http://www.bmj.com/content/bmj/345/bmj.e5208.full.pdf (acccessed 9 May 2015)</ref>. Patients at high risk of PAD are those with [[Coronary Artery Disease (CAD)|cardiac disease]], diabetes mellitus, older than 70 years or 50 years old with multiple cardiovascular factors<ref name="Mahameed">Mahameed, AA, Bartholomew, JR, Disease of Peripheral Vessels. In: Topol, EJ, editor. Textbook of Cardiovascular Medicine. 3rd ed. New York: Lippincott Williams &amp; Wilkins, 2007, p.1531-1537</ref>. These factors include [[Smoking Cessation and Brief Intervention|smoking]], dyslipedmia, dysglycemia, [[hypertension]], family history of [[Atherosclerosis|atherosclerotic]] vascular disease. In lower socioeconomic areas, PAD is more frequent as a result of increased incidence of smoking <ref name="Fowkes">Fowkes G. Peripheral vascular disease. 2010. http://www.birmingham.ac.uk/Documents/college-mds/haps/projects/HCNA/09HCNA3D2.pdf (accessed 9 May 2015)</ref>. Some studies report no difference in prevalence between the sexes <ref name="Mahameed" />, however, other studies have found a 3:1 ratio comparing men to women<ref name="Fowkes" /><ref name="Patient" />. A few studies have suggested that black non-Hispanics have an increased prevalence of PAD, with a reported 2.39 to 2.83 odd ratio. Although, a study that controlled for atherosclerotic risk factors found a small difference between whites and African Americans; 1.54 and 1.89, respectively<ref name="Collins">Collines, TC, Petersen, NJ, Suarez-Almazor, M, Ashton CM. Ethnicity and peripheral arterial disease. Mayo Clin Proc. 2005; 80(1): 48-54.</ref>.&nbsp;The majority of cases are asymptomatic..  
Smoking increases the risk of developing PAD fourfold and has the greatest impact on disease severity. Compared to non-smokers, smokers with PAD have shorter life spans and progress more frequently to critical limb ischemia and amputation. Additional risk factors for PAD include diabetes, hyperlipidemia, hypertension, race, and ethnicity.


== Aetiology  ==
== Etiology ==


The most common cause of PAD is '''atherosclerosis''', similarly, they share the same risk factors: smoking, diabetes, age, hypertension, and hyperlipidemia. Uncommon vascular symptoms, such as vasculitis, thromboangiitis obliterans, popliteal entrapment syndrome, and fibromuscular dysplasis, account for less than 10% of cases <ref name="Mahameed" />.
Peripheral artery disease is usually caused by atherosclerosis. Other causes may be inflammation of the blood vessels, injury, or radiation exposure.<ref name=":1" />  


Atherosclerosis is a systemic disease. It is the formation of lipid deposits in the tunica media and associated with damage to the endothelial lining <ref name="Martini">Martini, FH, Nath, JL, Bartholomew, EF. Fundamentals of anatomy and physiology. San Francisco: Pearson Education, 2015.</ref>.The endothelial cells become swollen with lipids and create a gap between in the linings. Platelets stick to the exposed collagen fibers, forming a localized clot that restricts arterial blood flow, leading to inadequate tissue perfusion. This and other complex interactions can lead to progression from asymptomatic PAD, Intermittent Claudication, Critical Limb Ischemia, Acute Limb Ischemia <ref name="Mahameed" />. It is estimated that up to 60% of patients with PAD will have ischaemic heart disease, and 30% have cerebrovascular disease.<ref name=":1">Aronow WS, Ahn C. Prevalence of coexistence of coronary artery disease, peripheral arterial disease, and atherothrombotic brain infarction in men and women≥ 62 years of age. The American journal of cardiology. 1994 Jul 1;74(1):64-5.</ref> Reports suggest that within 5 years of diagnosis, 10-15% of patients suffering from intermittent claudication will die from cardiovascular disease.<ref>Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA. Inter-Society Consensus for the management of Peripheral Arterial Disease (TASC II) Eur J Vasc Endovasc Surg 33. S1–S75. 2007.</ref> This highlights the importance of identification and modification of risk factors associated with PAD, heart disease, and stroke. 
Risk factors: Smoking, [[Hypertension]], [[Diabetes]], [[Hyperlipidemia|High cholesterol]], Increasing age (especially after reaching 50 years of age), Family history of peripheral artery disease, [[Coronary Artery Disease (CAD)|Heart disease]] or [[Stroke]], High levels of homocysteine (a protein component that helps build and maintain tissue).<ref name=":1" />
 
=== Risk Factors ===
 
==== Cigarette Smoking ====
Cigarette smoking increases the chance of having PAD by seven-fold<ref name="Price">Price, JF, Mowbray, PI, Lee, AJ, Rumley, A, Lowe, GDO, Fowkes, FGR. 1999, “Relationship between smoking and cardiovascular risk factors in the development of peripheral arterial disease and coronary artery disease”, European Heart Journal, Vol. 20, pp. 344-353.</ref>. Due to a change in the fibrin formation, endothelial cells, blood rheology, and lipoproteins decrease antioxidants in the blood<ref name="Price" />. Specifically, the change in endothelial cells that line the arterial walls is strongly associated with atherosclerosis <ref name="Hirsch">Hirsch, AT, et al. 2006, “Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)”, Circulation, Vol. 113, pp. 463-654.</ref>. As the number of cigarettes smoked each day increase, so does the risk of PAD<ref name="Price" />. A systematic review of 17 studies (n=20,278) reported that half of all PAD can be attributed to smoking and concluded that heavier smokers are more likely to develop PAD than light smokers. Moreover, they suggested that former smokers still have an increased risk when compared with patients who have never smoked.<ref>Willigendael EM, Teijink JA, Bartelink ML, Kuiken BW, Boiten J, Moll FL, Büller HR, Prins MH. Influence of smoking on incidence and prevalence of peripheral arterial disease. Journal of vascular surgery. 2004 Dec 1;40(6):1158-65.</ref>
 
==== Diabetes ====
'''[[Diabetes|Diabetes]]''', similarly to smoking causes abnormalities in endothelial cells and their function. The cells are unable to regulate the function and structure of the arterial walls<ref name="Creager">Creager, MA, Luscher, TF, Beckman, JA. Diabetes and vascular disease: Pathophysiology, clinical consquences and medical therapy. Circulation 2003;108:1527-1532.</ref>. Diabetes Mellitus leads to a two-to fourfold increase in risk of cardiovascular events <ref name="Mahameed" />. The TASC II guidelines report that those with diabetes have a similar relative risk of developing PAD to those that smoke. <ref name=":1" /> A prospective cohort study found that poor diabetes management was associated with an increased risk of PAD. <ref>Selvin E, Wattanakit K, Steffes MW, Coresh J, Sharrett AR. HbA1c and peripheral arterial disease in diabetes: the Atherosclerosis Risk in Communities study. Diabetes care. 2006 Apr 1;29(4):877-82.</ref>
 
==== Age ====
The risk of PAD increases as the population approaches the age of 50. It has been reported that PAD affects 0.9% of 40-49 year olds and increases to 14.5% of 70 year olds and above <ref name="Mahameed" />.Studies also have shown that men are the target population of PAD <ref name="Mahameed" />.
 
==== Gender ====
TASC II guidelines conclude that men are affected at a younger age than women. However, overall there is no clear distinction in risk.
 
==== Hypertension ====
[[Blood Pressure|Hypertension]] can be a risk for developing PAD. In a study conducted by Lewington et al. illustrated that for each 20-mmHg increase in systolic blood pressure or 10 mmHG in diastolic for people age 40-70 doubled the risk of cardiovascular disease and PAD <ref name="Mahameed" />.
 
==== Dyslipidemia ====
Developing PAD by 10% for every 10-mg/dL rise in total cholesterol<ref name="Mahameed" />. 


== Prognosis  ==
== Prognosis  ==
If PAD is left untreated it does not inevitably lead to amputation. At five years from diagnosis most patients with claudication have stable or improved symptoms.<ref>Leng GC, Lee AJ, FOWKERS FG, WHITEMAN M, Dunbar J, Housley E, Ruckley CV. Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. International journal of epidemiology. 1996 Dec 1;25(6):1172-81.</ref> Asymptomatic disease is identified as a marker of sedentary lifestyle rather than less severe disease and outcomes are similar to those with claudication. As much as 25% of symptomatic patients will need some form of intervention, but less than 5% of those will progress to critical limb ischaemia. <ref name=":0" /> The risk of amputation is 1-3.3% and all-cause mortality is 20% within five years from diagnosis of PAD. <ref name=":0" /> The risk of limb amputation is 30% in patients with critical limb ischaemia and five year all-cause mortality is 50%. <ref name=":0" /> Mortality rates for all patients that require leg amputation are twice as high when compared to those without amputation. Patients presenting with diabetes are at a greater risk of amputation or dying when compared to non-diabetic patients with PAD. <ref>Jude EB, Oyibo SO, Chalmers N, Boulton AJ. Peripheral arterial disease in diabetic and nondiabetic patients: a comparison of severity and outcome. Diabetes care. 2001 Aug 1;24(8):1433-7.</ref>
If PAD is left untreated it does not inevitably lead to amputation. At five years from diagnosis most patients with claudication have stable or improved symptoms.<ref>Leng GC, Lee AJ, FOWKERS FG, WHITEMAN M, Dunbar J, Housley E, Ruckley CV. Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. International journal of epidemiology. 1996 Dec 1;25(6):1172-81.</ref> Asymptomatic disease is identified as a marker of sedentary lifestyle rather than less severe disease and outcomes are similar to those with claudication. As much as 25% of symptomatic patients will need some form of intervention, but less than 5% of those will progress to critical limb ischaemia. <ref name=":0">Crawford F, Welch K, Andras A, Chappell FM. Ankle brachial index for the diagnosis of lower limb peripheral arterial disease. <abbr>Cochrane Database Syst  Rev</abbr>2016;9:CD010680.pmid:27623758</ref> The risk of amputation is 1-3.3% and all-cause mortality is 20% within five years from diagnosis of PAD. <ref name=":0" /> The risk of limb amputation is 30% in patients with critical limb ischaemia and five year all-cause mortality is 50%. <ref name=":0" /> Mortality rates for all patients that require leg amputation are twice as high when compared to those without amputation. Patients presenting with diabetes are at a greater risk of amputation or dying when compared to non-diabetic patients with PAD. <ref>Jude EB, Oyibo SO, Chalmers N, Boulton AJ. Peripheral arterial disease in diabetic and nondiabetic patients: a comparison of severity and outcome. Diabetes care. 2001 Aug 1;24(8):1433-7.</ref>


== Symptoms  ==
== Symptoms  ==
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== Investigations  ==
== Investigations  ==


A tool used to gain a diagnosis of PAD is [[Ankle-Brachial Index|Ankle Brachial Pressure Index]] (ABI), a simple and inexpensive test that measures the ratio between blood pressure in the legs to the [[Blood Pressure|blood pressure]] in the arms<ref name="Mahameed" />. The lower the pressure in the legs illustrates that PAD is present. An ABI of 0.9- 1.0 is normal, 0.70-0.89 is a mild disease, 0.40- 0.69 is a moderate disease, and less than .40 is a severe PAD<ref name="Mahameed" />. When measuring for ABI, make sure the patient is calm and in a rested position <ref name="NICE">NICE National Institute for Health and Care Excellence. Lower limb peripheral arterial disease: diagnosis and management, 2012. https://www.nice.org.uk/guidance/cg147/chapter/guidance#management-of-intermittent-claudication (accessed 9 May 2015)</ref>. It is also important to assess individuals if they have diabetes, non-healing wounds on their legs and feet, unexplained pain in their peripherals, and check for femoral and popliteal pulses<ref name="NICE" />.
A tool used to gain a diagnosis of PAD is [[Ankle-Brachial Index|Ankle Brachial Pressure Index]] (ABI), a simple and inexpensive test that measures the ratio between blood pressure in the legs to the [[Blood Pressure|blood pressure]] in the arms<ref name="Mahameed">Mahameed, AA, Bartholomew, JR, Disease of Peripheral Vessels. In: Topol, EJ, editor. Textbook of Cardiovascular Medicine. 3rd ed. New York: Lippincott Williams &amp; Wilkins, 2007, p.1531-1537</ref>. The lower the pressure in the legs illustrates that PAD is present. An ABI of 0.9- 1.0 is normal, 0.70-0.89 is a mild disease, 0.40- 0.69 is a moderate disease, and less than .40 is a severe PAD<ref name="Mahameed" />. When measuring for ABI, make sure the patient is calm and in a rested position <ref name="NICE">NICE National Institute for Health and Care Excellence. Lower limb peripheral arterial disease: diagnosis and management, 2012. https://www.nice.org.uk/guidance/cg147/chapter/guidance#management-of-intermittent-claudication (accessed 9 May 2015)</ref>. It is also important to assess individuals if they have diabetes, non-healing wounds on their legs and feet, unexplained pain in their peripherals, and check for femoral and popliteal pulses<ref name="NICE" />.


Other investigations that are commonly used in the assistance of a diagnosis of PAD are Blood pressure, [[Electrocardiogram|Electrocardiography]], [[Blood Physiology|Full blood count]], Urea and electrolytes, Random blood glucose or HBA1C, Serum cholesterol, Thrombophilia screen in patients less than 50 years old.   
Other investigations that are commonly used in the assistance of a diagnosis of PAD are Blood pressure, [[Electrocardiogram|Electrocardiography]], [[Blood Physiology|Full blood count]], Urea and electrolytes, Random blood glucose or HBA1C, Serum cholesterol, Thrombophilia screen in patients less than 50 years old.   

Revision as of 07:01, 6 June 2021

Original Editors - Students from Glasgow Caledonian University's Cardiorespiratory Therapeutics Project.

Top Contributors - Victoria Michaud, Lucinda hampton, Kim Jackson, Admin, Adam Vallely Farrell, Chris Seenan, Vidya Acharya, 127.0.0.1, Michelle Lee and WikiSysop  

Introduction[edit | edit source]

Peripheral Arterial Disease.gif

Peripheral artery disease is a common type of cardiovascular disease, which affects 236 million people across the world. It happens when the arteries in the legs and feet become clogged with fatty plaques through a process known as atherosclerosis.

While some people with this disease experience no symptoms, the most classic symptoms are pain, cramps, numbness, weakness or tingling that occurs in the legs during walking – known as intermittent claudication. These problems affect around 30% of people with peripheral artery disease. Intermittent claudication is more common in adults over 50, men and people who smoke.[1]

The management of PAD varies depending on the disease severity and symptom status. Treatment options for PAD include lifestyle changes, cardiovascular risk factor reduction, pharmacotherapy, endovascular intervention, and surgery.[2]

Epidemiology[edit | edit source]

Prevalence: 12-14%, 20% of the over 70s in Western populations[3].

Smoking increases the risk of developing PAD fourfold and has the greatest impact on disease severity. Compared to non-smokers, smokers with PAD have shorter life spans and progress more frequently to critical limb ischemia and amputation. Additional risk factors for PAD include diabetes, hyperlipidemia, hypertension, race, and ethnicity.

Etiology[edit | edit source]

Peripheral artery disease is usually caused by atherosclerosis. Other causes may be inflammation of the blood vessels, injury, or radiation exposure.[2]

Risk factors: Smoking, Hypertension, Diabetes, High cholesterol, Increasing age (especially after reaching 50 years of age), Family history of peripheral artery disease, Heart disease or Stroke, High levels of homocysteine (a protein component that helps build and maintain tissue).[2]

Prognosis[edit | edit source]

If PAD is left untreated it does not inevitably lead to amputation. At five years from diagnosis most patients with claudication have stable or improved symptoms.[4] Asymptomatic disease is identified as a marker of sedentary lifestyle rather than less severe disease and outcomes are similar to those with claudication. As much as 25% of symptomatic patients will need some form of intervention, but less than 5% of those will progress to critical limb ischaemia. [5] The risk of amputation is 1-3.3% and all-cause mortality is 20% within five years from diagnosis of PAD. [5] The risk of limb amputation is 30% in patients with critical limb ischaemia and five year all-cause mortality is 50%. [5] Mortality rates for all patients that require leg amputation are twice as high when compared to those without amputation. Patients presenting with diabetes are at a greater risk of amputation or dying when compared to non-diabetic patients with PAD. [6]

Symptoms[edit | edit source]

Most patients with PAD are asymptomatic. Claudication is the most reported symptom. It is an aching or burning sensation in the muscles of the leg that it reliably reproduced after a set walking distance and is relieved with rest. It is not exacerbated by position or present at rest. The site of pain can often help in providing an indication to the site of the disease. Occlusion or stenosis of the aorta commonly causes bilateral buttock, thigh, and calf claudication. Occlusion of the common iliac, common femoral, and superficial femoral arteries causes unilateral buttock, thigh, and calf claudication.

For a diagnosis of acute limb ischemia a patient must present with a sudden onset of the Six P's (Pain, Pallor, Pulseless, Parasthesia, Paralysis, 'Perishingly cold, Sudden onset of claudication.

The video below is a good summary of the basics of PAD

[7]

Investigations[edit | edit source]

A tool used to gain a diagnosis of PAD is Ankle Brachial Pressure Index (ABI), a simple and inexpensive test that measures the ratio between blood pressure in the legs to the blood pressure in the arms[8]. The lower the pressure in the legs illustrates that PAD is present. An ABI of 0.9- 1.0 is normal, 0.70-0.89 is a mild disease, 0.40- 0.69 is a moderate disease, and less than .40 is a severe PAD[8]. When measuring for ABI, make sure the patient is calm and in a rested position [9]. It is also important to assess individuals if they have diabetes, non-healing wounds on their legs and feet, unexplained pain in their peripherals, and check for femoral and popliteal pulses[9].

Other investigations that are commonly used in the assistance of a diagnosis of PAD are Blood pressure, Electrocardiography, Full blood count, Urea and electrolytes, Random blood glucose or HBA1C, Serum cholesterol, Thrombophilia screen in patients less than 50 years old.

Clinical Manifestations[edit | edit source]

Diabetic foot ulcer.jpeg

According to NICE:[9]

  • Non-healing wounds on legs or feet
  • Unexplained leg pain
  • Pain on walking that resolves when stopped
  • Pain in foot at rest made which worsens with elevation
  • Ulcers
  • Gangrene
  • Dry skin
  • Cramping
  • Aching

Medical Management[edit | edit source]

One method of treating PAD is to reduce cardiovascular risk factors by quitting smoking, managing diabetes mellitus, treating dyslipidemia and hypertension [8]. Another method is to treat PAD symptoms to improve quality of life through pharmacotherapy, exercise rehabilitation program, revascularization, thrombolysis and surgical procedures [8]. The current NICE clinical guidelines on Cardiovascular disease have identified several key aspects in the management of PAD in the primary care setting. It identifies that all patients should receive the following before a referral is made to secondary care.[10] These include;

Risk Factor Modification[edit | edit source]

Smoking cessation therapy[edit | edit source]

Patients with PAD that continue to smoke persistently have worse outcomes. A 2016 AHA ( American Heart Association) statement was updated to include that patients with PAD are now strongly advised to avoid second-hand smoke.[11] When compared with former smokers, they have a greater risk of amputation and their chance of surviving 5 years post diagnosis is halved when compared to non-smokers.[12] It is important that patients are made aware of this association with smoking and the benefits of smoking cessation. A combination of behavioural counselling with medication has been shown to increase the proportion of successful attempts at quitting when compared to standard care.[13] Cessation of smoking may help in preventing further declines in symptoms.

HBA1C control  (target value <48 mmol/mol)[edit | edit source]

Numerous studies have shown that an improvement in glycemic control in patients with diabetes reduces the risk of microvascular complications, but has little effect on the risk of amputation.[14] NICE recommend reaching a target HBA1C level of <48 mmol/mol for all patients with diabetes. [10]

Blood pressure control (target value  <140/90 mm Hg- for patients <80 years old)[edit | edit source]

Management of hypertension lowers a patients cardiovascular risk. Ramipril is recommended as first line therapy in guidelines worldwide.[15]

Antiplatelet medicine[edit | edit source]

Clopidogrel (or aspirin) 75 mg lifelong - An RCT of patients with atherosclerotic vascular disease showed that clopidogrel 75 mg was significantly better than aspirin 325 mg for prevention of vascular complications at a mean follow up of 1.9years.[16] When clopidogrel is contraindicated, aspirin is an acceptable alternative. Warfarin is most commonly reserved for patients with limb ischaemia due to arterial emboli.

Statins[edit | edit source]

Atorvastatin lifelong - A meta- analysis of 12 observational studies reported that statin therapy plays a role in reducing all-cause mortality and the incidence of stroke in those with PAD. NICE guidelines recommend reducing non- HDL cholesterol concentration in patients with PAD by 40%. [10]

Symptom Control[edit | edit source]

Supervised exercise therapy for 3 months - NICE recommends that a supervised exercise programme is offered to all patients where applicable consisting of 2hrs a week for a 3month period. [10] They report that it is more cost effective than either unsupervised exercise or angioplasty. Despite this, it is estimated that up to 70% of clinical commission groups in the UK fail to provide this service.

Physiotherapy Management[edit | edit source]

The least invasive and most appropriate treatment for PAD conducted by Physiotherapists would be by prescribing an exercise program. The recommended parameters of physical exercise are a 6 month program of 30-35 minutes walking sessions at a frequency of 3-5 times a week at near-maximal pain tolerant.

Supervised exercise programs have proved to have better results than unsupervised exercise programs. An updated Cochrane review 2018 reports that the original version of this review was released in 2006, prescribed exercise therapy consisted mostly of “go home and walk” advice. However, the compelling evidence now suggests that "Evidence of moderate and high quality shows that SET (supervised exercise programs) provides an important benefit for treadmill‐measured walking distance (MWD and PFWD) compared with HBET (home-based exercise programs) and WA (walking advice) respectively."[17]

Even for clients having invasive therapies exercise is important A 2018 Cochrane review comparing mono invasive therapies (monotherapies) to supervised exercise programs (SET) with invasive therapies, concluded " that exercise is a complication-free treatment, it appears to offer significant improvements in patients walk distances with a combination of both SET and intervention offering a superior walking outcome to monotherapy in those requiring invasive measures."[18]

Treadmill walk.jpg

A 2018 review of the best exercise prescription for PAD summarised their findings thus

  • Supervised treadmill exercise improves treadmill walking performance in patients with PAD.
  • Supervised treadmill exercise has greater benefit on treadmill walking performance than home-based walking exercise.
  • Home-based walking exercise interventions that involve behavioral techniques are effective for functional impairment in people with PAD and improve the 6-min walk distance more than supervised treadmill exercise.
  • Upper and lower extremity ergometry improve walking performance in patients with PAD and improve peak oxygen uptake.
  • Lower extremity resistance training can improve treadmill walking performance in PAD, but is not as effective as supervised treadmill exercise.[19]

The optimal exercise program for PAD recommended by the American Heart Association states the following

Exercise Prescription for Supervised Exercise Treadmill Training in Patients With Claudication[edit | edit source]

  1. Modality Supervised Treadmill Walking
  2. Intensity 40%–60% maximal workload based on baseline treadmill test or workload that brings on claudication within 3–5 min during a 6-MWT
  3. Session duration 30–50 min of intermittent exercise; goal is to accumulate at least 30 min of walking exercise
  4. Claudication intensity Moderate to moderate/severe claudication as tolerated
  5. Work-to-rest ratio Walking duration should be within 5–10 min to reach moderate to moderately severe claudication followed by rest until pain has dissipated (2–5 min)
  6. Frequency 3 times per week supervised
  7. Program duration At least 12 wk
  8. Progression Every 1–2 wk: increase duration of training session to achieve 50 min. As individuals can walk beyond 10 min without reaching prescribed claudication level, manipulate grade or speed of exercise prescription to keep the walking bouts within 5–10 min
  9. Maintenance Lifelong maintenance at least 2 times per week

Based on currently available evidence. Exercise prescription should be individualized to each patient as tolerated. 6-MWT indicates 6-minute walk test. [20]

A recent research study showed that Nordic walking training improved the gait pattern of patients with PAD remarkably and caused a significant increase in the absolute claudication distance and total gait distance. The combined training of Nordic walking with the isokinetic resistance training of the lower extremities muscles (NW + ISO) increased the amplitude of the general center of gravity oscillation to the greatest extent. However, only treadmill training had little effect on the gait pattern. Hence, Nordic walking can be used to rehabilitate patients with PAD as a form of gait training[21].

Outcome Measures[edit | edit source]

Prevention[edit | edit source]

According to Warren[22] there are several methods one can prevent PAD. Firstly, help change the patient's lifestyle by educating them on the risk factors and the effects PAD. If the patient smokes cigarettes, it is important to address the issue and promote cessation. Those who consume a high fat diet have a higher chance of being diagnosed with PAD, thus one should encourage a reduced fat diet as a strong prevention method. Along with diet, it is important to live an active lifestyle. By being active and working up to the general standards of physical activity per week will allow a decrease in weight along with a decrease in risk of PAD.

Conclusions[edit | edit source]

Highlights from the 2016 AHA advice regarding PAD management

  • Patients with peripheral artery disease (PAD) should be on a program of guideline-directed medical therapy (including antiplatelet drugs that thin blood and statins to lower cholesterol) and should participate in a structured exercise program.
  • Restoring blood flow to the legs through vascular procedures is appropriate for many patients with severe symptoms due to PAD.
  • Eliminating exposure to all tobacco – including second-hand smoke – is highly recommended for patients with PAD.[11]

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ The Conversation Walking can relieve leg pain in people with peripheral artery disease Available: https://theconversation.com/walking-can-relieve-leg-pain-in-people-with-peripheral-artery-disease-151240(accessed 6.6.2021)
  2. ↑ 2.0 2.1 2.2 Zemaitis MR, Boll JM, Dreyer MA. Peripheral arterial disease. StatPearls [Internet]. 2020 Jul 6.Available :https://www.ncbi.nlm.nih.gov/books/NBK430745/ (accessed 6.6.2021)
  3. ↑ Radiopedia PAD Available:https://www.ncbi.nlm.nih.gov/books/NBK430745/ (accessed 6.6.2021)
  4. ↑ Leng GC, Lee AJ, FOWKERS FG, WHITEMAN M, Dunbar J, Housley E, Ruckley CV. Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. International journal of epidemiology. 1996 Dec 1;25(6):1172-81.
  5. ↑ 5.0 5.1 5.2 Crawford F, Welch K, Andras A, Chappell FM. Ankle brachial index for the diagnosis of lower limb peripheral arterial disease. Cochrane Database Syst  Rev2016;9:CD010680.pmid:27623758
  6. ↑ Jude EB, Oyibo SO, Chalmers N, Boulton AJ. Peripheral arterial disease in diabetic and nondiabetic patients: a comparison of severity and outcome. Diabetes care. 2001 Aug 1;24(8):1433-7.
  7. ↑ American Heart Association PAD What is it? Available from: https://www.youtube.com/watch?v=XTSgpiPqIbk (last accessed 7.9.2019)
  8. ↑ 8.0 8.1 8.2 8.3 Mahameed, AA, Bartholomew, JR, Disease of Peripheral Vessels. In: Topol, EJ, editor. Textbook of Cardiovascular Medicine. 3rd ed. New York: Lippincott Williams & Wilkins, 2007, p.1531-1537
  9. ↑ 9.0 9.1 9.2 NICE National Institute for Health and Care Excellence. Lower limb peripheral arterial disease: diagnosis and management, 2012. https://www.nice.org.uk/guidance/cg147/chapter/guidance#management-of-intermittent-claudication (accessed 9 May 2015)
  10. ↑ 10.0 10.1 10.2 10.3 National Institute for Health and Care Excellence. Cardiovascular disease: risk assessment and reduction, including lipid modification (clinical guideline CG181). 2017
  11. ↑ 11.0 11.1 Newsroom. New peripheral artery disease guidelines emphasize medical therapy and structured exercise 13.11. 2016 Available from: https://newsroom.heart.org/news/x-new-peripheral-artery-disease-guidelines-emphasize-medical-therapy-and-structured-exercise (last accessed 7.9.2019)
  12. ↑ Lassila R, Lepäntalo M. Cigarette smoking and the outcome after lower limb arterial surgery. Acta chirurgica Scandinavica. 1988;154(11-12):635-40.
  13. ↑ van de Graaf RC, van Schayck OC. Helping people to give up smoking; efficacy and safety of smoking cessation interventions. Nederlands tijdschrift voor geneeskunde. 2017;161:D1131.
  14. ↑ Adler AI, Stevens RJ, Neil A, Stratton IM, Boulton AJ, Holman RR. UKPDS 59: hyperglycemia and other potentially modifiable risk factors for peripheral vascular disease in type 2 diabetes. Diabetes care. 2002 May 1;25(5):894-9.
  15. ↑ Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA. Inter-Society Consensus for the management of Peripheral Arterial Disease (TASC II) Eur J Vasc Endovasc Surg 33. S1–S75. 2007.
  16. ↑ National Institute for Health and Care Excellence. Clinical knowledge summaries: Peripheral arterial disease. 2015
  17. ↑ Hageman D, Fokkenrood HJ, Gommans LN, van den Houten MM, Teijink JA. Supervised exercise therapy versus home‐based exercise therapy versus walking advice for intermittent claudication. Cochrane Database of Systematic Reviews. 2018(4). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6513337/ (last accessed 6.9.2019)[1]
  18. ↑ Aherne T, McHugh S, Kheirelseid EA, Lee MJ, McCaffrey N, Moneley D, Leahy AL, Naughton P. Comparing supervised exercise therapy to invasive measures in the management of symptomatic peripheral arterial disease. Surgery research and practice. 2015;2015.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4639651/ (last accessed 6.9.2019)
  19. ↑ McDermott MM. Exercise rehabilitation for peripheral artery disease: a review. Journal of cardiopulmonary rehabilitation and prevention. 2018 Mar;38(2):63. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5831500/ (last accessed 6.9.2019)
  20. ↑ Diane Treat-Jacobson, Mary M. McDermott, Ulf G. Bronas et al.Optimal Exercise Programs for Patients With Peripheral Artery Disease: A Scientific Statement From the American Heart Association. AHA Journal Vol. Circulation.130 No.4 Available from: https://ahajournals.org/doi/10.1161/CIR.0000000000000623 (last accessed 7.9.2019)
  21. ↑ W Dziubek, M Stefańska, K Bulińska, K Barska Journal of Clinical …, 2020 - mdpi.comEffects of Physical Rehabilitation on Spatiotemporal Gait Parameters and Ground Reaction Forces of Patients with Intermittent Claudication
  22. ↑ Warren, E. Ten things the practice nurse can do about peripheral arterial disease. Practice Nurse 2013; 43; 12: 14-18.
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