Peripheral Arterial Disease: Difference between revisions

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== Definition/Description  ==
== Introduction ==
[[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]].


Peripheral arterial disease (PAD) is known as a condition where by the blood flow in the limb arteries are obstructed <ref name="Henderson">Henderson, J, Pollack, A, Harrison, C, Miller, G. 2013, “Peripheral arterial disease”, Australian Family Physician, Vol. 42, no. 6, pp. 363.</ref>. Commonly, the legs are the most affected <ref name="Henderson" />. These arteries are obstructed due to plaque deposits that restrict blood flow through the peripheries <ref name="Warren">Warren, E. Ten things the practice nurse can do about peripheral arterial disease. Practice Nurse 2013; 43; 12: 14-18.</ref>. Although blood flow may be also restricted by deep vein thrombosis, which may be a blood clot that occurs in the periphery of the limbs <ref name="Warren" />. Most patients are asymptomatic, but  may experience intermittent claudication (pain on walking). Common symptoms of PAD include pain during walking and rest, skin ulcers, cramping, aching, clubbing of the finger or toenails, cold skin, blue tinged skin, and slow blood refill <ref name="Mahameed" />. Thus there is a lack of blood flow to remove anaerobic metabolites that cause a pain sensation when built up&nbsp;<ref name="Warren" />. Critical limb ischaemia occurs when the blood flow reduction is so severe that it causes pain on rest or loss of tissue (ulceration or gangrene).<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>  
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>


== Epidemiology  ==
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>


Peripheral artery disease affects around 13% of the Western population who are more than 15 years old.<ref name=":0" /> 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 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, dyslipedmia, dysglycemia, hypertension, family history of 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..
The video below is a good summary of the basics of PAD
{{#ev:youtube|https://www.youtube.com/watch?v=XTSgpiPqIbk|width}}<ref>American Heart Association PAD What is it? Available from: https://www.youtube.com/watch?v=XTSgpiPqIbk (last accessed 7.9.2019)</ref>  


== Aetiology ==
== Epidemiology ==
[[File:Smoking-1026556 960 720-2.jpg|right|frameless]]
Prevalence: 12-14%,  20% of the over 70s in Western populations<ref name=":0">Radiopedia [https://www.ncbi.nlm.nih.gov/books/NBK430745/ PAD] Available:https://www.ncbi.nlm.nih.gov/books/NBK430745/ (accessed 6.6.2021)</ref>.


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" />.  
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.


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. 
== Etiology ==
[[File:Diabetes-528678 960 720.jpg|right|frameless]]
Peripheral artery disease is usually caused by atherosclerosis. Other causes may be inflammation of the blood vessels, injury, or radiation exposure.<ref name=":1" />  


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>  
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" />


'''[[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>
== History and Presentation ==
The most characteristic symptom of PAD is claudication which is a pain in the lower extremity muscles brought on by walking and relieved with rest.


'''Age -&nbsp;'''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" />.  
* Although claudication has traditionally been described as cramping pain, some patients report leg fatigue, weakness, pressure, or aching. 
* Symptoms during walking occur in the muscle group one level distal to the artery narrowed or blocked by PAD. eg Patients with aortoiliac artery occlusive disease have symptoms in the thigh and buttock muscles, patients with femoropopliteal PAD have symptoms in their calf muscles.  
* Some patients with mild or moderate PAD rarely sustain a walking pace that increases the blood flow requirement of the lower extremity muscles. By being physically inactive, these patients avoid the supply-demand mismatch that triggers claudication symptoms.
* Other patients with PAD have muscle discomfort when they walk but fail to report these symptoms because they attribute them to the natural consequences of aging.  


'''Gender -'''  TASC II guidelines conclude that men are affected at a younger age than women. However, overall there is no clear distinction in risk.  
Patients with severe PAD can develop ischemic rest pain.  


'''Hypertension -&nbsp;'''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" />.  
* These patients do not walk enough to claudicate because of their severe disease.  
* They complain of burning pain in the soles of their feet that is worse at night. They cannot sleep due to the pain and often dangle their lower leg over the side of the bed in an attempt to relieve their discomfort. The slight increase in blood flow due to gravity temporarily diminishes the otherwise intractable pain.  


'''Dyslipidemia -&nbsp;'''Developing PAD by 10% for every 10-mg/dL rise in total cholesterol<ref name="Mahameed" />. <br>
=== Clinical Manifestations ===
[[File:Arterial ulcer peripheral vascular disease.jpeg|right|frameless]]Image: A 71-year-old diabetic male smoker with severe peripheral arterial disease presented with a dorsal foot ulceration (2.5 cm X 2.4cm) that had been chronically open for nearly 2 years.


== Prognosis  ==
* Non-healing wounds on legs or feet
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>


== Symptoms  ==
* Unexplained leg pain
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. 
*Pain on walking that resolves when stopped
*Pain in foot at rest made which worsens with elevation
*[[Chronic Leg Ulcers|Ulcers]]
*Gangrene
*Dry skin
*Cramping
*Aching<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>


== Investigations  ==
== Evaluation ==
Making the diagnosis of PAD should factor in the patient’s history, physical exam, and objective test results. Key points in the history include an accurate assessment of:


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<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" />.
* Patient’s walking ability<ref name=":1" />. For Objective Measures  see below, under physiotherapy
* [[File:Ankle-brachail index.png|right|frameless]]On physical exam, patients with PAD may have diminished or absent lower extremity pulses. This finding can be confirmed with the [[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> 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" />.


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, Thrombophillia screen in patients less than 50 years old. <br>  
* Other investigations include:
** Doppler US: initial investigation; assess flow and atherosclerotic plaque
** Angiography (CT, MR, DSA): direct imaging of the vessels and runoff.<ref name=":0" />


== Clinical Manifestations  ==
== Management ==
[[File:Dementia Walking Picture.jpg|right|frameless]]
Management strategies for PAD attempt to achieve two distinct goals: lower cardiovascular risk and improve walking ability. All patients with PAD, regardless of the presence or absence of symptoms, have an increased risk of stroke, myocardial infarction, and thrombosis compared to patients without arterial disease. These cardiovascular events probably account for the shorter life expectancy of patients with PAD. Therefore, all patients diagnosed with PAD should undertake lifestyle changes aimed at lowering their cardiovascular risk profile. Key targets for lifestyle changes include quitting smoking, lowering cholesterol, and controlling hypertension and diabetes.


According to NICE:<ref name="NICE" /><br>
Other treatment involves:


*non-healing wounds on legs or feet
Medical therapy: involves the use of cilostazol, a medication that promotes vasodilation and suppresses the proliferation of vascular smooth muscle cells; the use of statins to improve the atherosclerotic disease; [[Pharmacological Management of Hypertension|antihypertensives]].<ref name=":1" /><ref name=":0" />
*unexplained leg pain
[[File:3D Medical Animation Vascular Bypass Grafting.jpeg|right|frameless]]
*pain on walking that resolves when stopped
Revascularisation
*pain in foot at rest made which worsens with elevation
*ulcers
*gangrene
*dry skin
*cramping
*aching


== Medical Management ==
* Balloon angioplasty or stent placement provides a minimally invasive, percutaneous treatment option for patients with PAD symptoms that do not respond to exercise or medical therapy
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.<ref name=":2">National Institute for Health and Care Excellence. Cardiovascular disease: risk assessment and reduction, including lipid modification (clinical guideline CG181). 2017</ref> These include;
* Surgical options for PAD include bypass grafts to divert flow around the blockage or endarterectomy to segmentally remove the obstructive plaque.<ref name=":1" />
* '''Risk Factor Modification'''
** <u>''Smoking cessation therapy''</u> - Patients with PAD that continue to smoke persistently have worse outcomes. 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.<ref>Lassila R, Lepäntalo M. Cigarette smoking and the outcome after lower limb arterial surgery. Acta chirurgica Scandinavica. 1988;154(11-12):635-40.</ref> 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.<ref>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.</ref> Cessation of smoking may help in preventing further declines in symptoms.
** <u>''HBA1C control  (target value <48 mmol/mol)''</u> - 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.<ref>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.</ref> NICE recommend reaching a target HBA1C level of <48 mmol/mol for all patients with diabetes. <ref name=":2" />
** <u>''Blood pressure control (target value  <140/90 mm Hg- for patients <80 years old)''</u> - Management of hypertension lowers a patients cardiovascular risk. Ramipril is recommended as first line therapy in guidelines worldwide.<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>
** <u>''Clopidogrel (or aspirin) 75 mg lifelong''</u> - 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.<ref>National Institute for Health and Care Excellence. Clinical knowledge summaries: Peripheral arterial disease. 2015</ref> When clopidogrel is contraindicated, aspirin is an acceptable alternative. Warfarin is most commonly reserved for patients with limb ischaemia due to arterial emboli.
** <u>''Atorvastatin lifelong''</u> - 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%. <ref name=":2" />
* '''Symptom control'''
** <u>''Supervised exercise therapy for 3 months''</u> - NICE recommends that a supervised exercise programme is offered to all patients where applicable consisting of 2hrs a week for a 3month period. <ref name=":2" /> 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.


=== Management ===
=== Physiotherapy Management ===
One method of treating PAD is to reduce cardiovascular risk factors by quitting smoking, managing diabetes mellitus, treating dyslipidemia and hypertension <ref name="Mahameed" />. Another method is to treat PAD symptoms to improve quality of life through pharmacotherapy, exercise rehabilitation program, revascularization, thrombolysis and surgical procedures <ref name="Mahameed" />.  
The least invasive and most appropriate treatment for PAD conducted by Physiotherapists would be by prescribing an exercise program.  Exercise therapy involves walking until reaching pain tolerance, stopping for a brief rest, and walking again as soon as the pain resolves. These walking sessions should last 30 to 45 minutes, 3 to 4 times per week for at least 12 weeks. Despite being more effective, supervised exercise programs for PAD are not usually covered by insurance companies[[File:Treadmill walk.jpg|right|frameless]]
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.


=== Physiotherapy ===
* Lower extremity resistance training can improve treadmill walking performance in PAD, but is not as effective as supervised treadmill exercise.<ref>McDermott MM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5831500/ 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)</ref>
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.
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'''
# Modality Supervised Treadmill Walking
# Intensity 40%–60% maximal workload based on baseline treadmill test or workload that brings on claudication within 3–5 min during a 6-MWT
# Session duration 30–50 min of intermittent exercise; goal is to accumulate at least 30 min of walking exercise
# Claudication intensity Moderate to moderate/severe claudication as tolerated
# 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)
# Frequency 3 times per week supervised
# Program duration At least 12 wk
# 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
# 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. <ref>Diane Treat-Jacobson, Mary M. McDermott, Ulf G. Bronas et al.[https://ahajournals.org/doi/10.1161/CIR.0000000000000623 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)</ref>


Supervised exercise programs have proved to be have better results that 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."<ref>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)[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6513337/]</ref>
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<ref>W Dziubek, M Stefańska, K Bulińska, K Barska [https://pubmed.ncbi.nlm.nih.gov/32878323/ Journal of Clinical …, 2020 - mdpi.com]Effects of Physical Rehabilitation on Spatiotemporal Gait Parameters and Ground Reaction Forces of Patients with Intermittent Claudication
</ref>.


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."<ref>Aherne T, McHugh S, Kheirelseid EA, Lee MJ, McCaffrey N, Moneley D, Leahy AL, Naughton P. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4639651/ 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)</ref>
== Outcome Measures ==
* [[Six Minute Walk Test / 6 Minute Walk Test|6 Minute Walk Test (MWT)]]
* [[Timed Up and Go Test (TUG)|Timed Up and Go Test (TUG)]]
* EQ-5D
* Incremental shuttle walk test (ISWT)<ref>Dixit S, Chakravarthy K, Reddy RS, Tedla JS. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513323/ Comparison of two walk tests in determining the claudication distance in patients suffering from peripheral arterial occlusive disease.] Advanced biomedical research. 2015;4.Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513323/<nowiki/>(accessed 6.6.2021)</ref>


=== Prevention ===
== Prevention ==
According to Warren<ref name="Warren" /> 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.<br>
According to Warren<ref name="Warren">Warren, E. Ten things the practice nurse can do about peripheral arterial disease. Practice Nurse 2013; 43; 12: 14-18.</ref> 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.


== Resources  ==
== Prognosis ==
Even with treatment, the prognosis of PAD is generally guarded. If the patient does not change his/her lifestyle, the disease is progressive. In addition, most patients with PAD also have coexistence of cerebrovascular or coronary artery disease, which also increases the mortality rate. The outcomes in women tend to be worse than in men, chiefly because of the small diameter of the arteries. In addition, females are more likely to develop complications and embolic events.<ref name=":1" />


[http://www.nhs.uk/conditions/peripheralarterialdisease/Pages/Introduction.aspx Peripheral Vascular Disease], NHS Choices
== Conclusions ==
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.


[http://www.circulationfoundation.org.uk/help-advice/peripheral-arterial-disease/ Peripheral Arterial Disease], Circulation Foundation&nbsp;
* 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.<ref name=":3">Newsroom. [https://newsroom.heart.org/news/x-new-peripheral-artery-disease-guidelines-emphasize-medical-therapy-and-structured-exercise 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)</ref>


[http://www.mayoclinic.org/diseases-conditions/peripheral-artery-disease/basics/definition/con-20028731 Peripheral Artery Disease,] Mayo Clinic <div class="researchbox"> </div>
== References  ==
== References  ==


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[[Category:Conditions - Cardiovascular Disease]]
[[Category:Conditions]]
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Latest revision as of 16:01, 14 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]

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

[3]

Epidemiology[edit | edit source]

Smoking-1026556 960 720-2.jpg

Prevalence: 12-14%, 20% of the over 70s in Western populations[4].

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]

Diabetes-528678 960 720.jpg

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]

History and Presentation[edit | edit source]

The most characteristic symptom of PAD is claudication which is a pain in the lower extremity muscles brought on by walking and relieved with rest.

  • Although claudication has traditionally been described as cramping pain, some patients report leg fatigue, weakness, pressure, or aching.
  • Symptoms during walking occur in the muscle group one level distal to the artery narrowed or blocked by PAD. eg Patients with aortoiliac artery occlusive disease have symptoms in the thigh and buttock muscles, patients with femoropopliteal PAD have symptoms in their calf muscles.
  • Some patients with mild or moderate PAD rarely sustain a walking pace that increases the blood flow requirement of the lower extremity muscles. By being physically inactive, these patients avoid the supply-demand mismatch that triggers claudication symptoms.
  • Other patients with PAD have muscle discomfort when they walk but fail to report these symptoms because they attribute them to the natural consequences of aging.

Patients with severe PAD can develop ischemic rest pain.

  • These patients do not walk enough to claudicate because of their severe disease.
  • They complain of burning pain in the soles of their feet that is worse at night. They cannot sleep due to the pain and often dangle their lower leg over the side of the bed in an attempt to relieve their discomfort. The slight increase in blood flow due to gravity temporarily diminishes the otherwise intractable pain.

Clinical Manifestations[edit | edit source]

Arterial ulcer peripheral vascular disease.jpeg

Image: A 71-year-old diabetic male smoker with severe peripheral arterial disease presented with a dorsal foot ulceration (2.5 cm X 2.4cm) that had been chronically open for nearly 2 years.

  • 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[5]

Evaluation[edit | edit source]

Making the diagnosis of PAD should factor in the patient’s history, physical exam, and objective test results. Key points in the history include an accurate assessment of:

  • Patient’s walking ability[2]. For Objective Measures see below, under physiotherapy
  • Ankle-brachail index.png
    On physical exam, patients with PAD may have diminished or absent lower extremity pulses. This finding can be confirmed with the 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.[6] 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[6]. When measuring for ABI, make sure the patient is calm and in a rested position [5].
  • Other investigations include:
    • Doppler US: initial investigation; assess flow and atherosclerotic plaque
    • Angiography (CT, MR, DSA): direct imaging of the vessels and runoff.[4]

Management[edit | edit source]

Dementia Walking Picture.jpg

Management strategies for PAD attempt to achieve two distinct goals: lower cardiovascular risk and improve walking ability. All patients with PAD, regardless of the presence or absence of symptoms, have an increased risk of stroke, myocardial infarction, and thrombosis compared to patients without arterial disease. These cardiovascular events probably account for the shorter life expectancy of patients with PAD. Therefore, all patients diagnosed with PAD should undertake lifestyle changes aimed at lowering their cardiovascular risk profile. Key targets for lifestyle changes include quitting smoking, lowering cholesterol, and controlling hypertension and diabetes.

Other treatment involves:

Medical therapy: involves the use of cilostazol, a medication that promotes vasodilation and suppresses the proliferation of vascular smooth muscle cells; the use of statins to improve the atherosclerotic disease; antihypertensives.[2][4]

3D Medical Animation Vascular Bypass Grafting.jpeg

Revascularisation

  • Balloon angioplasty or stent placement provides a minimally invasive, percutaneous treatment option for patients with PAD symptoms that do not respond to exercise or medical therapy
  • Surgical options for PAD include bypass grafts to divert flow around the blockage or endarterectomy to segmentally remove the obstructive plaque.[2]

Physiotherapy Management[edit | edit source]

The least invasive and most appropriate treatment for PAD conducted by Physiotherapists would be by prescribing an exercise program. Exercise therapy involves walking until reaching pain tolerance, stopping for a brief rest, and walking again as soon as the pain resolves. These walking sessions should last 30 to 45 minutes, 3 to 4 times per week for at least 12 weeks. Despite being more effective, supervised exercise programs for PAD are not usually covered by insurance companies

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.[7]

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

  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. [8]

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[9].

Outcome Measures[edit | edit source]

Prevention[edit | edit source]

According to Warren[11] 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.

Prognosis[edit | edit source]

Even with treatment, the prognosis of PAD is generally guarded. If the patient does not change his/her lifestyle, the disease is progressive. In addition, most patients with PAD also have coexistence of cerebrovascular or coronary artery disease, which also increases the mortality rate. The outcomes in women tend to be worse than in men, chiefly because of the small diameter of the arteries. In addition, females are more likely to develop complications and embolic events.[2]

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.[12]

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 2.3 2.4 2.5 2.6 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. ↑ American Heart Association PAD What is it? Available from: https://www.youtube.com/watch?v=XTSgpiPqIbk (last accessed 7.9.2019)
  4. ↑ 4.0 4.1 4.2 Radiopedia PAD Available:https://www.ncbi.nlm.nih.gov/books/NBK430745/ (accessed 6.6.2021)
  5. ↑ 5.0 5.1 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)
  6. ↑ 6.0 6.1 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
  7. ↑ 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)
  8. ↑ 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)
  9. ↑ 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
  10. ↑ Dixit S, Chakravarthy K, Reddy RS, Tedla JS. Comparison of two walk tests in determining the claudication distance in patients suffering from peripheral arterial occlusive disease. Advanced biomedical research. 2015;4.Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513323/(accessed 6.6.2021)
  11. ↑ Warren, E. Ten things the practice nurse can do about peripheral arterial disease. Practice Nurse 2013; 43; 12: 14-18.
  12. ↑ 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)
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