Peripheral Arterial Disease

Kathy Sietsema, MD

This information was obtained at a lecture to the California Society of Pulmonary Rehabilitation (CSPR) by Kathy Sietsema, MD, Professor of Medicine at Harbor-UCLA Medical Center.

Peripheral arterial disease, (PAD), is included under the more general heading of peripheral vascular disease, or PVD. Plaques in the arteries of the legs decrease blood flow as the arteries become narrowed or blocked. This is the same disease process that causes heart attacks or angina when it affects the coronary arteries of the heart. So, why are we telling you about this? PAD is a disease of smokers with early symptoms that are often missed or ignored by patients and physicians. Like COPD, PAD symptoms creep up slowly over the years. There are approximately 10 million Americans with this diagnosis and probably many more who are not aware that they have this problem. While only 1% to 3% of those younger than 70 are afflicted, it rises to 10% for those over 70 years of age, with over 20% found if specific testing is done! 25% of those over 75 have PAD, though many are not diagnosed. This is a common disease that can be very serious since it is also a systemic disease. That is, it may be an indicator of future angina, heart attack, stroke, renal vascular hypertension or even erectile dysfunction. What should alert you to seek medical advice?

The first sign of PAD is intermittent claudication (IC). Claudication is characterized by pain or discomfort in the muscles of the legs brought on by exercise or walking and relieved by 2 to 5 minutes of rest. In addition to the usual symptoms of cramping pain in the calves after walking a block or so, there may be numbness, coldness, weakness, aching, or a fatigued feeling in the buttocks, hips, thighs, calves or even the feet.

A lot of folks ignore their symptoms, thinking it is due to aging. Others don’t walk enough to know that they have a problem! Does limb pain always mean that you have PAD? Of course not. There can be other causes, such as a herniated disk, arthritis, sciatica or run of the mill excessive exercise that your doctor would have to rule out. The important thing is that you seek help when you first have symptoms rather than waiting until the pain becomes constant, or the circulation so impaired that gangrene occurs!

The diagnosis is easy, inexpensive and takes about 10 minutes in your doctor’s office or in a specialized vascular laboratory. With a stethoscope, the physician can listen over the arteries for a diagnostic sound called a bruit (a “whooshing” sound with each heartbeat). With a blood pressure cuff and special device for listening (a Doppler probe), the doctor can measure the Ankle-Brachial Index, known as the ABI test. This measures the difference in the blood pressure between the arms (which are never affected) and the legs. About half of all people with abnormal tests are not yet aware of symptoms! An early diagnosis is a start in the right direction.

There are a number of risk factors that you can modify to help control your PAD as well as other atherosclerotic conditions. Number one is to STOP SMOKING! Smoking is absolutely the biggest risk factor! Elevated blood pressure, diabetes and high cholesterol all can be kept at a safe level with various methods including diet and medication. And speaking of diet, weight control to prevent obesity is also very important. Last, but certainly not the least of the risk factors, is a lack of exercise.

We now know that exercise is of great help for PAD! Because of the pain involved, it is almost impossible for an individual to get enough exercise in an unsupervised program. But several studies have shown that a supervised exercise program lasting at least 6 months can have a profound impact. The patient walks until approaching maximal pain, rests until the pain is gone, and then starts walking again. This walking program should be increased progressively up to 30 or 40 minutes a day for at least 3 days a week. The payoff for those who stick with it is improved walking ability with less pain.

Pain at night, constant pain and, of course, gangrene are all ominous symptoms. Surgery to bypass the blocked arteries is not usually effective treatment for most patients with claudication, but may be used in cases when it is needed to save a limb. In some cases, doing angioplasty (inflating a balloon inside the narrowed artery) or placing a stent (designed to hold the artery open) in the artery may be helpful. There are two medications on the market for the treatment of claudication, but the only one that really works is Pletal (Cilostazol). It is very effective in preventing claudication but, as you would expect, it is also expensive.

Harbor-UCLA in Torrance, CA is currently recruiting volunteers for a study of Type II diabetics with claudication. The contact number is (310) 222-2425. If you are interested but live in another area, try calling your local university to see if they have any studies for which you might be eligible. The take-home message from all of this information is to be aware of any symptoms of PAD that you might have, and to ask your doctor about a screening the next time you have an office visit. You can also watch the paper for free screenings at a health fair or your local hospital. But do be aware of these symptoms and seek help if you fit the profile of PAD or have the risk factors we listed earlier.