Introduction[edit | edit source] Show
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]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]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.
Patients with severe PAD can develop ischemic rest pain.
Clinical Manifestations[edit | edit source]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.
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:
Management[edit | edit source]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] Revascularisation
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 A 2018 review of the best exercise prescription for PAD summarised their findings thus
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
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
References[edit | edit source]
How do you assess for peripheral artery disease?Diagnostic tests and procedures. The ankle-brachial index (ABI) test is usually the first test used to diagnose PAD. The test compares blood pressure in your ankle with the blood pressure in your arm. Your provider uses a blood pressure cuff and ultrasound device for this painless test.
Which of the following are risk factors for peripheral artery disease?What are the risk factors for PAD?. Smoking.. High blood pressure.. Atherosclerosis.. Diabetes.. High cholesterol.. Age above 60 years.. What should you inspect when assessing the peripheral vascular system?Feel temperature along the legs.. Capillary refill.. Feel the distal pulses. Femoral. Popliteal. Dorsalis pedis. Posterior tibial.. Check the sensation in the lower limbs. Soft touch sensation, working distal to proximal.. What are the 5 P's of peripheral vascular disease?Acute limb ischemia presents more abruptly with onset of the “5 P's”: pain, paralysis, pallor, paresthesia, and pulselessness.
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