HealthPeripheral Arterial Disease: Recognizing the Importance of PAD Awareness Month

Peripheral Arterial Disease: Recognizing the Importance of PAD Awareness Month

Each September, the UK recognizes Peripheral Arterial Disease (PAD) Awareness Month. The vascular community is given the opportunity to highlight the facts of PAD and stress the significance of early detection and the need for improved therapy for the disease. This year, the global vascular community will be making a united effort to raise awareness of the often under-diagnosed and under-treated disease – Peripheral Artery Disease (PAD). “The public and healthcare community are not fully aware of the impact of PAD as a major health problem. Recognizing September as the month to raise awareness of PAD will put a spotlight on this disease and its consequences. It’s time for us to improve the care of PAD patients,” says Dr. Alan T. Hirsch, 2007 campaign chair and Chairman of the Minnesota Vascular Institute. During the month, the campaign will promote the LEGS acronym: Learn the facts about PAD, Evaluate your risk, Get tested and Seek treatment. The campaign materials will encourage patients to learn about risk factors and symptoms associated with PAD, and to seek care from a vascular specialist.

Understanding Peripheral Arterial Disease (PAD)

Why people get atherosclerosis is not entirely known. However, there are certain factors which can accelerate the process. These factors, called “risk factors”, have been shown by extensive research to increase the chances of developing atherosclerosis, both in the arteries of the heart and of the legs. Some risk factors are called “non-modifiable” risk factors because they cannot be changed. The most common non-modifiable risk factor for PAD is increasing age. It is estimated that 15-20% of those over 70 years have PAD. PAD is more common in men than in women and in those of Asian origin. This contrasts to coronary artery disease, which is more common in white people. High hereditary cholesterol is another non-modifiable risk factor for PAD. This is not cholesterol eaten in food, but a high level of cholesterol which is carried in the blood. This genetic condition, called familial hypercholesterolemia, leads to cholesterol deposition in artery walls and heart disease at an early age. In the context of PAD, atherosclerosis can begin in the 20s or 30s. Another two very important non-modifiable risk factors for PAD are diabetes and having existing cardiovascular disease. People with diabetes have a much higher prevalence of PAD because the high blood sugar levels cause damage to the artery walls and to the nerves which control blood flow. High blood pressure and smoking are examples of “modifiable” risk factors for PAD, in that treatment to control these conditions can reduce the risk of developing atherosclerosis. High blood pressure causes the artery walls to thicken and harden, leading to a narrowing of the arteries. This process increases the strain on the heart in order to maintain a sufficient blood supply to the body. High blood pressure is an important risk factor for atherosclerosis throughout the body’s arteries. Smokers are two to five times more likely to develop PAD than non-smokers. This is because some of the chemicals in cigarettes can damage the lining of the arteries and increase the likelihood of cholesterol deposition. Step by step, evidence of the effect of these chemicals has been found. Former smokers can reduce their risk of PAD to that of a non-smoker after 10 years of quitting. Cessation of smoking should be strongly advised to those with or at risk of developing PAD.

2.1 Risk factors for PAD

Peripheral arterial disease, which is often shortened to PAD, is a condition in which the arteries leading to the legs, feet, and in some cases, the arms become clogged by fatty deposits, or “plaques”. This occurs in a similar way to the process of coronary heart disease. The plaques are made up of cholesterol, calcium, and fibrous tissue. They build up on the artery walls and narrow the arteries, reducing the blood flow to the muscles. This diminishes the oxygen supply to the legs and impairs the leg muscles’ capacity to oxidize fats during exercise. This process, which can take many years to develop, is called atherosclerosis. PAD often goes unrecognized as the symptoms can be mistaken for those of aging. PAD develops almost exclusively in those who have smoked, or have diabetes, or have existing cardiovascular disease. It is uncommon in those under the age of 50 years with the exception of diabetic patients where the incidence is increased in those over 40 years of age.

  1. Understanding Peripheral Arterial Disease (PAD)

Risk factors for PAD

Diabetes is also a strong risk factor for PAD. The high blood sugar levels over time damage your arteries and the small blood vessels in your extremities. This damage can cause decreased blood flow and may raise the risk of those with diabetes developing PAD but not experiencing typical leg pain symptoms. High blood pressure is a factor as well. Not only can high blood pressure contribute to the atherosclerotic process, it accelerates the damage to the blood vessel lining. This can cause the formation of scar tissue within the artery and raise the risk of a blood clot. People with PAD often have a build-up of fatty deposits in the arteries, a condition called atherosclerosis. This is not localized only to the arteries in the legs. The atherosclerotic process in arteries in other places of the body can cause other health problems. Since PAD is the narrowing of arteries reducing leg circulation, just like other types of heart disease, heart attack is a high-risk factor for those with PAD. Family history of PAD, heart disease, or stroke is also a risk factor. If a close relative has or had the disease, your risk for PAD increases. Though risk factors significantly increase your chance of developing PAD, it’s possible to have this disease and have none of the symptoms.

Healthy blood vessels are flexible, strong, and elastic. They widen and narrow as needed to keep blood flowing at the proper rate. But several things can injure a blood vessel and set the stage for plaque buildup. The leading risk factor for PAD is smoking. Smoking can more than double your risk of PAD. People who smoke have the greatest risk of developing PAD. Dietary habits and patterns also play a significant role in the development of PAD. A diet that is high in saturated and trans fat can raise your LDL cholesterol. An elevated LDL cholesterol level is a major risk factor for PAD and is also directly related to the amount of trans and saturated fat you eat. High cholesterol and PAD have a direct link.

Symptoms and complications of PAD

Complications of PAD can be very serious and even life-threatening. The same process that causes narrowing and blockages in the arteries in the legs is also taking place in the coronary and carotid arteries. This increases the chances of PAD patients to have heart attacks, strokes, transient ischemic attacks, and aneurysms. In the legs, critical limb ischemia can develop, which is a severe blockage in the arteries that results in ulcers and sores that do not heal. This increases the risk of infection in the limb, and if left untreated, can progress to gangrene. In extreme cases, this may necessitate amputation of the affected limb.

In severe cases, when the blood flow to a limb is greatly decreased, there can be symptoms of pain at rest or at night in bed, and/or the presence of nonhealing sores on the feet or legs.

Symptoms of PAD tend to develop gradually and often are dismissed as a part of aging. Most common symptoms include: 1. Leg pain that occurs when walking or exercising and is relieved by rest. Many people complain of muscle pain or cramping, the severity of which can range from mild to severe. 2. Numbness, tingling, or weakness in the lower legs or feet. 3. Sores or infections on your feet or legs that heal slowly.

PAD Awareness Month: Why it Matters

PAD Awareness Month is an important time of year for people at risk for PAD, their families, and friends to take the opportunity to learn more about the disease. Because PAD can have a significant impact on quality of life and is associated with poor cardiovascular outcomes, it is important for individuals to understand their risk and take steps to prevent PAD, diagnose and treat it as early as possible. Unfortunately, despite being a common and impactful disease, public awareness and understanding of PAD is low. For example, a national survey of 2,500 Americans over 50 years of age showed that although 12 million Americans are known to suffer from PAD, only 20% were familiar with the disease. Awareness among ethnic minorities is even lower with only 15% of African Americans and 11% of Hispanics being familiar with PAD. Low awareness coupled with the fact that the symptoms of PAD are often dismissed as normal signs of aging makes it highly likely that many individuals currently suffering from PAD are doing so without a clear understanding of their symptoms and at risk to their long-term health. These are the individuals that we would most like to reach during PAD Awareness Month.

Importance of raising awareness about PAD

Mass media efforts can improve public awareness about PAD. There are many opportunities to educate the public about PAD and its prevention. National and local public health education campaigns can be very effective in reaching people at risk for PAD and its associated cardiovascular diseases. PAD awareness efforts can be coordinated with other cardiovascular disease prevention programs, as PAD shares many risk factors and disease pathways with coronary artery disease and cerebrovascular disease. Successful public education about PAD will lead to early detection of the disease in higher risk patients. A simple test such as measuring the ankle brachial index can diagnose PAD in its earliest stages, and detecting PAD before the onset of disabling symptoms can lead to implementation of evidence-based medical therapies that can prevent heart attack, stroke, and loss of limb. Improved public awareness about the link between PAD and its associated cardiovascular diseases can empower patients with PAD to seek comprehensive care and encourage healthcare providers to recognize the systemic nature of the disease. PAD awareness can foster public and political will to support PAD research and treatment programs. A coordinated effort to improve public and healthcare provider awareness about PAD can ultimately reduce the global burden of PAD and its associated cardiovascular diseases.

Although the prevalence of peripheral artery disease is 10%–20% in the general population, general awareness of the disease, its risk factors, and its symptoms is low. PAD is a red flag. The presence of PAD is associated with an increased risk of heart attack and stroke. In fact, many patients with PAD have a heart attack or stroke as their first symptom of the disease. Up to 50% of patients with PAD have claudication, a painful cramping in the leg with exercise due to decreased blood flow. Claudication is a signal that atherosclerotic disease is widespread throughout the body, and patients with PAD and claudication are at increased risk for potentially disabling or fatal cardiovascular events. Approximately 10% of patients with claudication will progress to a severe limitation of physical activity and critical limb ischemia. Patients with critical limb ischemia do not have enough blood flow to the extremity to maintain metabolic demand. They often suffer from foot pain at rest that is frequently severe enough to disturb sleep and may require amputation of the ischemic limb. Atherosclerotic lower extremity amputations are an important cause of morbidity and mortality, as 30% of patients with diabetes and limb amputation do not survive 5 years. Yet, despite the high rate of adverse cardiovascular outcomes associated with PAD and its negative impact on quality of life, the public and many healthcare providers remain unaware of the consequences of the disease. PAD awareness among the general population is significantly lower than awareness of coronary and carotid artery disease.

Events and initiatives during PAD Awareness Month

Throughout September, Global Vascular Institute, its affiliates, and partners from the Vascular and Endovascular community come together to support a number of initiatives aimed at increasing understanding of PAD among the public and primary care health professionals. A number of initiatives focusing on public awareness of vascular disease and encouraging screenings among at-risk populations continue to be the main focus for those involved with the PAD Coalition. This year, GVI will continue its efforts with the “Love your Limbs?” campaign. This initiative encourages those with PAD to think about their quality of life and take an online assessment to determine their risk for limb amputation and receive information to help them take the next step in seeking treatment for their PAD. The results of this assessment can be utilized by the patient and a healthcare professional to take a more proactive approach to managing and/or treating PAD. Additionally, the results and data accumulated from this initiative can be used as a tool to help determine levels of public understanding about PAD and the risks for those suffering from the disease. This information is critical to the growth of the Love your Limbs? campaign and will help determine whether there is a change in public awareness and understanding of the risks of PAD over time.

Spreading knowledge and resources

Spreading knowledge and resources is crucial in enhancing the public perception of an illness. A little while back, not much was known about diabetes and heart disease, and they were not considered to be serious health risks. It was through public information and government-led initiatives that these diseases became more serious in the eyes of the public and are now two of the most well-known and researched health problems today. People diagnosed with PAD may feel that not much can be done or even that it is not a serious health risk. By making information readily available and educating the public, PAD can be taken more seriously and receive more attention from health professionals and researchers. This, in turn, will result in better quality care and a better understanding of the illness. Access to knowledge and the ability to manage one’s own health is key in treating and maintaining a productive lifestyle in those suffering from PAD. By placing knowledge in the hands of one’s health, they now have the ability to change for the better. Patients learning about PAD through educational events and their healthcare provider can now take more initiative in their health. With educational resources available at the PAD Coalition website, patients can access information about the illness, treatment options, strategies for improving claudication, and tips on how to stop the progression of PAD. This includes detailed descriptions of drug therapies and recommendations for cardiovascular risk management from the American Heart Association and the American College of Cardiology. The PAD Coalition also provides an online tool that helps patients determine their risk for a heart attack or stroke caused by blocked arteries in the legs.

Taking Action: Preventing and Managing PAD

Medications and surgeries can be used to treat symptoms or to attempt to improve walking distance; however, these treatments are only partially effective. They do not usually change the underlying disease and are not a substitute for lifestyle changes. More information about medical treatments for PAD can be found in section 4.2.

4.1 Lifestyle changes for PAD prevention The most effective way to treat PAD is to make lifestyle changes. This will lower your risk for heart attack and stroke as well as improving your symptoms and increasing your walking distance. The more severe your PAD, the more aggressive you will need to be in modifying your lifestyle.

By making suitable lifestyle changes, you can vastly reduce your risk for developing peripheral arterial disease. Additionally, if you already have PAD, these same lifestyle changes can be used to manage your disease, increase your walking distance, and ease the pain in your legs. There are a number of medical treatments and interventions that can be utilized to help treat the symptoms of PAD and improve walking distance. These range from medications to surgical procedures. It is important to discuss the suitability of these treatments with your healthcare professional.

Lifestyle changes for PAD prevention

The main lifestyle changes that are recommended for people with PAD are: Stopping smoking – smoking is strongly linked to the development of PAD and making a decision to stop is the most effective thing you can do to improve your symptoms and reduce the risk of them getting worse. Increasing your physical activity – this will improve your symptoms and lessen your chance of developing other CVD related problems. This may be through exercise therapy, which has been shown to improve walking ability and quality of life in people with PAD. If it’s hard for you to walk because of your PAD, you can still make small changes to increase your activity, such as using the stairs more often, and doing more around the house. Adopting a healthy diet – this can help to lower your cholesterol, blood pressure and risk of developing heart disease or having a stroke. A healthy diet is one that is low in saturated fat, trans fat, and cholesterol, and high in fruits, vegetables, and fibre. You should also try to reduce the amount of salt you eat to under 6g (0.2oz) a day.

PAD is a long-term condition caused by a build-up of fatty deposits in the walls of the arteries. Lifestyle changes are a key part of managing PAD. They can help you prevent the disease from getting worse. They can also reduce your risk of developing other health problems, such as heart attack and stroke, which are more likely to happen to people with PAD. Making lifestyle changes may be hard at first. It may help to know that taking these steps is as effective in reducing the risk of heart attack and stroke as it is in people who do not have PAD.

Medical treatments and interventions for PAD

  • Atherectomy – this is similar to angioplasty, but involves the removal of the atheromatous plaque from the artery by means of a specialized catheter. This is a newer and currently expensive procedure, but early results have been very promising.
  • Angioplasty – widely used for revascularization of the lower limbs, angioplasty is a minimally invasive endovascular procedure in which a blocked artery is dilated with the use of a balloon catheter. Though a common procedure for those with ischemic heart disease, the effectiveness of angioplasty for PAD has not been conclusively proven, and the risks and benefits should be weighed carefully.
  • Medications can be somewhat effective in the treatment of claudication. Trental (pentoxifylline) has been shown to improve symptoms. The effectiveness of cilostazol, a newer drug, is even better. More aggressive treatment of claudication usually begins with the intervention of a specialist. A vascular surgeon can offer a variety of treatments and the interventional cardiologist may also get involved. These treatments aim to improve symptoms and try to prevent progression of the disease. They do not cure the disease, but can be effective in preserving limb function.

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