peripheral%20arterial%20disease
PERIPHERAL ARTERIAL DISEASE
Peripheral arterial disease includes a range of vascular syndromes caused by atherosclerosis and thromboembolic pathophysiological processes that alter the normal structure and function of the aorta, its visceral arterial branches and the arteries of the lower extremity.
Individuals at risk for lower extremity peripheral arterial disease should undergo review of vascular symptoms and comprehensive vascular examination to assess walking impairment, claudication, ischemic rest pain and/or the presence of nonhealing wounds.
Patients with peripheral arterial disease may be symptomatic or asymptomatic. Symptoms may range from claudication presenting as exertional leg pain to critical limb ischemia presenting as rest pain, ulceration or gangrene.

Patient Education

  • Patient should be educated about peripheral arterial disease (PAD)
  • Explain to the patient the therapeutic goals of PAD
    • The importance of risk factor modification, how exercise can improve symptoms and the goal to improve quality of life
    • Patients are more likely to participate in therapeutic and preventive measures if they have a full understanding of the potential benefits
  • Patient should be informed of the risk of death from coronary and cerebrovascular events (5-10% per year) is much higher than progression to critical limb ischemia (CLI) and amputation (<1% per year)

Lifestyle Modification

Assess Severity of Claudication

  • Treadmill exercise test
  • 6-minute walk test
    • For individuals not amenable to treadmill testing
  • Walking Impairment Questionnaire (WIQ)
    • Assess degree of walking impairment
  • Medical Outcomes Short Form 36 Questionnaire (SF-36)
    • Assess improvements in physical function, vitality, and quality of life

Smoking Cessation

  • Smoking is the most important and strongest risk factor in regards to the etiology and clinical progression of peripheral arterial disease (PAD)
    • The amount and duration of tobacco use correlate directly with the development and progression of PAD
    • Continued smoking in patients with intermittent claudication (IC) is associated with a higher risk of developing disabling claudication, critical limb ischemia (CLI), amputation, need for surgical intervention, myocardial infarction (MI) and death
    • Patient should be made aware that cardiovascular (CV) benefits of smoking cessation accrue almost immediately
  • Primary goal: Complete smoking cessation
    • Smoking cessation increases long-term survival in patients
  • Assess patient’s tobacco use and strongly urge patient and family to stop smoking
    • Inquire about the status of tobacco use in patients who are smokers or former smokers at every visit
  • Determine the patient’s degree of addiction and readiness to quit smoking
    • Identify patients who are willing to quit
    • Smoking cessation interventions such as pharmacological therapy (eg Nicotine replacement, Bupropion, Varenicline), counseling, and behavioral modification therapy should be offered
    • Varenicline, a nicotinic receptor partial agonist, has showed superior quit rates compared with Nicotine replacement and Bupropion
      • Patients on Varenicline have decreased craving and withdrawal symptoms
      • However, it was also noted that both Bupropion and Varenicline were associated with changes in behavior

Weight Management

  • Weight of patient may be directly related to claudication distance
    • Overweight patients with IC benefit directly from losing weight by increasing claudication distance
  • Goal body mass index (BMI) for Asian adults is 18.5-22.9 kg/m2
  • Goal BMI for European adults is 18.5-24.9 kg/m2

Supervised Exercise Program

  • Exercise is the most effective treatment for PAD
    • Recommended as a primary efficacious treatment modality to alleviate claudication symptoms for all patients with IC
  • Also a treatment option for patients with claudication prior to possible revascularization  
  • Regular walking results in an increase in the speed, distance, and duration walked, with decreased symptoms at each workload or distance
    • Exercise also improves maximal treadmill walking distance, quality of life, and community-based functional capacity
  • Exercise programs can range from physician recommending unsupervised program to formal supervised treadmill programs
    • The best results are attained by motivated patients in a supervised setting
  • Non-supervised exercise therapy is indicated when supervised exercise program is not feasible or available
    • Unsupervised training may be more effective than no training at all
    • Unsupervised patients should be given detailed instructions prior to exercise initiation
  • Exercise recommendations:
    • Treadmill and track walking the most effective exercise for claudication
    • Initial treadmill workload is set to a speed and grade that elicit claudication symptoms within 3-5 minutes
    • Patients walk at certain workload until they achieve claudication of moderate severity which is followed by a brief period of rest (standing or sitting) until symptoms resolve
    • Warm-up and cool-down period of 5-10 minutes each is recommended
    • Exercise-rest-exercise pattern is repeated throughout the session which initially lasts for 35 minutes then increased by 5 minutes each session until 50 minutes of intermittent walking is achieved
    • Perform exercise 30-45 minutes/session 3-5 times per week for a minimum of 12 weeks 
    • Alternative exercise strategies which can improve functional status and walking ability in patients with claudication include cycling, upper-body ergometry and low-intensity or pain-free walking that prevents moderate to maximum claudication while walking 
  • Exercise-induced clinical benefits have been observed as early 4 weeks andcontinue to improve after 6 months of participation 
  • Daily exercise improves limb ischemic symptoms, blood pressure, lipid profile, and glycemic control
  • Follow-up should include periodic assessment of CV risk factors, limb symptoms and functional status in patients with PAD
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