Peripheral%20arterial%20disease Patient Education

• Patient should be educated about PAD
• Explain to the patient the therapeutic goals of PAD
  • The importance of risk factor modification, how healthy diet and 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 CLTI and amputation (<1% per year)

Smoking Cessation

• Smoking is the most important and strongest risk factor with regards to the etiology and clinical progression of PAD
  • The amount and duration of tobacco use correlate directly with the development and progression of PAD
  • Continued smoking in patients with IC is associated with a higher risk of developing disabling claudication, CLTI, amputation, need for surgical intervention, MI and death
  • Patient should be made aware that 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
    • Supervised vascular workout ≥3x/week for ≥30 minutes over ≥3 months is recommended
• 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