Peripheral Arterial Disease Awareness Month 2023-2024 Edition.

Why is it crucial to check for peripheral arterial disease?
Failure to recognize the signs of PAD will cause a significantly higher risk of cardiovascular disease, which otherwise goes undetected. It is important to identify patients at risk of PAD or cardiovascular disease because everyone should reduce cardiovascular risk factors.

• Social media posts
• PVD Awareness Month handheld sign—encouraging doctors who are helping patients save their limbs every day to take a photo using a handheld “I saved a limb today!” sign
• Lawmaker one-pager
• White Socks Campaign!

In a study published by the Atherosclerosis Journal 10, it was found that PAD patients with leg amputations on entry were five times more likely to have a subsequent amputation and had a nearly two times higher increase in rates of cardiovascular death (and all-cause mortality) and an increase in the composite outcome of MI, stroke, cardiovascular death, or hospitalization. The study also found that critical limb ischemia (CLI) is associated with a 1-year mortality rate of 20% and a 1-year limb loss rate of 20%

However, we can’t find what we aren’t looking for. That is why I am on a mission to educate health care providers and the community at large about the early signs of vascular disease, Anuj Shah

What are the treatments for peripheral artery disease?
Dr. Shah devises customized treatment plans and offers a range of effective treatments for PAD, including:

• Medications
• Physical rehabilitation
• Supervised walking therapy
• Lifestyle changes, such as diet and exercise
• Minimally invasive procedures to open blockages when necessary

Dr. Shah first assesses your condition based on your symptoms, medical and family history, and other factors. He typically begins with lifestyle approaches, such as diet and exercise, and utilizes other treatments when needed. A healthy lifestyle with stress-relief, regular exercise, and a nutrient-dense diet can aid in the management and prevention of PAD.

Although PAD and amputation are not highly publicized medical issues, they are life-threatening and a leading cause of mortality, especially among those with diabetes. When we look at mortality rates, the only thing with a worse mortality rate than amputation over five years is stage 4 lung cancer.

“Five-year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer” 1 published in the Journal of Foot and Ankle Research.

According to the National Heart, Lung, and Blood Institute (NLBI) 2, 18 million individuals in the United States are afflicted with some form of peripheral arterial disease (PAD).

PAD Misconception #2: Peripheral arterial disease only impacts the elderly.
Peripheral Arterial Disease becomes more apparent as people age, but precursors of atherosclerosis are present from a young age. In the Framingham Heart Study 6 they looked at the top peripheral arterial disease risk factors. They found that every 40-milligram increase in LDL, your odds ratio was 1.2, which means there is a 20% higher risk of getting peripheral arterial disease. For every ten cigarette smokes per day, your risk of PAD went up 40%. For mild diabetes, the odds ratio was 1.5 and for mild hypertension, it was 1.5 moderate hypertension 2.2, and for diabetics it was 2.6.

A study derived from results of a National Health and Nutrition Examination 3 projected that the prevalence of PAD continues to grow with age. When people are in their 40’s to 60’s, we see about 1 million cases of PAD, but we see around 4 million cases of PAD of people in their 70’s to 80’s and it continues to grow.

A study by the New England Journal of Medicine in 1999 4, estimated that the number of people with PAD was eight to nine million and projected the number would continue to go up in the next decade with a number coming around 12 million in 2020.

A study published by Vascular Disease Management in 2016 5 found that we have already significantly surpassed that number and currently PAD prevalence is estimated at 18 million.

When we look at the independent factors of peripheral arterial disease, diabetes and smoking are the two biggest ones and the odds ratio is around four for diabetes. It’s almost a 400-fold increase in peripheral arterial disease.

PAD Misconception #3. Peripheral Arterial Disease is only a nuisance. It won’t kill you.
In the “Reduction of Atherothrombosis for Continued Health Registry” 7 The American College of Cardiology looked at major adverse PAD events, or what we call the major adverse PAD event (MACE), in three different populations: people who had documented coronary artery disease (CAD), people who had Cerebral vascular disease, and people who had peripheral arterial disease. In other words, somebody who already had a heart attack, somebody who already had a stroke, and somebody who had pre-existing peripheral arterial disease.

When we look at the various cardiovascular risks, cardiovascular death, non-fatal myocardial infarction, non-fatal stroke and stroke combination, or MACE, it’s consistently similar across the board and that’s why vascular specialists say peripheral arterial disease is CAD risk factor equivalent.

When a patient has PAD, the risk factor of future mortality and morbidity are significantly higher and there is also tremendous overlap. Patients that have coronary artery disease are oftentimes the same patients who have PAD, and they are the same people who end up suffering from a stroke.

In the study “Ten Year Mortality in Different Peripheral Arterial Disease Stages: A Population Based Observational Study on Outcome” 8 , it was found that over ten years, the all-cause mortality rate for PAD patients was 33.1%. The percent of deaths that were attributed to cardiovascular issues as the main cause of death was 35.6% and 15.8% of deaths cited cardiovascular issues as a contributing factor in the cause of death.

The study found that the risk of cardiovascular mortality was approximately twice as high for age adjusted PAD patients and the risk increases significantly as the patients progress through the stages of PAD (Asymptomatic PAD, Intermittent Claudication and severe Critical Limb Ischemia).

The history of peripheral arterial disease is very similar to coronary artery disease (CAD), where a patient has stable CAD and then develops acute coronary syndrome. Similarly, you have stable PAD (claudication), when people have pain when they walk, but it gets better when they stop walking, but the stable PAD later changes into critical limb ischemia (CLI).

If you look at claudication’s, which are “stable PAD patients,” the risks of non-fatal myocardial infarction (MI) and stroke is around 20%. This is a CAD risk factor equivalent and the death rate is 15 to 30%.

When people develop critical limb ischemia (CLI), which is a more vigorous form of peripheral arterial disease, the outcomes are abysmal.

PAD Misconception #4: Detection of Peripheral Arterial Disease is difficult.
Many patients will come in with symptoms including leg pain, so this is not entirely true. However, patients do often have atypical symptoms of PAD. The classic symptom of peripheral arterial disease is intermittent claudication. Claudication is when you start walking, you get an exertional calf pain, usually related to one muscle group, whether it’s in the gluteal region or the calf and it resolves within ten minutes of rest.

Unfortunately, less than one third of PAD patients have classic claudication symptoms. A majority of patients will have atypical leg pain symptoms, where the pain is not exertional leg pain, which is not just the calves, but other muscle groups. This pain may not even stop the patient from walking or fail to relieve with rest. There are many clinical variations of PAD symptoms. This is a large part of the problem as to why it becomes so difficult for primary care physicians and podiatrists to detect PAD.

When we look at the rate of foot exams in primary care offices, from my personal experience, I would estimate that less than 5% of the overall population gets their feet examined. Many cardiologists also routinely fail to get annual foot exams, so as a group we are not much better.

PAD Misconception #5: PAD does not impact every other organ and system in the body.
A PAD diagnosis completely changes people’s long-term prognosis. Atherosclerosis causes coronary artery disease and the same atherosclerosis can happen in all other vessels. Essentially, it all stems from the same vascular tree. When it happens in the cerebral system, it causes Transient Ischemic Attack (TIA) and ischemic stroke. In the heart, it causes myocardial infarction and unstable angina. In the kidney arteries, it causes renal artery stenosis, renovascular hypertension, and intestinal ischemia. Mesenteric ischemia comes from PAD. Erectile dysfunction often stems from PAD, either from Leriche syndrome (aortoiliac occlusive disease) or from potential arteries or internal iliac arteries with stenosis. Claudication, critical limb ischemia, gangrene and amputation are all systemic manifestation of atherosclerosis.

PAD Misconception #6: The health of one limb does not impact the health of the other limb.
What happens to one limb can directly impact what happens to the other limb. The level of amputation directly relates to the pressure you put on the contralateral limb. Many times, the people who have a transmetatarsal amputation (TMA) are the same people who will get a below-the-knee amputation (BKA) in that leg.

These are the same patients who will end up getting above knee amputation in their leg and the same people will get a contralateral limb amputation.

These patients will end up going to nursing homes, they will develop decubitus ulcers and they will catch infections. They will then have decubitus ulcers and will need a Foley catheter. They may also develop a urinary tract infection (UTI).

This creates a vicious cycle where patients come to the hospital and become susceptible to catching a hospital acquired infection. They then go back and their entire trajectory after one amputation will constantly change and thus the vicious cycle repeats.

PAD Misconception #7: PAD can only be detected by one type of medical specialist.
DYK: Less than one third of PAD patients will have classic symptoms?

I believe in a comprehensive approach to medical treatment that empowers physicians to screen and test for the symptoms of PAD. All doctors and medical professionals have an ethical responsibility to test for and detect PAD because it directly affects mortality and morbidity. As health care providers, we have great power, but great power comes with great responsibility.

There are medical and legal responsibilities when patients have peripheral arterial disease and it gets missed and unfortunately, somebody will ultimately end up getting an amputation as a result.

PAD is not difficult to screen for. The problem is that unfortunately, many physicians don’t screen for it at all. Oftentimes, a medical history and physical exam is all it takes. Sometimes, additional testing for PAD is required. We use the ankle-brachial index (ABI), which is one of the easiest ways of detecting peripheral arterial disease in an earlier setting.

We need to differentiate intermittent claudication or peripheral arterial disease from venous claudication and neurogenic claudication.

ABOUT DR. ANUJ R. SHAH

Dr. Shah is an interventional cardiologist and an endovascular specialist originally trained at Mt. Sinai. He has been in practice for 11 years and is passionate about the improvement of leg circulation and peripheral arterial disease. He is currently the Director of Apex Heart and Vascular and still has privileges at Mount Sinai as an assistant professor. He is a regional authority on peripheral arterial disease and critical limb ischemia and frequently is featured in the media and podcasts on diabetes management.

AMPUTATION PREVENTION RESOURCES AND ADDITIONAL READING ON PAD:

1. Five Year Mortality and Direct Costs of Care for People with Diabetic Foot Complications Are Comparable to Cancer
2. Facts About Peripheral Arterial Disease (PAD)
3. Prevalence of and Risk Factors for Peripheral Arterial Disease in the United States
4. Mortality over a Period of 10 Years in Patients with Peripheral Arterial Disease
5. Reducing Amputation Rates in Critical Limb Ischemia Patients Via a Limb Salvage Program
6. Framingham Heart Study
7. Reduction of Atherothrombosis for Continued Health Registry
8. Ten Year Mortality in Different Peripheral Arterial Disease Stages: A Population Based Observational Study on Outcome
9. High Mortality Risks After Major Lower Extremity Amputation in Medicare Patients with Peripheral Artery Disease
10. Fate of Individuals with Ischemic Amputations in the REACH Registry: Three-year Cardiovascular and Limb-related Outcomes
11. The Costs of Diabetic Foot: The Economic Case for the Limb Salvage Team
12. A Cost-Utility Analysis of Amputation versus Salvage
13. Limb Salvage Versus Amputation: A Closer Look At The Evidence, Costs And Long-Term Outcomes

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