What should a doctor recommend to patients with Peripheral Arterial Disease (PAD)

Peripheral arterial disease (PAD) is an insidious cardiovascular condition that often goes undiagnosed until it is already in a more advanced stage and starts exhibiting overt symptoms, and this happens all too often due to underutilisation of diagnostic methods. But, unlike many other cardiovascular diseases (CVDs), it can be successfully managed if it is diagnosed in a timely manner.

There were about than 202 million individuals with PAD in 2010, though today that number is likely higher – primarily due to rising prevalence of some risk factors, like ageing of population and diabetes [1]. Besides those two, there are others, like tobacco smoking and obesity – i.e. lifestyle factors that are within the patient’s control. But, as any doctor would attest, many have great difficulties curtailing their nicotine addiction and maintaining a healthy weight (particularly if that involves physical activity), unless they are confronted with the gravest outcomes for their life and well-being.

Unfortunately, when it comes to that, it can already be too late for an effective (conservative) treatment. Diagnosis of PAD as such carries with it a significantly greater risk of mortality (from all causes): the 5-year mortality rate (from the date of diagnosis) is in the ballpark of 30% (versus 10% for the control group) and about 75% of those deaths are of cardiovascular nature [2].

That should come as no surprise since PAD, more specifically the ABI (Ankle-Brachial Index) score (the best diagnostic method for PAD) is recognised as an important indicator of overall cardiovascular health and can improve the accuracy of cardiovascular risk prediction beyond the FRS (Framingham risk score) [3]. There are many more statistics that physicians can use for stressing the importance of recommendations for their PAD patients.

6 tips for patients with Peripheral Arterial Disease (PAD)

Timely diagnosis of PAD on the basis of ABI score (or through other diagnostic methods) is the first prerequisite for effective management and treatment. Managing risk factors post more invasive treatment such as revascularisation is also beneficial, but of course less desirable than preventing or at least reducing the risk of serious complications of PAD (arterial wounds, critical limb ischaemia and amputations). Some of the risk factors are non-modifiable and are not extensively covered in this article, while the modifiable ones can be found below in a list of recommendations every physician can consult when dealing with a patient with (diagnosed) PAD.

List of recommendations for patients with Peripheral Arterial Disease (PAD)

• Smoking cessation. Physicians should warn patients who smoke that tobacco is the leading modifiable risk factor for not only PAD, but also other CVDs, like coronary artery disease (CAD) – the biggest killer amongst all diseases (accounting for 9.43 million deaths in 2016) [4]. The patients should also be made to understand the harmful comorbidity of both diseases since studies have shown that patients with both CAD and PAD fare worse in terms of cardiovascular health than those with only CAD [5]. Smoking as such also increases the severity of PAD and substantially increases the risk of 5-year mortality to between 40% and 50% [6, 7]. Additionally, should the patient require (bypass) surgery, smoking will have a deleterious effect on the outcome of the procedure: at least a 50% reduction in the chance of surviving in the 5-year period after surgery [7].

• Maintaining healthy bodyweight. Patients who are overweight or obese (although even underweight individuals are at risk) should be encouraged to maintain a healthy weight, both through healthy eating and physical exercise (this is also important from the perspective of managing hypertension). Studies have indicated that underweight individuals (BMI less than 18.5 kg/m2) with PAD are at an increased risk of mortality, while older (but otherwise healthy) individuals with greater BMI have a higher incidence of PAD [8, 9].

• Managing hyperlipidaemia. Physicians should remind patients to maintain a healthy diet (low in fatty food) and be conscientious when/if taking lipid-lowering medications (statins and other drugs) as this has benefits beyond managing PAD. Namely, since PAD is indicative of systemic atherosclerosis, which is connected to a significant risk of cardiovascular mortality, managing hyperlipidaemia reduces the likelihood of adverse outcomes (vascular mortality, total mortality, CAD events, strokes and noncoronary revascularisations) [10].

• Managing hypertension. Like in the case of hyperlipidaemia, this has positive effects beyond PAD. Physicians should again remind their patients of the importance of physical exercise for managing hypertension [11]. Studies have shown that a decrease of mere 2 mmHg in systolic blood pressure translates to reduced mortality from stroke by 6% and from CAD by 4% – a reduction by 5 mmHg, on the other hand, reduces the risk of stroke and CAD by 14% and 9%, respectively [12]. There is even a growing body of evidence that in some cases physical exercise can be as effective as antihypertensive medications [13]. Still, patients who are already on an antihypertensive drug programme should, of course, not be instructed to stop taking their medications.

• Diligent hyperglycaemia management. Diabetic patients are particularly at risk of both incidence of PAD and greater morbidity and mortality associated with it. For example, intermittent claudication (the most typical PAD symptom), is 3.5 times more prevalent in male and 8.6 more prevalent in female diabetics than in non-diabetics (of respective genders) [14]. Also, diabetics whose PAD progresses to critical limb ischaemia (CLI)—according to studies there are from 50% to up to 76% of such individuals—suffer more severe outcomes than non-diabetics [15, 16, 17]. This is very telling information, which physicians can and should use when dealing with diabetic patients with PAD who are non-compliant with their treatment regimen. Proper management of diabetes as such has many positive benefits on the progression and severity of PAD [18].

• Regularly checking Ankle-Brachial Index. This recommendation is more in the physician’s sphere of influence since it is unlikely the patient will have proper diagnostic tools at his personal disposal. However, physicians should explain to their already diagnosed patients the rationale behind the need for checking ABI periodically: worse score is indicative of PAD progression and inefficiency of treatment/management.

Managing PAD in non-compliant patients can be a challenge for many physicians, who should consult the list of recommendations above for helpful information that could convince the patients to change their ways when it comes to the disease they are affected with.