Focused approach is required for timely detection and effective treatment of Peripheral Arterial Disease (PAD) patients

Introduction

Peripheral Arterial Disease or PAD is typically characterized by a gradual build-up of plaque in arteries to the legs. This gradual plaque build-up can result in diminished flow to the artery, which can further cause various complications. PAD can cause challenges with the mobility, thereby impacting the quality of life. PAD can lead to chronic disorders such as limb ischemia, and some other serious infections, which can spread to tissues, muscles, bones and or into blood. PAD is often linked with cardiac arrest or a stroke and can hence lead to mortality in patients as well. As per 2016, GBD estimates, PAD is a widely prevalent disease, and it impacts around 120 million people across the globe. PAD contributes to over 25% of overall burden of Cardiovascular diseases and around 1.7% of burden of other diseases. [8, 9, 10]

Until a few years back, European cardiologists were specialized to treat and diagnose disorders related to the heart as well as the vessels. However, with the advent of new subspecialties, and with technological advancements, there has been a shift in the focus on treatments and diagnosis of cardiovascular diseases. This has led to the loss of interest of cardiologists in treating vascular diseases and has shifted their focus only on cardiac disorders. This is contrary to the knowledge that vascular diseases, such as PAD, can be one of the prime reasons of cardiac disorders in patients and hence focusing on vascular disorders can reduce mortality of cardiac patients as well [4, 5].

Peripheral Arterial Disease (PAD)

Peripheral arterial disease is usually detected after permanent damage had already occurred, resulting in a high rate of amputation, morbidity, and loss of life. PAD can cause multiple challenges with the mobility, impact the quality of life, can lead to chronic disorders, can cause serious infections, and increases the risk of cardiac arrest or a stroke as well in patients. Accurate identification and management of PAD are vital to reduce the risk of cardiovascular disease and adverse limb events such as amputation. [7]

PAD is a widely prevalent disease and has high incidence rates as well. As per 2016 GBD estimates, PAD is prevalent in around 120 million global patients. A US study highlighted the PAD prevalence to be around 10.7% of the population and the mean incidence to be around 2.4%, which is extremely high compared to many other vascular disorders. Given the high incidence and increase in the ageing population, the prevalence of PAD is expected to increase to an epidemic size, and it is imperative to take a proactive approach in the diagnosis and treatment of PAD. [6, 7, 10]

The risk group for peripheral arterial disease (PAD) and PAD complications

Most cardiologists during their consultation do not even palpate the peripheral pulses and do not cross-examine their patients for any vascular symptoms, such as claudication. The timely diagnosis of PAD and other vascular disorders can help in the proper identification of any cardiovascular risk, leading to a more effective treatment.

PAD can result in pain during exertion, or impairment in walking, can cause loss of sensation in the extremities, and if left untreated can cause persistent infections and wounds. These wounds or infections can ultimately lead to a gangrenous lesion needing amputation of an extremity or digits. PAD is also associated with the higher risk of myocardial infarction, coronary artery disease, and cerebrovascular disease, and is also considered as a marker for cardiovascular disability and death. [6]

Multiple risk factors can contribute to PAD, including age, genetics, smoking, lifestyle habits, other chronic medical conditions, and demographics such as race, ethnicity and gender.

• Age: Older people are more at risk for PAD. PAD is most prevalent in population over 65 years of age. In underdeveloped nations, the average age group for PAD prevalence is around 50 years.
• Genetics: A genetics or family history of PAD or any other related vascular disorder can lead to the increased risk of PAD in patients. Multiple clinical studies have established the correlation between genetics and PAD incidence.
• Smoking: Smoking can damage blood vessels, increase cholesterol, raise blood pressure, leading to increased risk of PAD in patients
• Lifestyle related factors: Other lifestyle related factors such as low physical activity, stress and unhealthy eating can result in increased risk of PAD and other vascular disorders
• Medical Conditions: Chronic medical conditions such as Diabetes, Obesity, CKD, Metabolic Syndrome and few others can lead to PAD
• Demographics: Specific races such as African American, American Indian women, and Hispanic and Latino adults are at higher risk of PAD. [9]

Decline in interest of dealing with Peripheral Arterial Disease (PAD)

Until around last decade, European cardiologists were specialized in treating both cardiac as well as vascular disorders. However, with the advancements in technological methods both in diagnosis and treatment, and with the advent of new specialties and subspecialties, cardiologists are becoming more focused on cardiac disorders and have narrowed their approach. This narrowed focus has eventually led to the neglect of vascular disorders by cardiologists. According to a European survey conducted a few years ago, the young cardiologists have less interest and see minimal patients related to peripheral vascular diseases, such as PAD.

The decline in interest of cardiologists has further resulted in the increased gap in care of an ever-increasing PAD population. Cardiologists are not including peripheral vessel assessment in their regular cardiovascular check-up. They are not asking for vascular symptoms or conducting vascular screening tests such as endothelial function assessment, carotid and femoral imaging, ankle-brachial index measurement, and aortic stiffness estimation, while doing their patient assessments. Most of the vascular disease patients are taken care of by vascular surgeons, vascular medicine specialist or thrombosis specialists or at some places, by angiologists. All this has resulted in sub optimal diagnostics and treatment of the PAD and other vascular disease patients.

On the other hand, it is imperative to note that vascular disorders, such as PAD, are the leading causes of cardiac diseases and stroke in patients. It has been well established by research, that timely diagnosis and effective treatment of PAD and other vascular disorders can reduce the incidence of and mortality in cardiac disorders. A study noted that timely screening and proper management of PAD and other vascular disorders can reduce mortality by around 7% in cardiac patients. Furthermore, investigating vascular disorders such as PAD can improve the diagnosis and prediction of cardiac risks in patients, leading to early and effective treatment.  Even if the patient has an already existing cardiac condition, the simultaneous presence of PAD would indicate increased risk of mortality and adequate preventative steps can be taken to prevent death.

It is essential to note that most patients suffering from cardiac diseases might also have vascular conditions and vice-versa. Hence, all-around care of these patients is important to improve their overall cardiovascular health. This is, however, not usually fulfilled since stroke centres, cardiology, and vascular departments are divided in hospitals and care clinics. In addition, the evaluation of peripheral vessels is not considered as a priority by cardiologists.

Setting up of multidisciplinary teams including a vascular surgeon, cardiologist, and other physicians is imperative and recommended as per the guidelines of ESC. This can help improve the management techniques of cardiovascular patients. The state of peripheral vessels must be integrated into patient management as this can help enhance the quality of life and overall patient outcomes. [4, 5]

In addition, effective screening techniques can lower mortality due to cardiovascular problems, due to the timely identification of vascular diseases such as PAD. PAD screening should, generally be done in adults above the age of 50 years with the above-mentioned risk factors. [6] Traditionally, Ankle-Brachial Index (ABI) measurement has been commonly used as a first-line screening test to detect the lower extremity artery disease such as PAD. Ankle-Brachial Index (ABI) is a noninvasive vascular screening test, calculated by dividing the highest systolic pressure in the ankle with the highest systolic pressure in the arm. [1, 2, 3] The test is highly sensitive and specific, with very well-established accuracy, and is widely used for the early detection for timely treatment of PAD (peripheral-Arterial Disease).

Emerging Ankle-Brachial Index (ABI) measurement Devices

An advanced example of the emerging innovative Ankle-Brachial Index measurement devices is the MESI mTABLET device. The MESI mTABLET diagnostic system is an all-in-one comprehensive system of top-notch diagnostic modules, patient records, and medical apps. The device is designed and produced for healthcare professionals, with a modern practice in mind. The device features an Automated wireless Ankle-Brachial Index system with multi cuff technology, which allows simultaneous measurement of brachial and ankle pressures. It also incorporates PADsense™ algorithm for the detection of severe Peripheral Arterial Disease.

All measurements and patient data are automatically stored and synchronized with the built-in electronic medical record – MESI mRECORDS, available on the MESI mTABLET and from any web-enabled device, simply and securely.

This non-invasive device simultaneously measures the ankle-brachial index (ABI) and uses waveform analysis and vascular evaluation technology to generate diagnostic information. The device can be implemented into any system and improves the overall experience of the users. The MESI mTABLET device helps the patients to adhere to the diagnostic guidelines and ensures that all patients at risk can get a timely diagnosis, using a very simplified procedure.

Other unique features of the device are:

• Objective results from diagnostic measurements, triage, specialist opinions, consultations, and any other data to enable progressive analytics.
• Constant upgrades with additional diagnostic tools and medical apps to boost functionality.
• Consistent formats to enhance communication, reduce reporting inconsistencies, and improve diagnosis and treatment time. [11, 12, 13, 14]

Conclusion

PAD is a highly prevalent disease, with morbidity and mortality similar to coronary artery disease, however, the disease is less accurately investigated and treated. This leads to an increase in the cardiac arrest risk in patients. The narrowed focus of cardiologists on cardiac symptoms, is further leading to neglect of vascular disorders assessment. A multidisciplinary approach is very much required for an effective diagnosis and timely management of PAD. Furthermore, new, and innovative diagnostic technologies are necessary to improve the overall patient outcomes in PAD.