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Peripheral arterial disease (PAD) is caused by atherosclerosis, the leading cause of death and disability in patients age 50 and older. PAD progresses gradually and silently over many years, occluding the lumen of arteries that supply blood to the extremities. Symptoms of peripheral arterial insufficiency include intermittent claudication, rest pain, and impotence. Nonoperative management--including the control of risk factors such as hypertension, diabetes, hyperlipidemia, and smoking--is the most effective method to lower the risk of morbidity from PAD. Diagnostic technologies such as color duplex imaging, MRI, and MRA complement the clinical assessment of PAD and provide a stronger foundation for treatment decisions in the primary care setting.
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PMID:Peripheral arterial disease. Medical management in primary care practice. 1130 19

Peripheral arterial disease affects approximately 8-10 million people in the United States. Approximately one-third to one-half of these individuals are symptomatic. The risk factors that contribute to peripheral arterial disease are similar to those associated with other forms of atherosclerosis, including diabetes mellitus, cigarette smoking, hypercholesterolemia, high blood pressure, and hyperhomocysteinemia. Of these, diabetes and cigarette smoking pose the greatest risk for developing peripheral arterial disease. The prognosis of patients with these risk factors is limited because of their greater risks for myocardial infarction, stroke, and cardiovascular death. Cardiovascular mortality correlates inversely with the ankle/brachial index, and the risk of death is greatest in those with the most severe peripheral arterial disease. Treatment regimens to reduce cardiovascular morbidity and mortality in patients with peripheral arterial disease should include risk factor modification and antiplatelet therapy. The cardinal symptoms of peripheral arterial disease include intermittent claudication and rest pain, with the latter being indicative of critical limb ischemia. Therapeutic strategies that focus on improving the patient's quality of life, reducing the severity of claudication, and improving limb viability include supervised exercise training, pharmacotherapy, and revascularization. Two drugs-pentoxifylline and cilostazol-currently are approved by the Food and Drug Administration for the treatment of patients with claudication. Meta-analyses have suggested that, compared with placebo, pentoxifylline improves maximal walking distance by approximately 20-25%. Cilostazol is a phosphodiesterase type 3 inhibitor. In clinical trials, cilostazol has consistently improved maximal walking distance as compared with placebo, with the range of improvement being approximately 40-60%. Drugs that are currently under investigation include propionyl-L-carnitine, vasodilator prostaglandins, L-arginine, and the angiogenic factors, vascular endothelial growth factor and basic fibroblast growth factors.
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PMID:Medical management of peripheral arterial disease. 1140 4

Elevated serum total homocysteine, an established risk factor for peripheral arterial disease, is influenced by the vitamin B12 and folate status. Since these vitamins are inversely correlated with erythrocyte mean corpuscular volume, an investigation of whether mean corpuscular volume is higher in patients with symptomatic peripheral arterial disease than in healthy subjects was performed. Furthermore, a determination of predictors of increased mean corpuscular volume levels in this population free of symptomatic coronary artery disease, cerebrovascular disease, and diabetes mellitus was carried out. From 469 consecutive patients with symptomatic peripheral arterial disease, 100 fulfilled study inclusion criteria. Peripheral arterial disease was confirmed by angiography. One hundred age-matched subjects without peripheral arterial disease as verified by ankle-brachial index measurements >0.9 served as control subjects. Patients with PAD displayed a significantly higher mean corpuscular volume level (94.5 fl) than control subjects (90.9 fl, p<0.001). Logistic regression analysis showed that current smoking status (p<0.001) and mean corpuscular volume (p=0.009), but not total homocysteine or lipid parameters discriminated case control status. In addition, logistic regression analysis revealed a relationship of mean corpuscular volume with smoking (p=0.001), gamma-glutamyltransferase (p<0.001), and total homocysteine (p=0.012). This model predicted mean corpuscular volume values with an accuracy of 83%. Elevated mean corpuscular volume is a predictor of symptomatic peripheral arterial disease in the sample studied. A deficiency of folate and/or vitamin B12 may be responsible for this observation, as indicated by the correlation of mean corpuscular volume with total homocysteine. Due to the additional association of mean corpuscular volume with smoking and gamma-glutamyltransferase, an unhealthy lifestyle with low vitamin intake may cause elevated mean corpuscular volume values in patients with PAD.
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PMID:Association between erythrocyte mean corpuscular volume and peripheral arterial disease in male subjects: a case control study. 1157 Jun 59

Peripheral arterial disease (PAD) is associated with a high morbidity and mortality, largely from coronary and cerebrovascular disease, which often overshadows the PAD itself. Best Medical Therapy (BMT), comprising smoking cessation, antiplatelet agent use, cholesterol reduction, exercise therapy, and the diagnosis and treatment of hypertension and diabetes mellitus; is evidenced based and can result in significant reductions in cardiovascular risk, as well as some improvement in PAD. Previous data have largely been restricted to patients with coronary artery disease, and their relevance to PAD has been extrapolated. However, data are now starting to become available, such as the Heart Protection Study, with data specific to PAD patients. This article reviews the data regarding the use of BMT in patients with PAD, and based on this, makes recommendations for the use of BMT in this group of patients.
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PMID:What constitutes best medical therapy for peripheral arterial disease? 1262 55

Peripheral arterial disease (PAD) is a clinical condition that has often been neglected. The clinical diagnosis of PAD may be made on the basis of an accurate history by using the WHO/Rose Questionnaire or the Edinburgh Questionnaire. From a clinical point of view, PAD may be classified into four stages. The PARTNERS Programme (PAD Awareness, Risk and Treatment: NEw Resources for Survival) is a recent study based on a partnership to improve PAD care. In this population, the prevalence of patients who were PAD+/CVD- was approximately 12% in males and 15% in females; PAD+/CVD+ approximately 18% in males and 14% in females; PAD-/CVD+ 28% in males and 17% in females; and finally, patients without vascular disease (PAD-/CVD-) 42% in males and 54% in females. The lessons derived from the PARTNERS Programme Study were informative; PAD is detectable in routine practice, using a simple, inexpensive, always available, clinical test such as calculation of the ankle-brachial pressure index (ABPI). Fewer than half of individuals with PAD are aware of their condition, while physicians are unaware of the presence of PAD in 70% of their patients with the condition. Diabetics and smokers are at high risk for PAD. Diabetes is present in about 41% of patients with PAD and a history of smoking (> 10 pack for year) is present in over 63% of patients with PAD. Antiplatelet therapy is taken by only about half of patients with PAD. Finally, the lack of diagnosis and treatment means that PAD patients remain at elevated risk of heart attack and stroke. Efforts must be made to diffuse this information to improve the diagnosis and treatment of PAD to reduce the risk of future fatal and nonfatal cardiac and cerebrovascular events.
Diabetes Obes Metab 2002 Mar
PMID:Classification, epidemiology, risk factors, and natural history of peripheral arterial disease. 1218 Mar 52

The real prevalence of Peripheral Arterial Disease (PAD) is considerably underestimated if only symptomatic patients (i.e those with Intermittent Claudication) are taken into account instead of subjects with instrumental abnormalities such as a low Ankle-Branchial Index (ABI). The risk of both-fatal and non-fatal-cardiovascular events is particularly high in these patients either presenting with symptoms or asymptomatic. On the contrary the tendency to local worsening (need of revascularization or amputation of leg) is reduced. PAD is markedly prevailing in elderly, with a peak of incidence after the fifth decade of life. Owing to this, the prevalence is not significantly different in men compared to women. The risk factors related to PAD are the same as those observed in the other locations of atherosclerosis but cigarette smoking and diabetes seem to be more often associated to PAD than the remaining factors.
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PMID:PAD. Epidemiology and pathophysiology. 1235 42

Peripheral arterial disease (PAD) is a manifestation of systemic atherosclerosis strongly associated with cardiovascular (CV) morbidity and mortality. Approximately 12% of the US adult population is affected. Despite its prevalence, the disease has received little attention from clinicians. The primary causes of death in patients with PAD are myocardial infarction and stroke; thus, current treatment strategies for symptomatic PAD include aggressive modification of risk factors for CV disease such as cessation of smoking, treatment of hypertension and diabetes, and normalization of low-density lipoprotein cholesterol levels. All patients with PAD should be receiving antiplatelet therapy to prevent ischemic events. Medical treatment for patients with claudication includes exercise rehabilitation and drug therapy. Although many therapies for claudication have been thoroughly investigated, research continues on new treatments. In contrast, more prospective, randomized trials are needed to evaluate various therapies for treating patients with PAD.
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PMID:Treatment of peripheral arterial disease. 1242 82

Peripheral arterial disease (PAD) is most frequently caused by atherosclerosis. The prevalence of intermittent claudication is about 3 to 6% of the men over 60 years. But recent epidemiological studies demonstrate that prevalence of asymptomatic forms is two to three fold higher--about 3.4 to 12.1%. The most relevant diagnostic criteria for asymptomatic PAD is probably the measure of the ankle/brachial index. Most important risk factors for PAD are smoking and diabetes mellitus. Improving symptoms or stabilization are a common fate (50%) in PAD. About 25% will experience revascularization procedures (angioplasty or surgery), 4% will have severe amputation and worsening symptoms occur in 15% of patients. Critical limb ischemia is mostly rare (1%). It is not surprising that fate of claudicant and mortality is determined by coronary events and cardiovascular diseases.
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PMID:[Epidemiology of and risk factors for lower limb arteriopathy obliterans]. 1255 2

From March to July 1999, 940 private cardiologists in France recruited 100,429 patients of whom 30,430 (30%) had a previous history of atherothrombotic disease. The prevalence of patients with a previous history of Myocardial Infarction (MI), Ischemic Stroke (IS) or Peripheral Arterial Disease (PAD) was 19.7%, 7.2% and 10.7% respectively. Among patients with a history of atherothrombotic disease, myocardial infarction was the most frequent diagnosis responsible for 65% of all consultations. Each cardiologist described the secondary prevention treatment for 3 consecutive patients among whom 1 corresponded to each of the 3 atherothrombotic territories. The most frequent cardiovascular risk factors were hypercholesterolemia for myocardial infarction (77.9%), smoking for PAD (32.5%) and hypertension for IS (73.2%). Diabetes mellitus (1/4 patients), obesity (1/3) and sedentary way of life (1/3) were equally prevalent for each of the atherothrombotic territories. More than 90% of the patients received an antithrombotic drug. Antiplatelet agents were largely prescribed, anticoagulants being more frequently used for patients with atrial fibrillation, symptomatic cardiac heart failure or stroke of embolic origin. Thienopyridines represent 17.9% of the prescriptions. The prescription rate of statins after MI (58.9%) is lower than in published studies in secondary prevention. The lack of lipid measurement and the delay since last measurement are non-prescription factors. The rates of prescription are even lower in case of PAD (44.6%) or IS history (33.3%). More than half of the patients (56.6%) are treated with beta-blockers and 40.1% with ACE inhibitors. These rates are similar to what has been published. Atherothrombotic disease represents a large part of the daily activity of private cardiologists and is not limited to coronary heart disease. Despite their proven efficacy, drugs for secondary prevention for MI, except antithrombotic drugs, are insufficiently prescribed. This under-prescription is even higher in patients with PAD or IS history and may be related to the lack of clinical trials in these specific territories.
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PMID:[Factors influencing secondary prevention of atherothrombotic disease in the private outpatient cardiology setting: results of the Prisma survey]. 1271 Feb 91

Peripheral arterial disease, which is caused by atherosclerotic stenosis or occlusion of the leg arteries, is an important manifestation of systemic atherosclerosis. The age-adjusted prevalence of symptomatic and asymptomatic peripheral arterial disease is approximately 12% in the general population. The overall prevalence and incidence of the disease is likely to increase with the aging of the population. Peripheral arterial disease is a relatively benign condition in terms of local disease. Five years after the diagnosis, 75% of the patients remain clinically stable. On the contrary, life expectancy, even in the absence of any history of myocardial infarction or ischemic stroke, has decreased by 10 years. These patients have approximately the same relative risk of death from cardiovascular causes as do patients with history of coronary or cerebrovascular disease. Moreover, the severity of peripheral arterial disease is closely associated with the risk of myocardial infarction and death from vascular disease. The lower the ankle-brachial index, the greater the risk of cardiovascular events. Furthermore, peripheral arterial disease is a significant independent predictor for cardiovascular mortality also in coronary patients. The risk factors associated with peripheral arterial disease are essentially the same as for coronary heart disease: older age, cigarette smoking, diabetes mellitus, hypertension, and hyperlipidemia. The excess morbidity and mortality for cardiovascular disease in these patients has not been fully explained. Patients with peripheral arterial disease show a systemic endothelial dysfunction and an increase in the serum concentration of activated white blood cells, endothelin, and C-reactive protein that may trigger acute coronary syndromes. In peripheral arterial disease the functional status is often severely impaired. Peak exercise performance has decreased to about 50% of that of age-matched controls, equivalent to moderate-severe heart failure. Epidemiological studies support the concept that patients affected by peripheral arterial disease, without established coronary heart disease, have a coronary heart disease high risk equivalent. In spite of this, peripheral arterial disease remains an underdiagnosed and undertreated disease. As the role of cardiologists is expanding, the purpose of this review was to awaken the clinician to the significance of lower limb atherosclerotic occlusive diseases.
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PMID:[Why are cardiologists to be concerned about obliterating arterial disease of the lower leg?]. 1278 66


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