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Peripheral Arterial Disease (Dr. Gornik 9/15/10)

Wednesday, September 15, 2010 - Noon
Heather Gornik, MD

Heather Gornik, MD
Staff Physician in the Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sections of Clinical Cardiology and Vascular Medicine and Medical Director of the Non-Invasive Vascular Laboratory.

Description

More than 8 million Americans suffer from peripheral arterial disease, or PAD. Just as a heart attack is caused by a blocked artery in the heart, PAD is the same kind of blockage – only it takes place in the arm, leg or other part of the body. PAD is a leading cause for amputation, and puts you at risk for heart attack, stroke and death. It can build up over a lifetime, and the symptoms may not become obvious until later in life. Fully half of all people with PAD do not show any symptoms. Heather Gornik, MD, a Cleveland Clinic cardiologist answers your questions about PAD.

More Information

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Heather Gornik. We are thrilled to have her here today. Thanks for joining us Dr. Gornik, let’s begin with the questions.

Dr__Heather_Gornik: Thank you for inviting me today.


Peripheral Arterial Disease (PAD)

beauty1: I have plaque in the arteries of my legs? Is that hardening of the arteries? Can diet take care of that? I don't want to take medications if I don't have to

Dr__Heather_Gornik: Good question. Plaque in the arteries of the legs is the same thing as hardening of the arteries and is also known as atherosclerosis or PAD. Unfortunately while diet can help prevent further plaque deposition it cannot significantly reverse the plaque that is already there.

sherri: Are the risk factors for heart disease the same as PAD? If I have PAD, can I get heart disease?

Dr__Heather_Gornik: Dear Sherri - fantastic question. The risk factors for coronary artery disease and PAD have a high degree of overlap. In fact, most patients with PAD, do have some coronary artery disease and many patients with coronary disease have PAD. If you have one of these problems, your doctor should evaluate you for the other problem. As another comment, I would say that the greatest health risk for patients with PAD is not amputation - but a heart attack.


Symptoms of PAD

tarrellou: I have terrible pain in my feet and toes - could it be PAD? I have been to an orthopedic doctor and he does not seem to think it is the bones in my feet.

Dr__Heather_Gornik: Yes -absolutely - it could be PAD. You should ask your primary doctor to evaluate you for PAD with a history, examination of your pulses, and the ankle brachial index test - or ABI. Your symptoms could be due to many things such as neuropathy, vein disease, or leg cramps but I think PAD should be considered too. Unfortunately PAD is not often on the top of the list of things that doctors first consider that can cause leg pain.

jessica05: My dad has terrible pain in his leg. He is on a blood thinner; he also has spots on his legs. I am really not sure what to do - what steps to take.

Dr__Heather_Gornik: Dear Jessica, pain in his leg could certainly be due to PAD. It could also be due to other vascular problems such as chronic venous insufficiency. Definitely take your dad to his physician and specifically mention that you are concerned about his leg pain and spots on his legs. The spots could also be due to mild bruising in the skin due to blood thinners.

rulcs: When walking on the treadmill I get pain and numbness in my right leg. could that be PAD?

Dr__Heather_Gornik: Definitely, especially if the pain and numbness goes away within a few minutes of stopping. If this is the case, you have what is called claudication, a classic symptom of PAD. I would recommend that you discuss this with your physician and I would strongly recommend an ABI test. We even perform the ABI test before and after treadmill exercise to see how impaired the circulation is in the legs with exercise.

jets1: I have pain in my legs that mostly occurs at night - sometimes it wakes me up from sleep. I wonder whether that is PAD. Should I see a doctor and what tests should I get.

Dr__Heather_Gornik: It could possibly be PAD, but more likely you are having nocturnal leg cramps which are a common symptom. In addition to a vascular exam, your physician may want to check some routine blood work on you.

WISH_00: I have pain in the fingers and numbness in my right hand - it happens when I take walks. also - my hands get very cold. could that be blocked arteries in my arms?

Dr__Heather_Gornik: Good question. Raynaud's, which we discussed earlier in the chat, is usually something that happens in both arms. If your symptoms are only happening in one arm, I would be worried about a blocked artery and also non-vascular problems such as a spine problem or compression of nerves to your right arm. Please see your doctor about this symptom.

mike_s: I have had swelling in my lower legs for sometime and I have had all the test which come back negative. Also I have heart disease and all the test for that have come back negative. Don't know what else to do.

Dr__Heather_Gornik: Leg swelling is a very common symptom in our vascular clinics. As you allude to the most common causes are congestive heart failure, vein disease (chronic venous insufficiency) medications and some medical conditions (such as kidney, liver and thyroid disease). Assuming you have been tested for all of these entities, you may have idiopathic leg swelling. Compression stockings may help you. You may also want to ask your physician if you can have less common causes of swelling such as lymphedema or obstruction of your veins. A vascular specialist may be able to further pin down the cause of your leg swelling. But regardless of the cause, compression stockings should help.


Diagnostic Testing

SamuelT: I WOULD LIKE TO KNOW THE PREFERRED TEST FOR PERIPHERAL ARTERIAL PRESSURE AND OBSTRUCTIVE DIAGNOSIS. LEGS GO TO SLEEP WHEN I SIT TOO LONG. HAVE TO GET UP AND WALK TO GET RELIEF. 75 YEARS OLD. BP RANGE 100/60 TO 140/80, TAKING ATENOLOL…

Dr__Heather_Gornik: Hi Samuel. Your symptoms sound atypical for PAD, but given your age and the fact that you have hypertension, I would recommend a test for PAD called the ABI. The ABI is a test that measures blood pressures in the arms and the legs using a hand-held Doppler device with you lying down. The ratio of blood pressure in the arms to the legs is calculated. Low blood pressures in the legs leads to an ABI less than 1, and this can be used to diagnose PAD.

bobross: The ABI is a standard test to diagnose PAD. Why has the venous refill time (VRT) not using a PPG been promoted to diagnose venous insufficiency?

Dr__Heather_Gornik: A question beyond the scope of this patient chat on PAD…but an interesting one. I see a number of reasons why this is not the case. 1. Lack of large scale validation of refill time as a diagnostic tool and correlation with clinical events (we have this for tens of thousands of patients with PAD). 2. A technical issue, but venous refill time is volume dependent, and in the setting of low venous volumes can lead to inaccurate results. We do perform venous physiological testing in our vascular lab, but it is a study that must be performed by experienced personnel and interpreted by experienced readers nuanced in subtleties (such as low venous volumes, venous obstructive physiology). Thus, it is not a test that I feel can be taught to a health professional (nurse, medical assistant) to perform in an hour or two. The ABI is such a test that can be performed accurately by non vascular lab specialists after a few hours of training (albeit high quality training). That being said, I do think we need to raise awareness of venous disease! The good news is the physical exam is often much more reliable for diagnosing venous disease than it is for arterial disease.

alexdan: How does a physical exam diagnose PAD? How PAD differ from varicose veins and pain?

Dr__Heather_Gornik: Really great question. For the physical exam for PAD, the physician or other health care provider is assessing for absent or diminished strength of the pulses in the legs. For the physical exam for chronic vein disease the health care provider is looking for varicose veins, leg swelling and skin changes of chronic vein disease such as brown patches or skin thickening. PAD is a disease of arteries that can cause pain in the legs with walking, severe pain in the legs at rest and non-healing sores. What is tricky is that chronic vein disease can also cause similar symptoms. The good news is that the physical exam and simple tests such as the ABI can help distinguish the two.


Peripheral Arterial Disease (PAD) Medical Management

roslyn: What medication reduces the pain of pad/also does acupuncture help?

Dr__Heather_Gornik: Hi Roslyn. There are 2 FDA approved medications to reduce pain with walking due to PAD or claudication. These are pentoxyfylline and cilostazol. Cilostazol is the much more effective of the two drugs for claudication. As for acupuncture, I know of no large scale research on this topic and it is not known to be an effective PAD therapy. If you do get acupuncture please be sure the provider knows this as any breaks in skin could be riskier in terms of wounds and infection in the PAD patient. Exercise can really help PAD symptoms tremendously, especially a supervised exercise program, such as in a PAD rehab.

OP21: I have a 100% blocked artery in my leg - what can be done for that?

Dr__Heather_Gornik: There are many treatment options for completely blocked leg arteries including catheter balloon stent procedures and vascular surgery. Believe it or not supervised exercise training and medications such as cilostazol may also help with leg pain with walking. As it turns out, my colleague in vascular surgery, Dr. Srivastava will be discussing invasive treatment options next week.

jj678: I have PAD, the guy at the store said I should take Ginko - is that true - can it help PAD? Are there other vitamins I can take?

Dr__Heather_Gornik: Good question. Unlike Platexia, Ginko has been studied rigorously. Some studies have shown improvements for patients but overall this has not been shown to be a highly effective therapy. The only neutracuetical that has some significant evidence of benefit in PAD is Proprionyl-L-carnitine.

andydoodah: What medication is good for the claudication pain?

Dr__Heather_Gornik: Cilostazol is the more effective of the two medications that are available for treatment of PAD. Patients taking this medication can expect about a 50% improvement in how far they can walk without stopping due to pain.

Dr__Heather_Gornik: There are some side effects to know about such as palpitations, headaches and diarrhea. But for many patients this drug is helpful

DixonB: Hello - Am a 59 year old male in excellent general health, taking no prescriptions, nonsmoker. Had a DVT in my right calf seven years ago, treated with Warfarin. Heard of a new natural supplement called Platexia, recommended for use by diabetics and cardio patients as a remediation and prevention tool. What can you tell me about this product? is it safe? Does it have demonstrable benefits? Will discuss with my doctor after I learn more about it. Thank you in advance.

Dr__Heather_Gornik: I do not have experience among my patients in use of Platexia. From what I understand, this is a nutraceutical/herbal supplement that contains tryptophan, lycopene and some other compounds. This has not been studied in a rigorous scientific fashion for the prevention or treatment of PAD patients and I do not think it has been ever shown in a rigorous trials to have demonstrable benefits. This is not a standard remedy for PAD. On the flip side, there are a lot of medications that have been scientifically proven to help PAD patients and patients with coronary artery disease, particularly the statins, Ace-inhibitors, and certain antiplatelet drugs.

Dadojunior: Good afternoon - I submitted an inquiry about the benefits / effectiveness of Platexia regarding mitigation and prevention of DVTs. What can you tell me about this enzyme?

Dr__Heather_Gornik: Good afternoon. The answer posted above was more focused PAD than DVT. To my knowledge this herbal supplement has not been studied for vascular disease.


PAD Management – Stem Cell Therapy

fl1_er: Can you talk about stem cell therapy and peripheral artery disease? Is that something available?

Dr__Heather_Gornik: Stem cell therapy is at the cutting edge frontier for PAD. The hope is that the body could be encouraged to grow new blood vessels from stem cells that can be developed into the cells that make up blood vessel walls. This is called angiogenesis. There are some trials for stem cells for patients with very severe PAD (ulcers or rest pain aka critical limb ischemia) that are either ongoing or in the works. If you are interested in stem cell research for PAD, one place to look is www.clinicaltrials.gov - type in keywords peripheral artery disease stem cells. To clarify for everyone on the chat, this is experimental therapy and not available therapy that a doctor can prescribe.


PAD Management – EECP

fran: I was wondering if EECP helps peripheral artery disease?

Dr__Heather_Gornik: For everyone on the web chat, EECP is a treatment that is usually used to treat severe chest pain not treatable by current therapies. This involves inflating a series of blood pressure cuffs on the legs to stimulate blood flow. I don't know of specific trials for EECP to treat claudication that have been published but I recently saw an article on the safety and effectiveness of eecp for patients who have both angina and PAD (see Vasc Med. 2010 Feb;15(1):15-20. Epub 2009 Oct 19. The efficacy and safety of enhanced external counterpulsation in patients with peripheral arterial disease. Thakkar BV)


PAD and Exercise

sar_09: I have PAD and was told I should exercise. I have some problems orthopedic that makes walking more difficult - can I use an exercise cycle?

Dr__Heather_Gornik: Great question. Walking ideally on a treadmill is the best and most effective form of exercise training for PAD. That being said, studies have shown some benefit for PAD patients with other types of exercise such as cycling, arm ergometry (arm cycling), and weight training. So please cycle - if that is what you can do.

ChelW: I know exercise is important with PAD. Do you see benefit to a supervised exercise program (Cardiac or Pulmonary Rehab) vs exercise on your own? Are there PAD specific rehab programs?

Dr__Heather_Gornik: I love this question!!! Supervised exercise training such as in a rehab training program has been shown to be more effective than an exercise on your own program. Despite this, unfortunately most insurance plans including Medicare do not provide coverage for supervised rehab for PAD - Even though they cover rehab for angina, heart valve disease, certain post transplant patients. Despite this - Some cardiac rehab programs do provide programs for PAD patients. At Cleveland Clinic we are fortunate to have a PAD rehab program.

andydoodah: What is the benefit of exercise and can it be just walking or join a gym is better?

Dr__Heather_Gornik: Exercise training has many benefits for the patient with PAD. It trains the muscles to work more efficiently with impaired blood flow. It helps the small vessels function. It helps with strength and balance and it may also help stimulate the growth of new blood vessels called collaterals. Research has shown that formal exercise training in a rehab program is the most successful for PAD. But if you don’t have a PAD rehab in your area, you can definitely do exercise training on your own. Please go to www.vdf.org for information on PAD. This brochure can be downloaded www.vdf.org/pdfs/VDFWalkingBrochure_000.pdf and will provide you with information on a walking program.


PAD – Surgical and Interventional Treatments

carolee: My aunt had angioplasty in her leg. She is still having claudication. Does that mean the test was unsuccessful?

Dr__Heather_Gornik: Not necessarily. There are some patients who have a dramatic response to a successful angioplasty procedure and some who still have leg symptoms despite a successful angioplasty. I would be curious to know how severe her PAD is in her other leg and if this is contributing to her symptoms. Of course after an angioplasty it is important to have regular follow up which may include repeat ABI measurements and ultrasounds to make sure the vessel stays open.

andydoodah: Is the bypass surgery different and more difficult for the right leg than the left?

Dr__Heather_Gornik: I know you are reluctant to take medications but many of these medications such as statins to lower cholesterol might be very helpful to prevent heart attack or stroke and further progression of the plaque. In fact, I think medications such as statins have been the major advance in the treatment of plaque in the past 30 years.

TWILLIAMSLMSW: My father was evaluated on 09/13 for angioplasty. However, this will not be an appropriate option. It appears that the "bypass" is the next plan of care. Are there any specific questions that we should ask the physician regarding any other options? plans of care? if he receives the bypass …what is the typical hospitalization? recovery? He also is dx with polycythemia. He is a currently pharmacist working prn.

Dr__Heather_Gornik: You have many very specific questions regarding what to expect after open vascular surgery - I think I am going to defer your questions to Dr. Srivastava who will be hosting a chat specifically on surgery for PAD patients such as your dad next week. These are the nitty-gritty details she would love to discuss.

TWILLIAMSLMSW: thank you…

smithk: I have PAD both legs with a left femoral artery aneurysm. Is it possible to have rupture in my aneurysm? What do they do for peripheral aneurysms? When do they decide to treat them?

Dr__Heather_Gornik: I also encourage you to log in next week with the Web chat on vascular surgery. I will say that the risk of rupture of a peripheral aneurysm increases with the size of the aneurysm and surgeons generally consider repair for peripheral aneurysms of greater than 2 - 3 cm depending on the location.

cat12: I have PAD almost no circulation in my legs, Did have a bypass 2 months ago, but no improvements. Does it take some time to feel better after bypass?

Dr__Heather_Gornik: I will say that sometimes it does take time to recognize full improvement after bypass. You may also want to talk to your vascular surgeon about an exercise program or other medications that may help your symptoms.

Dr__Heather_Gornik: In some cases, despite improving the blood flow greatly to the legs, symptoms are not completely resolved. Researchers in PAD think there may be some muscle damage that occurs in this face of long term poor blood flow that is not completely reversible.


Other Vascular Conditions: Raynaud’s Phenomenon

sm432: My fingers are getting discolored and cold - what can I do to help this?

Dr__Heather_Gornik: You have what sounds like Raynaud's phenomenon, especially if the color changes in your fingers come and go and are precipitated by exposure to cold temperatures. The first line of treatment for Raynaud's is maintaining your body temperature in the "warm range." Also wearing warm clothes, hat, gloves. There are also some medications we can use for more severe cases of Raynaud's. These medications dilate the blood vessels. I want to clarify to our audience is different from PAD. PAD is due to plaque clogging the arteries while Raynaud's is usually a more benign condition caused by spasm of the arteries.


Other Vascular Conditions: FMD

AK936: Sorry Dr. Gornik I realize that PAD is the topic today, however I was sent an email from Cleveland Clinic asking to join today regarding the FMD. I will be very interested to see what you and your staff comes up with. My vascular surgeon and I both agree that it is tied to and immune problem. I have been researching with numerous doctors, including University of Utah research hospital and am convinced that the FMD is tied to the immune disease as I am only 42 and have numerous hyper immune responses, including and IgE of 1750. My daughter is headed down the same road and she's only 8. Thank you for your help. I look forward to future findings.

Dr__Heather_Gornik: Thanks for joining us today and your comments. We will be having an FMD chat in December. Hopefully you can join us then too.

AK936: My question had previously been put in the queue, but I'd like to know the possibility of checking your FMD patients for a common denominator regarding hyper-immune or auto-immune diseases. I have FMD and an undiagnosed immune disease.

Dr__Heather_Gornik: This is a bit off our topic but it sounds like you know I have a great interest in FMD. Here at Cleveland Clinic we are participating in a number of research projects to try to figure out what are the "common denominators" that link patients with FMD. So perhaps - stay tuned. We hope to have some data in the next few years. For up to date information on FMD, and FMD patient care and research in the US and abroad, visit www.fmdsa.org


Other Vascular Conditions: Blood Clots

dcwandj: My brother has PAD, and two hospitalizations due to blood clots moving to his longs. For the last two months he has trouble swallowing, excess salvia and has loss fifty pounds. He is unable to sleep at night. So far his doc can not find the cause of his problems. Could this be related to PAD?

Dr__Heather_Gornik: Dear dcwandj, I am sorry your brother has had such horrible health problems. I am suspicious that he has venous disease, specifically venous thromboembolism rather than PAD. He should be checked for underlying things that can lead to blood clots such as clotting disorders and even cancer. His weight loss and trouble swallowing make me worried there could be a major problem in his esophagus or stomach. Please have him rechecked soon.

GrantS: My concerns are a Post Prostate Surgery that removed my Prostate and other glands that within a few months (4-5) I developed a blood clot in my right leg and in both lungs. Now I'm on 5mgs (daily with one day 7.5mg) Warfarin. What I've noticed is that both my feet feels as though I have on socks, but I can feel my fingers on my toes and at times, my right foot and ankle begin to swell if I'm sitting more than two hours. Although I have had Gout in the past, and being treated for it with 100mg daily tablet of Allopurinol, this swelling is nothing like a Gout attack. Is it possible that the numb feeling of my toes and occasional swelling of my ankle could be related to PAD?? Also, I'm a Veteran (Durham VA Center, NC) and get medical attention through them but my Primary Care Doctor seems to think that I have good circulation in my feet even though I'm Type II diabetic. If necessary, I can provide my medical records from Sep. 2009 through Mar. 2010. Please give me your opinion.

Dr__Heather_Gornik: Hello Sir. I am sorry to hear about your health problems. It sounds as if you developed a deep vein thrombosis (DVT) in your leg (and pulmonary embolism) and have numbness in both feet and right foot and ankle swelling. I would be worried in terms of the right leg swelling that your symptoms are due to vein damage following the DVT. This is called "post thrombotic syndrome." I would recommend your doctor evaluate you for this and perhaps see if you should wear elastic compression stockings. Your numbness/sock feeling sounds like it may be neuropathy, perhaps related to your diabetes. Neuropathy can be diagnosed on the physical examination by assessing your sensation. You are also at risk for PAD, so a simple ABI test that I mentioned above, would be reasonable, but I think you symptoms may also be due to other problems.

BillTwo: Another question that I would like to ask, since having my Prostate Surgery and not being physically active, could this been the start of my Blood Clots in my right leg and both lungs. If so, what was the cause?

Dr__Heather_Gornik: Bill - for our audience on the chat, you are asking about the cause of blood clots in the veins or deep vein thrombosis. You are right, one of the most common causes for DVT is prolonged bed rest and immobilization such as during and after a surgery. That coupled with the fact that your surgery was for cancer also increases the risk of a blood clot. The clots in your lungs probably came from your legs. This breaking off of DVT and traveling of the clot to the lungs is called a pulmonary embolism or PE.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Gornik, is now over. Thank you again Dr. Gornik for taking the time to answer our questions about PAD.

Dr__Heather_Gornik: Thank you for having us today.

Technology for web chats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC).

Reviewed: 09/10


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