Peripheral Artery Disease (PAD) Risk Factors, Symptoms, Testing and Medical Management

Podcast Transcript

Announcer:
Welcome to Love Your Heart, brought to you by Cleveland Clinic Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. These podcasts will help you learn more about your heart thoracic and vascular systems, ways to stay healthy and information about diseases and treatment options. Enjoy.

Lee Kirksey, MD:
Thank you for joining us. Hopefully you'll be able to view our full Heart,Vascular and Thoracic Institute presentation on peripheral arterial disease. Today, I have two of our distinguished members of our cardiovascular section, Dr. Fendrikova and Dr. Ouma. And I'll ask them a couple of questions regarding peripheral arterial disease. So maybe we'll begin with you Dr. Ouma. Patients want to know who is high risk. Am I high risk for peripheral arterial disease? So how would you describe that to them?

Geoffrey Ouma, DO:
Yeah, so when I see my patients, usually in the clinic, the most common risk factors that I talked to my patients about is diabetes. And I usually tell them that diabetes is probably the highest risk for peripheral arterial disease, maybe three times higher risk than other risk factors combined and followed by smoking. So I emphasize those two risk factors and obviously high cholesterol levels, as well as hypertension and other non-traditional risk factors that includes also family history, as well as obesity. And so I focus mostly on risk factors that are easily modifiable and the patient is comfortable, changing those lifestyle to improve their disease.

Lee Kirksey, MD:
I think that's great diabetes, smoking, a person that has disease, atherosclerotic disease, heart attack, or previous stroke obviously at risk. Those are important features for family members and patients too, to remember. So Dr. Fendrikova, you gave a great presentation on the identification of peripheral arterial disease. So what should a patient look for in terms of symptoms that they might experience?

Natalia Fendrikova Mahlay, MD:
So it is very important for the patients and especially patients who have cardiovascular risk factors. Those are the patients with diabetes who smoke, who have high blood pressure who have high cholesterol levels to recognize the symptoms peripheral arterial disease. Those symptoms include leg pain and especially pain whenever the patient would walk. Every time that somebody would walk, the leg pain would start and would cause the person to stop walking, take a rest before able to walk again. We in medicine call this symptom claudication, and we recognize that this is one of those symptoms of the peripheral arterial disease. In more severe cases, patients may have the more severe symptoms of pain at rest, as well as the non-healing wound on the leg. So if a person has those cardiovascular risk factors that we discussed, it is very important to recognize the symptoms and seek evaluation.

Natalia Fendrikova Mahlay, MD:
You should come to your doctor and ask, is it possible that I have the disease of my arteries? And then your physician will proceed with evaluation. This evaluation ultimately need to include evaluation of the pulses. And we in Vascular Clinics are well aware that the exam of the patient is not complete without the patient taking all off the shoes and us putting our hands on the pulses of the legs to evaluate for potential disease. And also there are very easy diagnostic tests available to make this diagnosis. One of those basic tests is called, Ankle-Brachial Index. And this is essentially a blood pressure cuffs placed on the legs and the arms and measuring and comparing the pressures. It is painless test, very easy to use, and it's widely available. We have the very capable Vascular Lab that exists in 15 locations throughout the Greater Cleveland area which is ready to help the patients whenever there is a need.

Lee Kirksey, MD:
I think that's so important to underscore that it's easily identifiable. If we do the appropriate testing which is a very simple blood pressure cuff, essentially around the ankle, painless a simple, quick, easy way to identify. And it's not only to identify peripheral arterial disease for procedures, but once we identify peripheral arterial disease then we can institute the appropriate medical therapy to reduce the chances of that disease progressing to reduce heart attacks, to reduce strokes. We're not identifying it just to do procedures so that's really important. And I liked your discussion this morning about best medical therapy. So maybe you can speak to the issue of cholesterol medication. Sometimes I see as a vascular surgeon, patients that are hesitant to start a cholesterol, even though they understand they have peripheral arterial disease.

Geoffrey Ouma, DO:
In the medical therapy for peripheral arterial disease, we get insights and guidelines that change to better monitor the disease. The most current guidelines step that we usually don't really depend on the number of the LDL which is the bad cholesterol. So long as we identify the risk factors, including diabetes, smoking, previous heart attack, really the numbers don't really come into play. We just treat with cholesterol pills. And so far, the current guideline mandates that we start with a higher dose which is called the high intensity statin therapy. In the past we really relied on the numbers and those days actually the outcomes were not as great because we are really treating the numbers, not the risk. So far nowadays we just put the patient on a high statin therapy regimen.

Lee Kirksey, MD:
So really important cholesterol statin therapy is critical to this process and risk pool cohorts suggests that patients that are diabetic, smokers, if you have these multiple high risk factors even if your cholesterol numerically is not elevated, one may benefit, the patient may benefit from being on a statin therapy. And there are multiple options. And for patients that are told they're intolerant, or have some history of intolerance, these are the experts along with our cardiology colleagues and getting you on the appropriate medication because there are many options. So Dr. Fendrikova, you have these patients that have an increased risk of heart attack and stroke. How do you monitor your peripheral arterial disease patient over time?

Natalia Fendrikova Mahlay, MD:
It really depends on the presentation of the patient and also if the patient had any interventions. So initial assessment as we discussed is the Ankle-Brachial Index test. And then we sometimes use the test, repeat this test after the exercise to evaluate what is the limitation of the patient to walk? What is the functional capacity of the patient? This test can be repeated in time and we have the certain numbers to look for. So if the number is declining between one test and another test, this may indicate the progression of the disease. In those patients who are involved in the best medical therapy. It is important to realize that it's not only the numbers. And in fact, the numbers may not indicate clinical improvement. So it is very important to interpret the results of those tests in the context of the actual reality. And also, we’re always on standby to help our interventional colleagues in vascular surgery, interventional cardiology, to help assess the patients after the intervention. We have the readily available tests, including ultrasound, including more sophisticated tests, to help assess the progress of the patients and a response to the therapy.

Lee Kirksey, MD:
That's important were we consider it married to the patient with peripheral arterial disease. Once it's diagnosed, the patient is followed over their lifetime for progression of that process by one of our vascular medical experts, one of our cardiologists, maybe one of our vascular surgeons, and it's additionally important these folks are experts with the non-surgical management, which frequently, and should include supervised exercise therapy or some structured exercise program or walking program will potentially improve your peripheral arterial disease. So thank you for tuning in with us today. Hopefully these questions and answers from our experts were helpful to you and join us again in the future.

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