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Peripheral Arterial Disease: A Focus on Patient Education and Awareness

PAD is a relatively common disorder due to atherosclerosis. It is caused by the hardening and narrowing of the arteries, which progressively reduces blood flow to the limbs, usually beginning with the lower extremities. This results in ischemic muscle pain, to more severe cases of critical limb ischemia (CLI) where there are ulcers and gangrene. An acute limb ischemia occurs when there is a sudden decrease in limb perfusion causing a threatening decrease in limb viability. If PAD could no longer be ignored and had appropriate emphasis placed upon it, intervention would be sought at a time when it is most effective. This would avoid irreversible limb loss and would improve the quality of life for patients with symptomatic PAD. At present, only a minority of those affected with PAD receive medical treatment aimed at alleviating symptoms or at altering the natural course of the disease. This is why it is necessary to propagate public awareness of PAD and its risk factors, as the prevention of a disease state is always the most effective way of dealing with it.

Let us begin by defining and understanding what Peripheral Arterial Disease (PAD) is. After an initial definition, we will explore the risk factors associated with PAD, which will help to justify our focus on patient education and awareness. Progression of PAD will then be compared to Coronary Artery Disease (CAD) and Cerebrovascular Disease (CVD). This is because when PAD is considered to be a similar manifestation of atherosclerotic disease affecting the arteries. Finally, we will look at the overall aim of this essay and how we plan to achieve this.

Understanding Peripheral Arterial Disease

Atherosclerosis is primarily caused by high cholesterol levels, high blood pressure, and cigarette smoking. Therefore, patients with these risk factors have a significantly higher chance to develop PAD. High cholesterol accounts for the majority of atherosclerosis. It will deposit plaques in the arteries, and cholesterol levels can help determine the severity of PAD. High blood pressure can cause arteries to narrow and harden, thereby causing damage to the artery walls and eventually leading to atherosclerosis. Cessation of smoking is paramount for those diagnosed with PAD. It is the most important intervention in reducing the risk of atherosclerosis and other cardiovascular events.

People with diabetes represent a special population with PAD. It is known that patients with diabetes are more likely to have atherosclerosis. The risk of having PAD doubles for diabetics, and it significantly increases when those patients have other cardiovascular risk factors. An estimate of one in three adults with diabetes over the age of 50 will have PAD. This makes it crucial for those diagnosed with diabetes to practice proper care and preventive measures for PAD. Patients with diabetes and PAD are at an increased risk of developing critical limb ischemia. This can lead to amputations, hospitalizations, increased mortality, and reduced quality of life in patients.

Peripheral vascular diseases have taken a turn for the worse due to the increase in the aging population. Peripheral artery disease (PAD), a product of atherosclerosis, has become a global disorder and a major health concern for those diagnosed with the disease. The WHO has predicted that this disease will continue to rise and become a leading cause for morbidity and mortality in the world. PAD is a debilitating disease caused by chronic reduction in blood flow to the extremities. It is generally a result of atherosclerosis. Atherosclerosis can be present in a patient at multiple sites, which will make these patients likely to develop more than one gathering of symptomatic or asymptomatic peripheral arterial disease. This is important for healthcare professionals to consider. The AA provides great comparisons of the severity of PAD, stating that it is equivalent to coronary artery disease and can lead to a heart attack. 20% of patients over 70 years of age with PAD will eventually require revascularization of an extremity. PAD will also obstruct the blood flow to the brain, increasing the risk for those patients to suffer from transient ischemic attack or stroke.

Causes and Risk Factors

As atherosclerosis is a common cause of PAD, it is important to understand that the risk factors for atherosclerosis are the same risk factors for PAD. In addition to this, it is important to remember that the potential severity of PAD progression from asymptomatic peripheral arterial disease to critical limb ischemia is different for everyone and largely dependent on both the cause of the PAD and the patient’s general health. The worst-case scenario for PAD is amputation of the affected limb, so all preventative measures should be taken to lessen the severity of the disease.

The causes of PAD are the result of a decrease in blood flow to the limbs. This decrease in blood flow can be linked to many factors; however, atherosclerosis is by far the most common cause. Atherosclerosis is the gradual clogging of the arteries by the buildup of a waxy substance called plaque. This occurs in all arteries throughout the body and is a normal part of aging. However, when plaque builds up in the arteries to the point that it inhibits the flow of blood, it becomes a very serious problem. Plaque can develop anywhere in the arteries and lessen the flow of oxygen-rich blood to the muscles. When plaque develops in the arteries in the limbs, it can cause pain in the legs and feet and increase the risk of blood clots developing in that area. Blood clots are another common cause of PAD in that they can completely block blood flow to the limbs. Blood clots can be caused by injury to the blood vessel or a sudden change in the blood flow, such as from atrial fibrillation. Coagulation disorders, uncontrolled lipid levels, and infection are also all common causes of PAD. Oftentimes, PAD can be made worse by exacerbating factors such as smoking, diabetes, high blood pressure, high cholesterol, or a family history of heart or vascular disease.

Symptoms and Diagnosis

The ABPI has a sensitivity of 90% and a specificity of 98% for detecting PAD when compared with angiography. It can also be used to determine disease progression or response to treatment.

An ankle-brachial pressure index (ABPI) is a simple and non-invasive way to diagnose PAD and determine its severity. This is calculated by dividing the systolic blood pressure at the ankle by the systolic blood pressure in the arm. An ABPI of less than 0.9 is indicative of PAD.

Several methods can be used to diagnose PAD. A clinical diagnosis can often be made based on typical symptoms and signs in a patient with a known risk factor for the disease.

Diagnosis of PAD:

– Symptoms of cerebral or abdominal ischemia may also occur in patients with multi-site disease.

– Other leg symptoms include paresthesia, coldness, impaired mobility, and change in the appearance of the skin and adnexa, such as hair growth and nail thickness.

– Two further symptoms typify late-stage PAD: ischemic rest pain and critical limb ischemia. Ischemic rest pain is forefoot pain at night that is relieved with dependency, such as sitting up or standing. Critical limb ischemia is characterized by the presence of ischemic rest pain and objective evidence of ischemia, such as ulceration or gangrene.

– Intermittent claudication (pain in the legs while walking that is relieved with rest) is the classic symptom of PAD. Patients with more severe disease may develop pain at rest, which often disturbs sleep.

Symptoms of PAD: claudication and others

Treatment Options

Time does not permit detailed consideration of every treatment option here, so we conclude with a proposed algorithm for the management of PAD, to help optimize individual patient treatment.

Surgical or endovascular luminal revascularization procedures are considered for patients with lifestyle-limiting intermittent claudication which has failed to improve with medical management, or those with critical limb ischemia. The choice between these methods will depend in part on local expertise and available facilities, and in part on the characteristics of the lesions and the patient’s surgical risk. Overall they are comparable in terms of symptomatic improvement and cost-effectiveness at 1 year, but percutaneous revascularization is associated with higher procedural morbidity and lower long-term procedural success. Although revascularization is effective in relieving symptoms and is the recommended initial treatment for patients with severe ischemia, it does not reduce the excess cardiovascular risk seen in these patients, so concomitant medical therapy is still required.

Medical management and risk factor modification should be considered the essential treatment for all patients with PAD, to prevent disease progression and reduce the markedly increased cardiovascular risk associated with this condition. This will involve aggressive treatment of high blood pressure, discontinuation of tobacco use, antiplatelet therapy to prevent occurrence of myocardial infarction or stroke, and the use of statins and possibly other lipid-lowering agents to decrease hyperlipidemia. Participants in a recent population-based study had little awareness of the nature or prognosis of their condition and were undertreated in primary prevention and secondary prevention of cardiovascular disease. A focused educational initiative could lead to improved outcomes for such patients.

The way of identifying any individual patient’s prospects for each option is not clear, but is likely to depend in part on the pattern and severity of the arterial disease, the presence of limb-threatening ischemia, and the coexistence of coronary or carotid disease, when the patient would also be a candidate for revascularization procedures at those sites.

Treatment options for peripheral arterial disease can be classified into three categories: medical management, minimally invasive procedures, and surgical revascularization.

Importance of Patient Education

Improving walking is crucial for patients with PAD to enhance their functioning and alleviate symptoms. Structured exercise programs that focus on increasing walking duration and ability can improve mobility and quality of life. Supervised exercise training, including treadmill exercise or strength training, can enhance treadmill walking performance in patients with PAD.

Health education is an important tool in raising awareness and promoting change. By providing information on the risk factors and consequences of Peripheral Artery Disease (PAD), healthcare practitioners can motivate individuals to make lifestyle changes. Educating individuals about the benefits of healthy practices and managing risk factors can further encourage them to adopt a healthier lifestyle. Awareness is the first step towards seeking change.

Promoting Awareness

Steps should be taken to assess the same by public surveys to know where the awareness levels stand today compared to previous years. An organized mass media campaign would be an expensive means but would be powerful in disseminating the information. Political will and support are also important for the above said causes. This can only fructify by constantly reminding the health authorities and creating public opinion on the same. This, in the future, will change the scenario of PAD diagnosis from “whom to do?” to “where to go?”

Any vascular-related symptoms should at once prompt the patient to inquire whether he/she has a problem with blood vessels. This mindset can only be seen if public awareness is widespread. Newspaper articles can be another cheap and attractive means to enhance public education. Public education material can be included in the form of brochures and posters in vascular labs and physicians’ outpatient clinics. The creation of a website for this purpose can also be beneficial.

Another recent Japan study has shown that public awareness of PAD is insufficient. This data would also apply to developing countries. Public awareness at all levels should be the first target and can be achieved by various means. The most cost-effective and easiest means would be by including the diagnosis and management of PAD in undergraduate medical curriculum.

It is highly notable that an aware population can contribute to early diagnosis of PAD in the country. The awareness programs in the western world have not only increased the inclusion of PAD in diagnostic camps, but have also hastened the referral of such patients to vascular specialists. The disease has earned more respect among the medical fraternity as well as lay persons.

Lifestyle Modifications

Individuals with PAD are at a heightened risk of developing cardiovascular disease (CVD), due to atherosclerosis being a systemic disorder, and should therefore aim to adopt the dietary patterns, emphasizing a reduction in dietary saturated and trans fat intake in accordance with the American Heart Association (AHA) guidelines. A simple guide for our patients on this consists of following the “cardiac diet” that is often recommended when an individual has been diagnosed with heart disease. There is no definitive evidence to suggest that this diet alone will improve PAD symptoms, but it is a relevant tool that our patients can utilize to improve overall cardiovascular health. One dietary supplement marking the possible exception to this is the use of Pycnogenol, which is an extract from the bark of the French maritime pine tree, providing antioxidant effects and collagen stabilizing properties. This supplement has been shown in one clinical study to improve general symptoms of intermittent claudication. This is not yet a mainstream recommendation but it is an interesting development in dietary management for PAD that is worth noting for the future.

Medication Management

One more crucial reason to overlook substance control is that a patient may have all the information and data needed to manage their body mindfully, but because of a lack of symptom recognition, they may misunderstand the significance and potential symptoms or complications. In most cases, this obstruction leads to immediate discontinuation of the medication altogether, without doctor’s counsel, and can result in significant harm to the patient. This is often the case with patients experiencing intermittent claudication. It was reported in research of patients participating in the Intermittent Claudication Evaluation that more than one-third of claudicants who stopped taking their cholesterol-lowering medication did so because they experienced leg pain. Of patients who stopped taking their medicine, only 13% consulted their doctor first, and nearly one-third of these patients were unaware that there was an alternative medication to treat their condition. This is far from responsible medication suspension, and educating patients about the use and possible outcomes of their drugs is a critical step in avoiding a similar situation.

Exercise and Rehabilitation

The most effective treatment for PAD is exercise. Supervised treadmill exercise has been shown to decrease symptoms and improve walking distances by 100-200%. There are many forms of exercise, but the ones that seem to be most effective are the ones that are done until near maximal claudication pain and then a few minutes longer. Most patients are very hesitant to exercise due to the severe pain experienced with walking. It is important to explain that the pain is only temporary and will not cause any harm to the limb muscles. It has been proven that PAD patients are not exercising to intensities high enough to improve claudication onset distances. This can be hard to convince the patient and have them continue but it is very important for them to understand that only exercise at or close to the onset of leg pain will be effective in improving their walking ability. It takes about 3 months for patients to notice a significant change in their walking ability and less leg pain. Unfortunately, there are still many patients who, despite counseling, medicine, and exercise, still have pain and disability from PAD.

Resources and Support for Patients

For increasing collaboration and understanding with healthcare providers, patients can inform their primary care physician or cardiologist about the VascularWeb by the SVS. This online resource provides credible information for patients. With the ability to also search related medical professional topics, VascularWeb may provide an opportunity for the patient and provider to discuss treatment plans based on the information provided on specific procedures. By better understanding what the patient has learned about his condition and treatment, the provider can establish a more cohesive treatment plan with the patient.

When Fred is interested in learning from others who are suffering from PAD and would like to share his experiences with them, he may find an online support community through DailyStrength.org. This online forum is dedicated to bringing people with similar health and life issues together and provides a secure environment for support and inspiration. Members are able to share their personal stories, talk about diagnosis and treatment, and receive encouragement from others who have successfully dealt with PAD. DailyStrength.com has several on-site support groups for other medically related conditions, and their members often share experiences related to PAD, so searching related groups may provide an extra opportunity for support.

There are several patient education resources that are available through the AHA (Appendix). These materials provide an in-depth look at PAD and its risk of related still, as well as guidelines for beginning a symptom relief treatment plan. As with Fred’s diagnosis and educational needs, these materials come in the form of a booklet (“So You Have Been Diagnosed with Peripheral Arterial Disease”), as well as an online version of patient educational information. These resources will provide the patient with a chance to further understand his disease and learn about what steps he needs to take in lifestyle changes and treatments to enhance his condition.

Patient Education Materials

The quality and accuracy of the patient materials varied widely. On the low end of the spectrum, some materials primarily served as advertising or promotional pieces for a specific organization or medical treatment, device, or procedure. These materials contained little in the way of educational content or explanation of PAD and focused on convincing patients to seek further treatment or services from the organization providing the material. Some of these promotional pieces contained little more than a mention of PAD or a related condition, some general information about the organization, and a statement along the lines of “see us for the best care for condition X,” urging the patient to take some further action such as visiting a healthcare provider. IPD Group policy workers determined that such materials were not useful to patients and elected to exclude them from further review or evaluation.

The patient materials we located consisted almost entirely of patient education brochures and pamphlets. These materials were on the websites of various government health agencies, medical clinics or laboratories, and patient-nonspecific websites discussing artery disease or a specific medical treatment or device. Most of these materials were in the form of printable, downloadable documents in PDF format, which could be easily obtained and reviewed by patients. Some were also available in HTML and could be read directly from the web browser. We saved and printed or otherwise obtained each of these materials, so that they could be reviewed and compared. Abbreviated content summaries and evaluations for each of these materials are in Appendix 1.

Support Groups and Online Communities

I find it increasingly common for patients to seek information on the internet, and often they stumble across online “communities” such as web forums and message boards, which can be an excellent source of both information and support. An internet search will yield many such communities for PAD patients, and many patients with internet access can benefit from becoming involved in one of them. At the time of writing, the ACLS Medical Training PAD forum is another newly established platform for PAD patients, and we hope to see it grow into a valuable resource for patients seeking peer support and information.

PAD patients can also find education and support programs through the Peripheral Arterial Disease Coalition. P.A.D. Pals is a national community-based patient support service utilizing a network of trained volunteers who have learned to successfully manage their own PAD or who may have cared for loved ones with the disease. Step-by-Step is a community-based lifestyle behavior change and support program designed to increase physical activity in men and women with symptomatic PAD. Both programs have published studies demonstrating their effectiveness and have the potential to improve patient quality of life.

The last decade has seen tremendous growth in the availability of support groups and online communities for patients. These resources allow patients to learn from the experiences of others who have similar health concerns. Support groups have been shown to improve health outcomes and quality of life. There are almost certainly support groups both for PAD and for other conditions affecting the patient. Patients should ask their healthcare providers, or look in local newspapers or the internet in order to find groups in their area. The internet in particular is a good resource for locating support groups, and offers the additional benefit of being able to connect with others without having to leave the house. Online support can come in other forms as well, such as one-to-one peer support or information exchange, both of which have been shown to have positive effects on quality of life.

Healthcare Provider Collaboration

While preventive efforts have been unique to individual health systems, the Wisconsin initiative to disseminate the CARE guidelines has fostered the development of a statewide effort involving multiple healthcare systems. This has been accomplished through the use of a national PAD conference, regional meetings, and active dissemination of materials. In Wisconsin, a concerted effort is also underway to create a web-based registry for PAD patients. In Western Australia, a similar multidisciplinary effort led to the development of clinical pathways for PAD and a script for PAD-specific wound care.

Patients with chronic illnesses often benefit when the healthcare team is in sync. This principle has been ascertained for PAD, diabetes, and other chronic illnesses. If patients are indeed to be central in managing their conditions, health systems must find ways to collaboratively work with patients and amongst themselves to meet patient needs. AHRQ is currently funding a 3-year study to test whether a web-based system can improve communication among professionals and with patients to create a care management plan that is tailored to the needs of individual patients.