Peripheral Artery Disease
(3/8/09) A reader asked us for more data on our updated article on PAD (item dated 1/29/09 below) in which we reported on the effects of treadmill walking that appeared in JAMA..
The investigation involved 153 patients randomly assigned to three different arms of treatment: 51 were assigned to supervised treadmill exercise three times per week, beginning with 15 minute sessions and working up to 40 minutee sessions; 52 patients were assigned to lower extremity resistence training three times per week, performing three sets of eight repititions of knee extensions, leg presses and leg curls using standard equipmemnt as well as squat toe-rise exercises; the remaining patients served as controls.
The exercise program lasted for six months. Outcome measures included distance walked in a six minute walk test, brachial artery flow-mediated dilation, overall physical functioning and quality of life.
The chief investigator, Dr. Mary McDermott, noted that this was the first randomized controlled clinical trial of exercise in PAD to include subjects without intermittant claudation. The treadmill group improved in all outcome measures.
The take home message from this study is that patients with PAD should undertake treadmill exercise as a step in improving their health. In general, walking is good medicine. The site states "Walkers have less incidence of cancer, heart disease, stroke, diabetes and other killer diseases.
They live longer and get mental health and spiritual benefits." Treat yourself to a good walk daily and see the benefits to your health after 6 months.
(1/29/09)- People with peripheral artery disease (PAD), with or without intermittent claudication, can benefit from regular supervised treadmill exercise and resistance training that targets their lower extremities.
Writing in the January 14, 2008 issue of the Journal of the American Medical Association, Dr Mary M McDermott (Northwestern University, Chicago, IL) and colleagues report that PAD patients randomized to supervised treadmill exercise experienced significant improvements in six-minute-walk test, treadmill walking performance, brachial-artery flow-mediated dilation, and quality of life, as compared with control patients.
"Based on findings reported in this trial, physicians should recommend supervised treadmill exercise programs for PAD patients, regardless of whether they have classic symptoms of intermittent claudication," McDermott and colleagues write. "Our findings regarding brachial-artery flow-mediated dilation suggest that supervised treadmill exercise improves global vascular health in patients with PAD." (See: JAMA 2009 Jan 14;301(2):165-74.) .
(2/27/08) The National Health and Nutrition Examination Survey (NHANHES) of 5376 asymptomatic people aged 40 or older indicates that the incidence of peripheral artery disease (PAD) is increasing when the 2003-2004 survey is compared to the 1999-2000 survey year.
PAD was identified by measuring the ankle-brachial index. If the score was below 0.9 on the index, the individual was identified as having PAD. NHANES is run by the Centers for Disease Control and Prevention and the survey is done nationally every two years.
Especially noteworthy is the finding that the prevalence of PAD in asymptomatic women, aged 40 years or older, rose from 4.1% during 1999-2000 to 6.3% in 2003-2004, a 54% jump.
For individuals aged 60-69, the incidence rose to 6.1%% in 2003-2004, an rise of 45% from 1999-2000. The rate for 70 and older held fairly firm at 15% during the years reported in the survey.
This information was reported by Dr. Andrew D. Sumner, medical director of the Heart Station and cardiac prevention at Lehigh Valley Hsospital in Allentown, Pa.
(2/16/06)- The budget bill that was recently signed by President Bush allocated funds, starting in 2007, for the free screening test of new enrollees to Medicare who are considered to be at high risk for abdominal aortic aneurysms. Abdominal aneurysms are responsible for at least 15,000 U.S. deaths each year.
One of the groups considered to be at high risk is men who have smoked more than 100 cigarettes in their lifetime. Another high-risk group is men and women whose family history includes aortic aneurysms. The free test for aortic abdominal aneurysms does not include those who are already covered by Medicare, only the new enrollees starting in 2007.
The backers of the bill for the free coverage estimate that about 58,000 people would be covered by its provision for the free screening test.
4/18/03)-Screening for peripheral arterial disease would seem
to be a step that is frequently overlooked in general medical
checkup, especially in the elderly. It could have serious
implications on the health of the elderly.
The September 14, 2000 issue of the Journal of the American Medical Association (JAMA) reports that peripheral arterial disease, a narrowing of the arteries in the legs and sometimes in the arms, is underdiagnosed and undertreated. The article suggests that this disease may be more common than the estimates of 8 million to 12 million Americans and that doctors are overlooking the disease because of the lack of symptom complaint (leg pain) by patients. Such pain may be present in only ten percent of individuals with this disease, with primary care physicians missing the indications by not paying attention to risk factors. Indications can be picked-up by a simple test involving comparing blood pressure in the arm and ankles.
A follow-up article appearing in the New York Times (Sept. 19, 2001, pp. A13) states: "The study found that only about half of the doctors treating the patients knew about the previous diagnosis in the more than1000 cases diagnosed before the study began, although the patients' charts included the information Among patients in whom the disease had already been diagnosed when the study started, more than 40% had not been prescribed aspirin or other blood-thinning medications and 13% were not on drugs to control high blood pressure, although most should have been taking them."
By identifying this disease at an early stage, patients' health and life expectancy may be improved. This JAMA study recommends that ankle-arm blood pressure comparison of the elderly should be undertaken by primary care doctors to screen patients for peripheral artery disease.
PERIPHERAL ARTERIAL DISEASE STATISTICS
Peripheral Arterial Disease (PAD) is frequently associated with other atherosclerotic diseases such as coronary artery disease (CAD) and cerebrovascular disease. According to Murray and Lopez, writing in Lancet (1997; 349:1498-1504), the above combination of diseases are the principle cause of death and disability in persons 50 years and older. It is estimated that 12% of the adult population in United States, approximately 10-12 million people, will be affected with PAD in their lifetime (See: Hiatt et al. Circulation 1995; 91:1472-1479).
The prevalence of PAD increases with age. The Framingham Heart Study reported that the average annual incidence of PAD based on symptomatic intermittent claudication (IC) increased from 6 per 10,000 men age 30-44 years to 61 per 10,000 aged 65-74. It is estimated that 20% of the population over the age of 70 has PAD. (See: Kannel & McGee. J Amer. Geriatr Soc. 1985; 33:13-18).
Because of the significant overlap between PAD, CAD and cerebrovascular disease, patients with PAD have significantly higher morbidity and mortality when compared to healthy controls. It is estimated that approximately 80% of mortality in PAD patients is from cardiovascular events, 63% of deaths are from CAD, 9% are from cerebrovascular disease and 8% are from other cardiovascular events such as ruptured aneurysm (See: Aronow & Ahn. Am. J Cardiol 1994; 74:64-65).
The most common clinical symptoms of PAD are aching pain, cramping or numbness in the affected limb. These symptoms are induced by activities that increase the oxygen and blood demand of the lower extremities. These activities include exercise and walking. Rest usually relieves these symptoms. However, the symptoms of classic claudication (exercise-induced calf pain, not present at rest, which require stopping and resolves within minutes of rest) are uncommon among patients with PAD.
The medical literature suggests that there are two primary goals in the management of PAD.
1. Relief of intermittent claudication that leads to improvement of functional status and quality of life.
2. Prevention of thrombotic events in peripheral, coronary and cerebrovascular circulation that prolongs overall survival.
Reaching these goals involves aggressive risk modification and pharmacological therapy. Smoking is a high risk factor, so that cessation of smoking is one issue that needs to be addressed using various methodologies both behavioral and adjunctive medical therapies such as nicotine replacement therapy, and bupropion. Blood pressure needs to be reduced to levels below 130/85 mm Hg. Low density lipid levels in the range of 100mg/dl and effective control of diabetes mellitus (glycosylated hemoglobin levels lower than 7%) are sought after through pharmaceutical therapies.
Faulkner et al (Med J Aust 1983; 1:217-219) showed that patients who quit smoking have an approximately 2 to 5 year better survival rate compared to those who continue to smoke.
Reports of the most solid data available on medications that help include coagulation modifiers such as Clopidogrel 75 mg/d or aspirin 81-325 mg/d, ACE inhibitors, Statins, and anti-claudication drugs.
A recent issue of the highly respected journal Drugs (Vol. 63(7): 637-647, 2003) states: "With aggressive risk factor modification and adequate pharmacotherapy, patients with peripheral arterial disease can have an improved quality of life as well as prolonged survival."
(Editors Note)-We received the following e-mail from one of our viewers in connection with this original article, and feel that the question is so important that we have added some information to this article that we feel will be helpful to all our viewers.
I read your article on Exercise and Disease by Harold Rubin
I have been trying to find info on claudation / intermittent claudation, how does it start, what kind of surgery relieves it. But have not come up with any info, I was wondering if you could direct me into a direction.
Response from Harold Rubin
This information is from Evidence-Based Physical Diagnosis
by Steven McGee.
Chronic arterial disease usually affects three distinct segments in the lower limbs:
1. the aortoiliac (especially the infrarenal abdominal aorta and common ileac arteries.
2. the femoropopleal (especially the superficial femoral artery in the abducter canal
3. the peroneolibial (below the knee).
Disease in each segment produces distinct patterns of claudication (lameness/limping).
Diagnostic standard is the ankle-to-arm systolic pressure index (AAI) obtained by measuring the highest blood pressure at the ankle with a hand-held Doppler flowmeter and dividing it by the blood pressure in the brachial artery. Values below 0.97 are abnormal. Most patients with claudication have AAIs between 0.59 and 0.8 and the disease in only a single segment.
We suggest you talk to the doctor about the condition and what steps he/she thinks should be taken on an immediate basis.
The September 14, 2000 issue of the Journal of the American Medical Association (JAMA) reports that peripheral artery disease, a narrowing of the arteries in the legs and sometimes in the arms, is underdiagnosed and undertreated. The article suggests that this disease may be more common than the estimates of 8 million to 12 million Americans and that doctors are overlooking the disease because of the lack of symptom complaint (leg pain) by patients. Such pain may be present in only ten percent of individuals with this disease, with primary care physicians missing the indications by not paying attention to risk factors. Indications can be picked-up by a simple test involving comparing blood pressure in the arm and ankles.
This research looked at 6,979 high-risk patients, who were either 70 years or older or 50 to 69 with a history of smoking or diabetes. They found that 29% had artery disease, including 823 diagnosed during the study. An article appearing in the New York Times (Sept. 19, 2001, pp. A13) states: "The study found that only about half of the doctors treating the patients knew about the previous diagnosis in the more than1000 cases diagnosed before the study began, although the patients charts included the information Among patients in whom the disease had already been diagnosed when the study started, more than 40% had not been prescribed aspirin or other blood-thinning medications and 13% were not on drugs to control high blood pressure, although most should have been taking them."
By identifying this disease at an early stage, patients health and life expectancy may be improved. This study strongly recommends that ankle-arm blood pressure comparison of the elderly should be undertaken by primary care doctors to screen patients for peripheral artery disease.
FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE "HOW TO SELECT A NURSING HOME".
Harold Rubin, MS, ABD, CRC, Guest Lecturer
Updated March 8, 2009
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