Winter 2009

Aggressive Management Best for Asymptomatic PAD

Despite substantial research showing that peripheral artery disease (PAD) puts people at increased risk for heart attack, stroke, amputation and other vascular-related conditions, PAD remains significantly under diagnosed and under treated.

"These are very vulnerable patients," says Michael S. Conte, M.D., chief of Vascular and Endovascular Surgery at UCSF Medical Center and one of the country's leading PAD experts. "Most are over 70. Many are diabetics or smokers or both, and have other vascular conditions — and many are asymptomatic. Moreover, the course of the disease in individual patients is unpredictable. That's why physicians must be especially diligent in looking for PAD in at-risk populations."

"When patients come in with a related condition like chest pain, it is not only important to do a complete cardiac evaluation, but it is just as important to ask about things related to other vascular territories, such as neurological symptoms, claudication symptoms, erectile dysfunction and foot ulcerations," says cardiovascular specialist Yerem Yeghiazarians, M.D. "Many of these patients will often have diffuse and, at times, asymptomatic vascular problems involving organs other than the heart arteries, and these can only be diagnosed by careful history, examination and appropriate screening."

"The key diagnostics are usually simple — typically a thorough examination of the legs and feet, a pulse exam and an ankle-brachial index," says Conte. "And if something emerges or if there are more active symptoms, we recommend a complete diagnostic evaluation by a vascular specialist."

Comprehensive Risk Factor Management

Once a patient is diagnosed, recent research indicates that PAD merits aggressive management of all cardiovascular disease (CVD) risk factors. A UCSF team is engaged in a five-year, randomized, controlled trial with PAD patients that examines how effectively reducing multiple CVD risk factors affects walking and vascular health.

"Anti-platelet therapy is the cornerstone," says nurse-scientist Roberta Oka, RN, DNSc, who is the study's principal investigator. But there also is strong evidence to support the use of lipid-lowering medications (statins). Hypertension and diabetes are aggressively monitored and managed. Diet and exercise are key adjunctive therapies, as are stress management and smoking cessation. Focusing on small, achievable goals set by the patient and provider — and improving self-efficacy for specific behaviors — helps patients achieve the lifestyle changes.

"Patient education also is fundamental," says Oka. "We focus on improving a person's understanding of their risk factors, and the synergy between pharmacologic and adjunctive strategies to optimize self-management."

Oka is especially concerned about the tendency to have lower expectations of what an older population can achieve. "This can lead to under medication and a failure to lower risk factors to clinical standards," says Oka. "We know this program is labor-intensive and not every practice can do all aspects of it, but setting goals and ongoing monitoring are extremely important. We have found patients to be very interested in improving their health and especially in improving their ability to walk, even in their late 70s and 80s, which can ease the burden on clinicians."

Optimal Targets for PAD Management

  • Smoking: Complete cessation
  • Antiplatelet therapy: Aspirin (81 mg daily) or other anti-platelet therapy, as appropriate
  • Lipid management: Treatment with lipid-lowering agents (such as statins) to achieve a target LDL of less than 100 mg/dl, or less than 70 mg/dl for patients at very high risk of events
  • Blood pressure control: Less than 120/80 mmHg for patients without complicating conditions (JNC 7* considers patients between 120/80 mmHg and 139/89 mmHg to be pre-hypertensive)
  • If diabetic: Normal fasting plasma glucose (less than 100 mg/dl) and normal HbA1c (less than 7 percent)
  • Nutrition and weight management: A healthy eating pattern (typically low fat and low cholesterol, leading to a BMI of 18.5 kg/m to 24.9 kg/m)
  • Exercise: 50 minutes walking, five days per week (Inter-Society Consensus for the Management of PAD* *)
  • Stress management: Improve emotional well-being

To contact Michael S. Conte, M.D., call (415) 353-4366.

To contact Yerem Yeghiazarians, M.D., call (415) 353-3815.

To contact Roberta Oka, R.N., DNSc, call (415) 514-3407.

*The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, 2003.

* *TransAtlantic Inter-Society Consensus (TASC) II, 2006.

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