Management of Peripheral Arterial Disease
Background: Peripheral arterial disease (PAD) is the chronic obstruction of the arteries supplying the lower extremities. The most common symptom is intermittent claudication resulting in aching pain, numbness, weakness, or fatigue in the muscle groups of the lower extremities.
Methods: Using the key words "peripheral arterial disease," "intermittent claudication," "atherosclerosis," and "cardiovascular disease," MEDLINE databases were searched from 1970 to the present. The most recent articles pertinent to current treatment recommendations for PAD and intermittent claudication were selected to document this review.
Results and Conclusions: Symptoms of intermittent claudication are induced by walking or exercise and usually resolve with rest. Disease severity varies from patients who are asymptomatic to those who have unremitting symptoms. A high overlap exists between PAD and coronary artery and cerebrovascular disease. Risks for long-term morbidity and mortality are identical for PAD, intermittent claudication, and coronary artery disease. Treatment of PAD is aimed at maintaining or improving functional status, reducing or eliminating ischemic symptoms, and preventing disease progression. Exercise and aggressive risk factor modification represent the cornerstones of treatment. Risk factors include smoking, diabetes, lipid abnormalities, hypertension, C-reactive protein, lipoprotein(a), and hyperhomocystinemia. Antiplatelet and lipid-altering therapies decrease risk of atherosclerotic vascular complications and are being studied to improve intermittent claudication. Cilostazol, a new antiplatelet, antithrombotic agent, reduces claudication symptoms. Angiogenic growth factors have shown preliminary success in patients with rest pain and ischemic ulcers and are being investigated for use in patients with intermittent claudication. Invasive revascularization procedures can be considered for patients with critical limb ischemia or when medical therapy fails.
Peripheral arterial disease (PAD) is a common manifestation of systemic atherosclerosis. The most frequent symptom is intermittent claudication, which results from poor oxygenation of the muscles of the lower extremities and is experienced typically as an aching pain, cramping, or numbness in the calf, buttock, hip, thigh, or arch of the foot. Symptoms are induced by walking or exercise and are relieved by rest.
Patients can be stratified into groups according to symptom severity. One half of all PAD patients older than 55 years are asymptomatic. Of the symptomatic patients, approximately 40% experience intermittent claudication, and 10% have critical limb ischemia. Intermittent claudication is usually accurately diagnosed based on the vascular history and physical examination, which should include palpation of the abdomen and peripheral pulses. Because palpation of the peripheral pulses alone is too insensitive a measure of PAD, noninvasive vascular tests, such as determining the ankle-brachial index, should be performed to quantify the degree of limb ischemia. The ankle-brachial index, which is the ratio of the ankle systolic pressure to the brachial artery systolic pressure (Table 1), is useful in assessing disease severity. An ankle-brachial index greater than 0.90 is considered normal; greater than 0.70 to 0.89 is considered mild disease; 0.5 to 0.69, moderate disease; and less than 0.5, severe disease.
Background: Peripheral arterial disease (PAD) is the chronic obstruction of the arteries supplying the lower extremities. The most common symptom is intermittent claudication resulting in aching pain, numbness, weakness, or fatigue in the muscle groups of the lower extremities.
Methods: Using the key words "peripheral arterial disease," "intermittent claudication," "atherosclerosis," and "cardiovascular disease," MEDLINE databases were searched from 1970 to the present. The most recent articles pertinent to current treatment recommendations for PAD and intermittent claudication were selected to document this review.
Results and Conclusions: Symptoms of intermittent claudication are induced by walking or exercise and usually resolve with rest. Disease severity varies from patients who are asymptomatic to those who have unremitting symptoms. A high overlap exists between PAD and coronary artery and cerebrovascular disease. Risks for long-term morbidity and mortality are identical for PAD, intermittent claudication, and coronary artery disease. Treatment of PAD is aimed at maintaining or improving functional status, reducing or eliminating ischemic symptoms, and preventing disease progression. Exercise and aggressive risk factor modification represent the cornerstones of treatment. Risk factors include smoking, diabetes, lipid abnormalities, hypertension, C-reactive protein, lipoprotein(a), and hyperhomocystinemia. Antiplatelet and lipid-altering therapies decrease risk of atherosclerotic vascular complications and are being studied to improve intermittent claudication. Cilostazol, a new antiplatelet, antithrombotic agent, reduces claudication symptoms. Angiogenic growth factors have shown preliminary success in patients with rest pain and ischemic ulcers and are being investigated for use in patients with intermittent claudication. Invasive revascularization procedures can be considered for patients with critical limb ischemia or when medical therapy fails.
Peripheral arterial disease (PAD) is a common manifestation of systemic atherosclerosis. The most frequent symptom is intermittent claudication, which results from poor oxygenation of the muscles of the lower extremities and is experienced typically as an aching pain, cramping, or numbness in the calf, buttock, hip, thigh, or arch of the foot. Symptoms are induced by walking or exercise and are relieved by rest.
Patients can be stratified into groups according to symptom severity. One half of all PAD patients older than 55 years are asymptomatic. Of the symptomatic patients, approximately 40% experience intermittent claudication, and 10% have critical limb ischemia. Intermittent claudication is usually accurately diagnosed based on the vascular history and physical examination, which should include palpation of the abdomen and peripheral pulses. Because palpation of the peripheral pulses alone is too insensitive a measure of PAD, noninvasive vascular tests, such as determining the ankle-brachial index, should be performed to quantify the degree of limb ischemia. The ankle-brachial index, which is the ratio of the ankle systolic pressure to the brachial artery systolic pressure (Table 1), is useful in assessing disease severity. An ankle-brachial index greater than 0.90 is considered normal; greater than 0.70 to 0.89 is considered mild disease; 0.5 to 0.69, moderate disease; and less than 0.5, severe disease.