Peripheral Artery Disease and Intermittent Claudication

Description

Alternative Names

Lifestyle Changes

Given the aging population and the significant heart risks associated with peripheral artery disease (PAD), experts believe that aggressive therapies are important. There is substantial evidence, however, that peripheral artery disease (PAD) is underdiagnosed and undertreated.

The treatment goals for PAD and claudication are twofold.

• To manage the pain of intermittent claudication, improve functioning, and prevent progression that might lead to gangrene and amputation.
• To reduce the risk for cardiovascular disease (i.e., heart attack and stroke). There is substantial evidence to indicate that even when patients were treated for PAD, they are frequently not being given information or therapies to reduce the risk for cardiovascular disease.

Lifestyle changes are critical for every patient with PAD. Medication is often required to improve function and protect the heart. In very severe cases, surgery may be needed to improve blood flow.

Screening for and Managing Diabetes

People with type 2 diabetes have three to four times the usual risk for PAD and intermittent claudication. They also tend to develop PAD at earlier ages and to be at a significant risk for heart disease. Patients with both diabetes and PAD should be screened for heart disease. In a 2003 study, aggressive reduction of blood pressure in PAD patients who had diabetes significantly reduced their risk for heart attack and stroke. Aggressive reduction of cholesterol levels, usually with a statin drug, is equally important.

In addition, patients with both diabetes and PAD are at significant risk for heart disease and severe complications in the legs and feet. For example, in one study, people with diabetes and intermittent claudication had a 30% chance of developing skin ulcers on their legs.

Quitting Smoking

For smokers, quitting is essential. It is one of the primary risk factors for PAD and a major cause of complications. (Quitting smoking may not alleviate leg pain, at least not in the short term, but it certainly may slow the progress of the blockage and reduce risk to the heart.) Smokers in their thirties and forties have a heart-attack rate that is five times higher than their nonsmoking peers. Cigarette smoking may be directly responsible for at least 20% of all deaths from heart disease, or about 120,000 deaths annually.

Exercise

In addition to quitting smoking, exercise is the most important life-style measure for patients with PAD and intermittent claudication.

Exercise to Help the Heart. The benefits of regular moderate exercise for the heart are undisputed. People who maintain an active lifestyle have a 45% lower risk of developing heart disease than do sedentary people. Some studies suggest that for the greatest heart protection, it is not the duration of a single exercise session that counts but the total daily amount of energy expended. Therefore, the best way to exercise may be in multiple short bouts of intense exercise, which can be particularly helpful for older people.

Exercise Training to Improve Blood Flow in the Legs. Exercise training also changes blood flow in the leg and, in many cases, is proving to be as beneficial as medications and surgical procedures in increasing pain-free walking distance. The best results are seen in motivated patients who are given supervised training and who have a relatively short recovery time after exercise. Unfortunately, insurance does not usually cover these programs, and patients should understand that exercise must be regular and consistent, or benefits will be lost.

Eating Habits

The goals of a heart-healthy diet are to eat foods that help obtain or maintain healthy levels of cholesterol and lipids (fatty molecules) by achieving the following:

• Reducing overall cholesterol levels and low-density lipoproteins (LDL), which are harmful to the heart.
• Increasing high-density lipoproteins (HDL), which are beneficial for the heart.
• Reducing other harmful lipids (fatty molecules), such as triglycerides and lipoprotein(a).

Any diet should also help keep blood pressure and weight under control.

General Recommendations. Although there are many major dietary approaches for protecting health, experts generally agree on the following recommendations for heart protection:

• Choose fiber-rich food (whole grains, legumes, nuts) as the main source of carbohydrates, along with a high intake of fresh fruits and vegetables.

Dietary fiber is the part of food that is not affected by the digestive process in the body. Only a small amount of fiber is metabolized in the stomach and intestine, the rest is passed through the gastrointestinal tract and makes up a part of the stool. There are two types of dietary fiber, soluble and insoluble. Soluble fiber retains water and turns to gel during digestion. It also slows digestion and nutrient absorption from the stomach and intestine. Soluble fiber is found in foods such as oat bran, barley, nuts, seeds, beans, lentils, peas, and some fruits and vegetables. Insoluble fiber appears to speed the passage of foods through the stomach and intestines and adds bulk to the stool. It is found in foods such as wheat bran, vegetables and whole grains. Fiber is very important to a healthy diet and can be a helpful aid in weight management. One of the best sources of fiber comes from legumes, the group of food containing dried peas and beans.

• Avoid saturated fats (found mostly in animal products) and transfatty acids (found in hydrogenated fats and many commercial products and fast-foods). Choose unsaturated fats (particularly omega-3 fatty acids found in vegetable and fish oils).

Click the icon to see an image of saturated fats.

Click the icon to see an image of trans-fatty acids.

• In selecting proteins, choose soy protein, poultry, and fish over meat.
• Weight control, quitting smoking, and exercise are essential companions of any diet program.

After embarking on any heart healthy diet, it generally takes an average of three to six months before any noticeable reduction in cholesterol occurs, although some people have reported better levels in as few as four weeks. An intensive program may be necessary to achieve significant improvements in cholesterol levels and to reduce other heart risk factors.

Vitamins

In general, no vitamins have been proven to reduce the risk for heart disease or PAD. Nevertheless, deficiencies in the B vitamins folate and B12 have been associated with a higher risk for heart disease in some (but not all) studies. Such deficiencies produce elevated blood levels of homocysteine, an amino acid that has been associated with a higher risk for heart disease and PAD. Folate improves blood flow through the arteries, which may be as important for the heart as its effect on homocysteine. It is unclear, however, whether folate and other vitamin B supplements can improve blood flow and reduce the risk for heart disease in PAD patients.

Alternative Agents

Glutathione. Glutathione is a natural compound produced in animal and plant cells, which is also a powerful antioxidant. In one small study, patients who took it experienced improved pain-free walking and there seemed to be improved blood flow. More research is warranted.

Gingko. One analysis of eight studies reported that the herbal remedy ginkgo biloba has some modest effect on pain-free walking. The drug has blood-thinning properties and is available over the counter. Although the risks for gingko appear to be low, there is an increased risk for bleeding at high doses and interaction with high doses of vitamin E and anti-clotting medications. This is particularly important since such medications are common in PAD patients.

Commercial gingko preparations have also been reported to contain colchicine, an agent that can be harmful in pregnant women and people with kidney or liver problems. It should be further noted that not all brands have any effect at all. In a 2002 study, one-third of 26 brands tested did not contain enough active ingredients to provide any benefits at all. It should be strongly noted that herbal remedies are not regulated and standards are not guaranteed.