Peripheral Arterial Disease And Stroke
By Joe Flasher
Why are we considering Peripheral Arterial Disease (PAD? Because this disease can cause a stroke or a second stroke, or a stroke can contribute to this disease developing. Peripheral arterial disease may not sound familiar, but it affects 8 to 12 million Americans, and is one of a host of cardiovascular disorders that go beyond the heart. New data from the American Heart Association's Heart Disease and Stroke Statistics - 2004 Update reveal the burden of these often-chronic diseases.
Some of these disorders include congestive heart failure, peripheral arterial disease (clogged vessels in the arms and legs), end-stage renal disease and venous thromboembolism (blood clot).
For the purposes of this article we are only concerned with Peripheral Arterial Disease. Peripheral artery disease (PAD) affects 12 to 20 percent of Americans 65 and older (4.5 to 7.6 million people). Despite its prevalence and cardiovascular risk implications, only 25 percent of PAD patients are undergoing treatment. PAD is a condition similar to coronary artery disease and carotid artery disease. In PAD, fatty deposits build up along artery walls and affect blood circulation, mainly in arteries leading to the legs and feet. In its early stages, a common symptom is cramping or fatigue in the legs and buttocks during activity. People with PAD have a higher risk of death from stroke and heart attack, due to the risk of blood clots
About 1 in 3 patients with PAD may experience intermittent claudication -the classic symptom used in diagnosing PAD 4,5 -most patients with PAD are asymptomatic ( without symptoms) 6 Intermittent claudication is defined as ischemia in the lower extremities, experienced as an aching pain, cramping, or numbness, typically in the calf.. These symptoms are usually induced by walking and relieved by rest. Symptomatic or not, patients with PAD often have widespread arterial disease and therefore have an increased risk of myocardial inraection (MI), stroke, and other thrombotic events. 8 Studies indicate a 1% to 3% annual incidence of nonfatal MI in these patients, with mortality rates approximately 2.5 times greater than those of the general population. 8 Cardiovascular diseases are responsible for about 52% of deaths in the general population and up to 75% in patients with PAD. 8
Recognition and management of the risk factors in patients with PAD are of extreme importance. The risk factors for lower-extremity atherosclerosis include, but are not limited to, age, male sex, hyperlipidemia, and diabetes mellitus (DM), hypertension, and smoking. Additional factors to be addressed include physical activity and diet.
"Although patients with PAD have widespread atherosclerosis, atherothrombosis (formation of a thrombus superimposed on an atherosclerotic plaque) is primarily responsible for the arterial ischemic events such as MI, stroke, critical leg ischemia, and cardiovascular death. Clinicians need to treat both the increased cardiovascular risk and the symptoms, if present. Platelets have been shown to demonstrate shortened survival but increased activation in patients with PAD. 8 Antiplatelet therapy has been shown to reduce the risk of serious vascular events (MI, stroke, vascular death) by about 25% in patients with manifestations of atherosclerAosis, including PAD.
We have considered drugs used for cholesterol, Hypertension in previous articles. Those drugs used in diabetes mellitus are numerous and can be considered in another article.
The use of tobacco contributes the most risk of developing PAD. 3 It has been documented that smoking decreases patient survival and longevity of vascularization procedures and contributes to the progression of arterial disease.
Smoking cessation not only reduces the risk of death from vascular causes and MI, but also slows the progression to leg ischemia in patients with PAD. 4, 5 Estimates indicate that approximately 80% to 90% of patients who present for percutaneous or surgical revascularization due to ischemic rest pain, severe claudication, or gangrene are current smokers. 3 It is also estimated that the 5- year mortality rate for patients who continue smoking is about 40% to 50%. 3 Additionally, smoking cessation may reduce the progression of the disease from asymptomatic to stable claudication to ischemic rest pain and finally to amputation.
PAD is a serious disorder that is now considered a coronary heart disease (CHD) risk equivalent. Thus, patients with PAD carry a risk for major coronary events that is equal to that of patients with established CHD. Recognition and management of the risk factors in patients with PAD are of extreme importance. These factors include age, male sex, hyperlipidemia, DM, hypertension, and smoking.
The use of tobacco is the most important cause of PAD. It has been well established that smoking contributes to the progression of arterial disease, as well as decreasing the longevity of vascularization procedures and patient survival.
Because patients with PAD are at a significantly increased risk for cardiovascular events and death, antiplatelet therapy should be strongly considered in the management of these patients. Although the data are not strong for the use of aspirin, aspirin is still considered the primary antiplatelet drug for patients with PAD. Currently, clopidogrel is the only antiplatelet medication that has received FDA approval for the reduction of atherosclerotic events (MI, stroke, and vascular deaths) in patients with atherosclerosis documented by recent MI, recent stroke, or established PAD. A formal exercise program is considered the most effective non-pharmacologic therapy for claudication.
I cannot emphasize the exercise and not smoking enough. It is extremely important to the prevention of stroke and other vascular problems
If there are any questions please notify me through the StrokeNet Newsletter.
American Stroke Association
Joe Flasher is a Pharmacist.
Copyright © February 2004
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