Peripheral artery disease (PAD) is probably one of the most underdiagnosed entities in the vascular world. When screening for atherosclerosis and PAD, clinicians should ensure that they are looking for specific patient risk factors. We know that the most common risk factor is smoking, followed by diabetes, hypertension, and hyperlipidemia. If patients have any of those known risk factors, a thorough vascular examination should be performed. Clinicians should examine patients with their shoes and socks off to ensure that an adequate pulse assessment is performed, in addition to carefully listening for bruits.
We know that patients older than 65 are at increased risk for PAD and that PAD is one of the top 3 causes of atherosclerotic cardiovascular disease. The incidence of PAD is estimated at more than 200 million worldwide and approximately 8.5 million in the United States and increases with age.1,2
Patients older than 65, and those between 50 and 64 with additional risk factors for atherosclerosis or a family history of PAD, should be actively screened for PAD. Patients younger than 50 but with diabetes and additional risk factors for atherosclerosis should also be screened.
We know that having vascular disease in one vascular bed is often a predictor for vascular disease in another vascular bed. If disease is present in 2 or more beds, the patient has defined polyvascular disease. If a patient has PAD, they are more likely to have carotid disease. Similarly, if a patient has carotid disease, they are more likely to have coronary artery disease. Thus, identification of polyvascular disease is important, and healthcare providers should initiate a conversation with their patients indicating that the presence of risk factors necessitates screening for PAD.
Patients have variable presentations of PAD, with approximately 50% having no symptoms and only 15% having the classic intermittent claudication symptoms described by Rose in 1962.3 If we wait for patients with classic symptoms to come in to our office, we will miss approximately 75% to 80% of patients with PAD. Claudication is not always the presenting symptom of PAD. Patients may have functional impairment, a history of nonhealing wounds, or other clues that should prompt a clinician to conduct a comprehensive vascular examination and send the patient for an ankle-brachial index, which is the primary diagnostic test for PAD.
Treating Risk Factors
Smoking cessation remains a vital component in reducing the risk of developing PAD, as smoking is the most common PAD risk factor. As clinicians, our job is not to be the critic, but to be the advocate for our patients’ smoking cessation success. Several things come into play at this point. Patients need to be psychologically prepared to quit. We know that approximately 70% of smokers really want to quit. We usually start with behavioral therapy and then look to nicotine replacement strategies. Medications such as bupropion and varenicline have been very effective. Hypnosis has also been successful in some patients.
Several organized programs including smoking cessation clinics and Nicotine Anonymous meetings are another option for patients. Clinics should consider hosting some meetings after office hours as this would show the commitment of the practice to use that space to engage patients in smoking cessation efforts. Although vaping had been suggested as a possible bridge to smoking cessation, we now know that vaping is associated with significant lung disease4 and is not a helpful smoking cessation strategy.
The use of supervised exercise programs in patients with lifestyle-limiting claudication must be strongly encouraged by clinicians. Exercise doesn’t cure PAD, but it certainly allows patients to exercise or walk without experiencing pain, which improves their quality of life. I’m a huge proponent of exercise, whether supervised or home walking programs, for patients with PAD. Studies have found that supervised treadmill walking improves walking distance in patients with symptomatic PAD.5 The Centers for Medicare & Medicaid Services (CMS) now reimburses for this type of program, similar to cardiac rehabilitation.6 These programs typically run approximately 3 times a week for at least 12 weeks. Patients walk until they get moderate pain, then rest until the pain subsides, and then they resume walking. This cycle of intermittent walking lasts for about 50 minutes. If supervised walking programs are not available, clinicians can provide their patients with instructions for home exercise therapy.