Peripheral arterial disease (Arteriosclerosis)

What is Peripheral arterial disease?

Peripheral arterial disease (Arteriosclerosis) Arteriosclerosis of the extremities is a disease of the blood vessels characterized by narrowing and hardening of the arteries that supply the legs and feet. This causes a decrease in blood flow that can injure nerves and other tissues.

Statistics on Peripheral arterial disease?

This is a common disorder. The incidence is approximately 1% per year for men over the age of 65 (as detected by intermittent pain in the calf/thigh).

Risk Factors for Peripheral arterial disease

The main predisposing factor for the development of peripheral vascular disease is atherosclerosis.

Risk factors for atherosclerosis include:

Smoking.
Dyslipidaemia (abnormal concentrations of lipids or lipoproteins in the blood).
Hypertension.
Diabetes Mellitus.

General Cardiovascular Disease 10-Year Risk Calculator

This risk assessment tool is based on data from the Framingham Heart Study to estimate 10-year risk for general cardiovascular disease outcomes (coronary death, myocardial infarction, coronary insufficiency, angina, ischaemic stroke, haemorrhagic stroke, transient ischaemic attack, peripheral artery disease, heart failure). This tool is designed to estimate risk in adults aged 30-74 years of age without CVD at baseline examination. Use the calculator below to estimate 10-year risk.

Predictors

Age		years
		Male	Female
Gender
		Yes	No
Have you been diagnosed with Type II diabetes?
Are you a smoker?^*
Are you prescribed medication to lower your blood pressure?

If you do not know the following blood pressure and cholesterol parameters ask your General Practitioner on your next visit.
Systolic blood pressure^**		mmHg

Total cholesterol^***	mmol/L OR	mg/dl

HDL cholesterol^****	mmol/L OR	mg/dl

Results

Significant (> 20%)
Elevated (10–20%)
Mild risk (< 10%)
You have a significant risk of future cardiovascular disease requiring aggressive risk factor modification. You should see a health professional to ensure appropriate management.

If diabetic, your sugar levels should be well controlled.
Continue to avoid tobacco use or if you are a smoker, consider stopping this is something your General Practitioner can help you with.
Blood pressure should be monitored closely. If elevated you should consider either lifestyle modification or appropriate medication. Your general Practitioner can advise you on this.
Cholesterol levels should be assessed at least annually. Depending on your level, you might be advised to commence lifestyle changes or medication.

Significant (> 20%)
Elevated (10–20%)
Mild risk (< 10%)
You have an elevated risk of future cardiovascular disease requiring risk factor modification. You should see a health professional to ensure appropriate management.

If diabetic, you should aim for your sugar levels to be well controlled.
Continue to avoid tobacco use or if a smoker, consider stopping this is something your general practitioner can help you with.
Blood pressure should be monitored closely. If elevated you should consider either lifestyle modification or appropriate medication. Your general Practitioner can advise you on this.
Cholesterol levels should be assessed at least annually. Depending on your level you might be advised to commence lifestyle changes or medication.

Significant (> 20%)
Elevated (10–20%)
Mild risk (< 10%)
You have a mild risk of future cardiovascular disease, consider risk factor modification. You may like to see a health professional to ensure appropriate management.

If diabetic, you should aim for your sugar levels to be well controlled.
Continue to avoid tobacco use or if a smoker, consider stopping this is something your general practitioner can help you with.
Blood pressure should be monitored closely. If elevated you should consider either lifestyle modification or appropriate medication. Your general Practitioner can advise you on this.
Cholesterol levels should be assessed at least annually. Depending on your level you might be advised to commence lifestyle changes or medication.

^*For these purposes "smoker" means any cigarette smoking in the past month.
^**Use current blood pressure, regardless of whether the person is on antihypertensive therapy.
^***Total cholesterol values should be the average of at least two measurements obtained from lipoprotein analysis.
^****HDL cholesterol values should be the average of at least two measurements obtained from lipoprotein analysis.

References:

D'Agostino RB, Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM, Kannel WB. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation 2008; 117: 743-753.
National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002; 106: 31433421.
Stancoven A, McGuire DK. Preventing macrovascular complications in Type 2 Diabetes Mellitus: glucose control and beyond. American Journal of Cardiology 2007; 99: 5H-11H.

This tool needs javascript enabled to work.Male risk estimate

Points

Age

HDL

Total Cholesterol

SBP Not Treated

SBP Treated

Smoker

Diabetic

-2

60+

<120

-1

50-59

30-34

45-49

<160

120-129

<120

35-44

160-199

130-139

35-39

<35

200-239

140-159

120-129

240-279

160+

130-139

Yes

280+

140-159

Yes

40-44

160+

45-49

50-54

55-59

60-64

65-69

70-74

75+

Points

CVD risk

Heart age (years)

-3 or less

Below 1%

< 30

-2

1.1%

< 30

-1

1.4%

< 30

1.6%

1.9%

2.3%

2.8%

3.3%

3.9%

4.7%

5.6%

6.7%

7.9%

9.4%

11.2%

13.2%

15.6%

18.4%

21.6%

25.3%

29.4%

> 80

18 +

> 30%

> 80

Female risk estimate

Points

Age

HDL

Total Cholesterol

SBP Not Treated

SBP Treated

Smoker

Diabetic

<-3

<120

-2

60+

-1

50-59

<120

30-34

45-49

<160

120-129

35-44

160-199

130-139

35-39

<35

140-149

120-129

200-239

130-139

Yes

40-44

240-279

150-159

Yes

45-49

280+

160+

140-149

150-159

50-54

160+

55-59

60-64

65-69

70-74

75+

Points

CVD risk

Heart age (years)

-2 or less

<1%

<30

-1

1.0%

<30

1.2%

<30

1.5%

1.7%

2.0%

2.4%

2.8%

3.3%

3.9%

4.5%

5.3%

6.3%

7.3%

8.6%

10.0%

11.7%

13.7%

>80

15.9%

>80

18.5%

>80

21.5%

>80

24.8%

>80

28.5%

>80

21+

>30%

>80

More than 20 points

Significant risk of future cardiovascular disease requiring aggressive risk factor modification. You should see a health professional to ensure appropriate management.

If diabetic, your sugar levels should be well controlled.
Continue to avoid tobacco use or if you are a smoker, consider stopping this is something your General Practitioner can help you with.
Blood pressure should be monitored closely. If elevated you should consider either lifestyle modification or appropriate medication. Your general Practitioner can advise you on this.
Cholesterol levels should be assessed at least annually. Depending on your level, you might be advised to commence lifestyle changes or medication.

10 to 20 points

Elevated risk of future cardiovascular disease requiring risk factor modification. You should see a health professional to ensure appropriate management.

If diabetic, you should aim for your sugar levels to be well controlled.
Continue to avoid tobacco use or if a smoker, consider stopping this is something your general practitioner can help you with.
Blood pressure should be monitored closely. If elevated you should consider either lifestyle modification or appropriate medication. Your general Practitioner can advise you on this.
Cholesterol levels should be assessed at least annually. Depending on your level you might be advised to commence lifestyle changes or medication.

Less than 10 points

Mild risk of future cardiovascular disease, consider risk factor modification. You may like to see a health professional to ensure appropriate management.

If diabetic, you should aim for your sugar levels to be well controlled.
Continue to avoid tobacco use or if a smoker, consider stopping this is something your general practitioner can help you with.
Blood pressure should be monitored closely. If elevated you should consider either lifestyle modification or appropriate medication. Your general Practitioner can advise you on this.
Cholesterol levels should be assessed at least annually. Depending on your level you might be advised to commence lifestyle changes or medication.

This information will be collected for educational purposes, however it will remain anonymous.

Progression of Peripheral arterial disease

Atherosclerotic and degenerative changes to the arteries of the legs lead to ischaemia of muscles and skin. This can be either chronic (usually only on exertion) or an acute episode of ischaemia (heart attack), usually related to an embolic event (a clot, usually from the heart).

Ischaemia of the muscles of the legs, particularly the calves, produces a characteristic pain on walking known as intermittent claudication, which stops on ceasing walking and recurs again when the same distance is walked. This may progress to occur at rest - classically at night, relieved by hanging the affected leg off the edge of the bed. Acute embolic disease can produce limb threatening ischaemia. Foot ulcers often develop around the malleoli and may be painful and show poor healing.

How is Peripheral arterial disease Diagnosed?

Baseline checks of lipid profile, blood sugar and renal function should be done. ECG may be useful if coronary artery disease is suspected to co-exist.

Prognosis of Peripheral arterial disease

The chances of losing a limb to peripheral vascular disease is quite high and hence the disease is associated with high morbidity. However most of the mortality associated with peripheral vascular disease is incidental and related to the fact that most patients have co-existing coronary artery disease and cerebrovascular disease - causing heart attacks and strokes, respectively.

How is Peripheral arterial disease Treated?

Risk factors for atherosclerosis should be addressed such as smoking, lipids, diabetes and hypertension. Patients should be encouraged to exercise - since this can improve blood supply by causing additional blood vessels to open up. Foot care and trauma reduction greatly reduce the morbidity associated with peripheral vascular disease. Antiplatelet drugs should be used to prevent risk of myocardial infarction and cerebrovascular disease.

Surgery should be considered for unstable disease or in the acute setting where limb threat is high. Options include angioplasty for stenoses and removal of clots in embolic disease. Severely necrotic limbs may require amputation.