Peripheral artery disease can signal cardiovascular trouble for heart, brain and legs

JACKSONVILLE, Florida — If you have not heard of peripheral artery disease, you are not alone. While physicians and health organizations have made headway in raising awareness that heart disease is the No. 1 cause of death worldwide, peripheral artery disease— despite being part of cardiovascular disease — is not as well-known.

The disease is most common in people over age 65. It also affects younger people who have additional risk factors, such as diabetes, smoking, obesity and high blood pressure.

Peripheral artery disease involves the lower limbs, but it has its basis in atherosclerosis — a vascular disease in which cholesterol plaque builds up in artery walls. This narrows the arteries, restricting circulation and possibly resulting in plaque breaking loose and forming a blood clot. Most patients with the disease will have vascular disease in more than one defined area, increasing the chances of serious complications.

Unfortunately, peripheral artery disease often is not diagnosed early enough and patients are often not treated with the most aggressive therapies. Addressing the issue of awareness and education in clinicians and patients is a key focus area in the new PAD National Action Plan led by the American Heart Association. This plan was developed in collaboration with 25 organizations and national leaders.

Amy Pollak, M.D., a cardiologist at Mayo Clinic in Jacksonville, Florida, co-chairs the effort to bring the plan to fruition, along with Dr. Aruna Pradhan of Brigham and Women's Hospital and Dr. Naomi Hamburg of Boston Medical Center.

The plan outlines goals to increase awareness of the disease for patients and health care providers; improve detection, treatment and ultimately health outcomes; reduce amputations related to peripheral artery disease through public health initiatives; increase and sustain research; and advance advocacy efforts.

"If you have polyvascular disease — meaning cholesterol buildup that affects more than one area of the body, such as the heart, brain or leg — then you are at very high risk of heart attack, stroke, death or limb loss related to amputation,” Dr. Pollak says. “Patients with polyvascular disease and diabetes are at the highest peripheral artery disease risk. We must ask about symptoms, treat these patients with aggressive medical therapy and follow them more closely."

As arteries leading to the legs develop significant cholesterol buildup that restricts blood flow, symptoms of the disease may appear. Some symptoms, such as lower leg cramps when walking, may be mild, severe or somewhere in between, but worsen as the disease progresses. Other symptoms may involve changes in the legs, such as coldness in one leg but not the other; shiny skin on the legs; slow growth of toenails and leg hair; sores on toes, feet or legs that do not heal; and no pulse or a weak pulse in legs. People may think some of these symptoms are just signs of aging, so it is important to address them with a health care professional. The most common symptom is a decreased ability to walk. Patients may not have any pain.

A physical exam can uncover symptoms that a patient may not be aware of or had simply attributed to something else. Dr. Pollak says it is important to remove socks and check the legs and feet of patients who fit the risk profile, even if they are younger. Clinicians can ask patients what sort of activities they can comfortably do to identify problems. And blood tests to check for diabetes and measure cholesterol also should be up to date.

Diagnostic tests, such as the ankle-brachial index test that compares blood pressure in a patient's ankle to that in their arm before and after exercise, can identify circulation issues in the legs. This test is a noninvasive way to identify the presence and severity of peripheral artery disease.

Angiograms use imaging technologies to home in on blockages and can be done with CTs or MRI. Catheter angiograms allow for treatment to open the arteries at the same time. When initiated early enough, a procedure in lower limbs known as revascularization restores blood flow and prevents the need for amputation. Losing mobility can affect a person's ability to work, making it more difficult to stay active and independent.

The stakes are high for patients and the health care system that cares for them. Approximately one-third of patients will die within five years of a peripheral artery disease diagnosis, and 20% will experience a heart attack or stroke.

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