According to the American Diabetes Association (ADA), peripheral arterial disease (PAD) occurs when blood vessels in the legs are narrowed or blocked by fatty deposits, resulting in decreased blood flow to the feet and legs. About 25% of people with diabetes older than 50 have PAD, but many who exhibit warning signs do not realize that they have it and will not get treatment for it. “Failing to detect PAD early can have significant consequences,” explains Peter Sheehan, MD, “including lower limb amputations and increased 5-year risk of heart attack or stroke.”
Dr. Sheehan notes that PAD is an unaddressed and underappreciated problem for patients with diabetes. “People with PAD may not feel up to participating in their normal daily activities and have a greatly reduced quality of life,” he says. “Many patients will experience leg pain or fatigue during walking and attribute it to just getting older, but others will not have any symptoms. PAD is particularly important for patients with diabetes because they have a greater likelihood of experiencing other forms of vascular disease, especially heart attacks or strokes. Patients can reduce their risk of these events by taking special care of the blood vessels.”
Spotting Risk Factors & Warning Signs
The ADA notes that having diabetes is a risk factor in itself for developing PAD, but other factors can further increase this risk, including smoking, hypertension, hypercholesterolemia, obesity, or a history of diabetes for more than 10 years, among other risk factors (Table 1). Warning signs include mild leg pain, difficulty walking, foot sores or infections, and numbness, tingling, or coldness in the lower extremities. Characteristic symptoms include claudication pain or fatigue in the legs while walking that disappears at rest, among others.
In 2003, the ADA released a consensus statement recommending that screening for PAD be performed in all patients with diabetes older than 50. In 2006, the American College of Cardiology/American Heart Association (ACC/AHA) expanded that recommendation to also screen people older than 50 who smoke and everyone older than 70. The PAD Coalition, an organization composed of over 70 professional societies—including the ADA, ACC, and AHA—recommends that the ankle brachial index (ABI), one PAD diagnostic, be used to screen for the disease early. People with diabetes younger than 50 may benefit from it if they have other PAD risk factors. The PAD Coalition also recommends that the ABI be reimbursed by Medicare. “Unfortunately, about 20% of Medicare beneficiaries have PAD, but the ABI isn’t consistently reimbursable,” says Dr. Sheehan. “There’s now a movement by professional societies to make the ABI and other PAD screenings a standard performance measure.”
Focus on the “ABCs”
A challenging aspect of PAD in people with diabetes is that many patients are asymptomatic or have fatigue or problems walking, Dr. Sheehan notes. “PAD is a marker of systemic atherosclerosis, and these patients are at the highest risk of any cardiovascular disease. For those who do have PAD, it’s recommended that they undergo aggressive intervention, including statin use, blood pressure control, and antiplatelet therapy with aspirin or clopidogrel.”
The key for clinicians is to ensure that patients are taking every measure to care for their diabetes, says Dr. Sheehan. “This means taking control of the ‘ABCs’ of diabetes: A1C, blood pressure, and cholesterol [Table 2]. Patients should be encouraged to aim for A1C levels that are below 7% or an estimated average glucose level of less than 154 mg/dL, get their blood pressure to less than 130/80 mm Hg, and get their LDL cholesterol below 100 mg/dL. Smoking cessation, proper diet, and regular exercise are also paramount. Some patients may benefit from taking aspirin or clopidogrel because they can further reduce the risk of heart attack and stroke. Regardless of intervention, addressing the ABC components of diabetes can help patients reduce their risks for PAD and simultaneously improve their quality of life.”
Exercise (eg, walking) and medications are often used to relieve symptoms of PAD, but results may vary from patient to patient. In some cases, surgery may be effective. “For some individuals with critical limb ischemia, endovascular procedures (eg, angioplasty) may yield some benefits for patients, but the long-term benefits are still unclear,” says Dr. Sheehan. “However, there’s growing support for the use of these interventions to avoid amputations. These procedures are becoming simpler and less risky than extensive open surgeries that were used in the past. The myth that clinicians can’t do anything for patients with PAD needs to be dispelled. With appropriate medical or surgical management, in addition to preventive measures, limbs and lives can be saved.”
Peter Sheehan, MD, has indicated to Physician’s Weekly that he has received research support from Genzyme and the Tissue Repair Company, and has been on an advisory panel for Advanced Biohealing, Ev3, and Executive Health Exams. He has also been on the speakers bureau for Bristol-Myers Squibb, Sanofi, Pfizer, Merck & Co., and Ev3. He is a board member of Greystone Pharmaceuticals, Inc. and is also a stock/shareholder of Greystone Pharmaceuticals, Inc., and HyperMed, Inc.
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