Understanding The Dangers Of PVD And PAD
Unfortunately, all too often, we shy away from valuable history and background information regarding the overall health of the patient. Many of us ask about diseases such as diabetes and some will routinely inquire about alcohol and smoking history. However, few of us spend the necessary time to truly evaluate and integrate historical data such as lipid profiles, etc. For example, peripheral vascular disease (PVD) is one finding in which we must consider all the historical information that is available in order to conduct a proper evaluation of the patient. Intermittent claudication is one sequela of diabetes which is sometimes underappreciated with regards to its seriousness and impact on peripheral vascular disease. This is an area where the patient’s overall health plays a major role. Many patients who have peripheral arterial disease (PAD) also have diabetes as a contributing factor. Did you know the incidence of diabetes has increased 33 percent over the last 10 years? Did you know that diabetes is not one disease but rather a “syndrome” of many other components (including obesity, hypertension, dyslipidemia, hyperinsulemia, and hyperglycemia) related to insulin resistance? According to a recent JAMA article, based on self-reported data from 1991-1999, the prevalence of diagnosed diabetes has increased 41 percent while obesity has increased 61 percent.1 These increases are associated with the increase in PAD and its related diseases. Keep in mind the prevalence of coronary artery disease in peripheral vascular disease is ~ 55 percent.2 Intermittent claudication is the primary symptom of peripheral arterial disease, according to the third edition of Harrison Internal Medicine.3 It is caused by an arterial obstruction in the lower extremity due to atherosclerosis. The symptoms are characterized by pain, discomfort, fatigue and numbness that patients feel in the affected limb during walking yet the symptoms resolve after a few minutes of rest. Be Aware Of The Alarming Risk Correlations With Diabetes Interestingly enough, the risk factors associated with the development of peripheral atherosclerosis are similar to those associated with the development of coronary atherosclerosis. These risk factors include: genetics, obesity, diabetes, smoking, dyslipidemia, hypertension, hyperecoagulabilty, hyperhomocysteinemia and age.3 At the recent University of Texas ‘Diabetic Foot Update’ Conference in December, Dr. David Allie, Chief of Cardiothoracic and Endovascular Surgery at the Cardiovascular Institute of the South, remarked “PVD is a marker for death.” Dr. Allie noted that the diagnosis of PVD carries a worse 5-, 10- and 15-year prognosis than breast cancer or Hodgkin’s Disease. He confirmed that 55 percent of those with PVD die from heart failure. This concern alone certainly warrants a closer look at a new patient’s lab work – including his or her triglyceride and cholesterol status. A 1998 article in the New England Journal of Medicine confirms the correlation between diabetes and heart disease. The study followed 1,300 patients without diabetes and 1,059 patients with diabetes with a seven-year follow-up period. The results showed that patients with diabetes had a 20 percent incidence of myocardial infarction during the study period whereas there was only a 4 percent incidence among patients without diabetes.5 Another article in Diabetes Care found that the risk of coronary artery disease is increased two to four-fold in people who have type 2 diabetes.6 Cardiovascular disease is the cause of death in 75 to 80 percent of people with diabetes. In fact, 50 percent of patients with diabetes have significant atherosclerotic disease when their diabetes is diagnosed.7 You’ll find an increased prevalence of elevated lipid levels in patients with diabetes in almost all categories vs. non-diabetics. In 1994, the journal, Lancet, published a study revealing that patients placed on a lipid lowering medication had a 30 percent reduced risk for total mortality, a 42 percent lower risk of coronary mortality and a 34 percent lower risk of a coronary event.8 As physicians, we should raise questions about the patient’s control of these different risk factors.