Peripheral artery disease is a widespread and vastly underdiagnosed disease, affecting nearly 12 million Americans, mostly those over the age of 50, though the incidence increases with age. The most common symptom of peripheral arterial disease is claudication, which is pain, fatigue or aching in the legs when someone attempts to walk. This is due to the poor blood flow to the muscles in the legs. Beyond simply the discomfort in the legs, we know that having peripheral vascular disease makes one much more likely to have poor cardiovascular outcomes. Among patients with symptomatic peripheral arterial disease, more than 10% will have a stroke, heart attack, or die from a cardiovascular cause within two years. And when we look longer term, the statistics are even more sobering. For patients with symptomatic peripheral arterial disease, their mortality rate is 25% at 5 years and 50% at 10 years. When looking at patients with critical limb ischemia (those who have pain at rest or wounds on their feet), the numbers are even worse: they have a mortality rate of 50% at 5 years and 90% at 10 years.
So, how do we appropriately identify this high risk group of patients? A thorough history and physical is very important, and there are a number of vascular risk factors that must be evaluated, including hypertension, diabetes, hyperlipidemia, kidney disease, family history of vascular disease, and smoking. Patients with any of these should be evaluated with a careful history of leg symptoms as well as evaluation of their peripheral pulses and examination of wounds on patient’s feet. I would advocate having patients remove their shoes and socks in the examination room so that a thorough exam can be performed.
Finally, it is important that patients with peripheral disease be referred to physicians who will appropriately treat their disease. The unfortunate truth is that in America, 50% of patients undergoing a lower extremity amputation will not have had any arterial evaluation prior to the amputation, and nearly 85% will not have had aggressive attempts at revascularization before being taken to amputation. To make matters worse, between 5 and 10% of patients undergoing an amputation will die before leaving the hospital, and the average survival for a diabetic patient undergoing an amputation is only 2 ½ years. When we see patients with symptoms or risk factors for peripheral arterial disease, it is important that they are referred to appropriate cardiovascular specialists who can offer them the treatments that can be not only limb saving, but lifesaving as well.
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