Peripheral Vascular Disease - Associated Cardiovascular Consultants, PA

Peripheral Vascular Disease

An Interview with Dr. Manoj Khandelwal, M.D.

Peripheral Vascular Disease (PVD), sometimes called Peripheral Arterial Disease (PAD), poses a significant mortality risk and therefore requires aggressive treatment, according to Dr. Manoj Khandelwal. However, PVD is sometimes asymptomatic and thus is not routinely detected by primary care physicians.

"In PVD we see the same occlusive process that involves the heart," Dr. Khandelwal said. Primarily, the disease affects the legs, but it also occurs in the vessels to the brain, shoulders and kidneys. An estimated 8-12 million people, most of them age 50 or above, have PVD, which manifests equally in both men and women but is more common in blacks than in whites. The standard risk factors for Cardiovascular Disease (CVD) also apply to PVD.

Why worry about PVD? Because data show that patients with PVD are six times more likely to die within 10 years as patients without PAD. "A six-fold increase is dramatic," Dr. Khandelwal said, explaining that PVD is a very strong marker for future events, including stroke, heart attack or abdominal aneurysm. Accordingly, Dr. Khandelwal described PVD as highly dangerous.

PVD is a marker of life-threatening events and also adversely affects the lifestyle of those who have it. "The pain in the leg can be so severe that it limits activity." Patients experiencing the symptoms, however, often attribute them to arthritis or back ailments. "It is a serious error to ascribe it to aging."

PARTNERS Findings

Dr. Khandelwal said the findings of PARTNERS (PAD Awareness, Risk, Treatment: New Resources for Survival)*, a primary care study, underscore the imperative that primary care physicians detect the disease. The study, conducted in 350 primary care practices in the U.S., involved physician/nurse partnerships. They studied 6,979 patients age 70 or older or age 50 to 69 who had diabetes or a history of cigarette smoking. All patients in the study were evaluated by thorough chart search for history of stroke, heart attack or aneurysm and by Ankle-Brachial Index (ABI), a 10-minute screening procedure for PVD that is 90% sensitive and 98% specific.

The ABI was measured using a 5-mHz Doppler device including a hand-held ultrasound probe (Cost: $495). With the study subjects on their backs, two systolic blood pressures were recorded in both ankles and the brachial systolic pressure in both arms. The ABI for each leg was determined separately by dividing the higher systolic pressure in that leg by the higher brachial pressure. An index for either leg of 0.90 or less indicated PVD.

Citing the PARTNERS study, Dr. Khandelwal said it found that 29% of the study group had severe PAD. Of those, 44% had only PAD with no other atherosclerosis and no cardiovascular disease. Of the overall study group, 13% had only PVD, 16% had PVD and CVD, 24% had only CVD, and 47% had neither PAD nor CVD.

One of the findings that Dr. Khandelwal especially noted was that while 83% of patients with a pre-study diagnosis of PVD were aware of their diagnosis, only 49% of their physicians were aware of it. "If you don't know the diagnosis, you can't be aggressive about treating it," Dr. Khandelwal said. To overcome this disparity in awareness, Dr. Khandelwal recommended that all physicians, particularly primary care physicians and cardiologists, simply make a habit of asking patients this question: Have you ever been diagnosed with PVD?

Treatment

Treatment of PVD parallels the treatment of CVD. Risk factors such as smoking and diabetes must be addressed. Aspirin therapy prevents the progression of the disease, and cholesterol-lowering drugs have also been shown to be effective. To address the severe pain that may be associated with PVD, the options are balloon angioplasty, stents and bypass surgery. "For a recurring illness balloon/stent angioplasty is ideally suited as it can be easily re-applied and carries the same risks every time," Dr. Khandelwal said. Bypass surgery, on the other hand, usually is done only once or twice and the risks increase exponentially.

The use of balloon angioplasty in the treatment of PVD has been advanced by miniaturization. "Previously, the procedure was not beneficial because of the size of catheters. But now the technology used in the heart can be used in the legs." Catheters 1mm wide make it possible to treat blockages below the knees with less danger to the patient. Dr. Khandelwal said cardiologists are ideally suited to perform these procedures because they use them to treat atherosclerosis associated with the heart. Gene therapy treatment may someday be included among the treatments for PVD, but for now, Dr. Khandelwal said it is indicated only for "zero-option patients."

PAD and CVD are closely linked and require global management. "Some patients may have a fine heart but can't do anything because of their legs. The link also works the other way. A PVD patient who is treated for leg pain starts to walk and discovers he has angina."

Dr. Khandelwal said PVD has become an important public health issue. Recognizing this, ACC plans to establish PVD screening in conjunction with referring physicians. The program is expected to be in place by September.

*PARTNERS study was reported in JAMA, Sept. 19, 2001, Vol. 286, No. 11.

Dr. Manoj Khandelwal is a graduate of Albert Einstein College of Medicine of Yeshiva University in Bronx, N.Y. He completed fellowships in Clinical Cardiology at the College of Physicians and Surgeons of Columbia University, New York, and in Interventional Cardiology at Massachusetts General Hospital, Harvard University, Boston. He is board certified in Internal Medicine and Cardiovascular Diseases, a fellow of the American College of Cardiology. Dr. Khandelwal is the coauthor of articles that have appeared in the Journal of Pharmacologic Methods and the Journal of the American College of Cardiology.

A take-home message about…… Peripheral Vascular Disease

Data show that patients diagnosed with PVD are six times more likely to die within 10 years, so aggressive treatment is necessary.
To overcome the disparity in patient-physician awareness of PVD, primary care physicians should routinely ask if their patients have ever been diagnosed with PVD.
Miniaturized catheters now make it possible to treat blockages below the knee with less danger to patients.

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