Nonpharmacologic Management of Peripheral Artery Disease

Transcript: Deepak L. Bhatt, MD, MPH: Perhaps now we can move on to discuss the management of peripheral artery disease [PAD]. I think there are a lot of challenges when…treating a patient with atherosclerosis in general, thinking about modifiable and nonmodifiable risk factors and thinking about comorbidities that increase patient risk for PAD. Marc, I can start off with you and you can tell us a little bit about those aspects.

Marc P. Bonaca, MD, MPH: The nonpharmacologic aspects?

Deepak L. Bhatt, MD, MPH: Yes, in particular the nonpharmacological aspects, starting with lifestyle. That’s often overlooked, not just in PAD, but in patients with vascular disease in general.

Marc P. Bonaca, MD, MPH: That’s a great point, Deepak, because we often talk about trials and biomarkers and things like that, but lifestyle is so important here. The 2 biggest risk factors, of course, are smoking and diabetes. It’s uncommon to find patients with severe PAD who don’t have a history of either one. Sometimes we see renal disease or blood calcifications, but overwhelmingly it’s smoking and diabetes. I think if you care about PAD, smoking cessation has to be top of mind. It has to be something—in spite of its challenges—that we really work on, because there is a special relationship with peripheral artery disease, and worse outcomes after intervention: worse outcomes in the limb, the heart, and the brain.

Beyond that, we’re seeing more PAD because there’s more diabetes. As Matt said, it’s changing the way that we see the disease. There’s more small vessel or tubule disease. Patients are showing up with CLI [critical limb ischemia], and that’s a big problem. I think an important lifestyle factor is the prevention of diabetes—healthy diet, exercise, and so on—but once you have it, foot hygiene is so important in terms of preventing the most severe manifestation of peripheral artery disease.

I think one thing that is counterintuitive for some patients with PAD is the mindset of, “If my legs hurt when I’m walking, maybe I’m hurting myself and I should stop walking.” The opposite is true. Walking is good for you. When you get discomfort or claudication, pain in the legs, walking is actually helpful: not for the pain itself, but exercise will improve their function. I think for patients who have PAD, lifestyle has to be focused on function. As Mike said, if you can’t get around your house and do what you need to do, it’s a huge loss. We need to encourage people to be active and walk, and recognize that it doesn’t have to be walking. If you have a patient with an amputation, arm ergometry still helps. It’s exercise of some form. I think smoking cessation, diet, exercise, and foot care are critical.

Deepak L. Bhatt, MD, MPH: I would mention in eye care, too. A lot of these folks have diabetes, as you mentioned. If they have PAD, there’s a good chance that issues might be brewing with their eyes as well.

You raised a really good point, Marc, that when people are walking and they feel pain, their brain is appropriately telling them, “Stop doing that, pain is bad.” Certainly for cardiac patients, when they have pain, we don’t typically say, “Oh, just work through it.” What we typically say is, “Stop, sit down, and take some nitroglycerin; or if it doesn’t go away, dial 911. It really is a different paradigm. Do you think, Mike, that has hurt our ability to get patients to exercise? Maybe it’s an unstated fear when they have pain: “Of course I should not keep walking to the point of more pain, that would be harmful.” Do you think that might be part of the psychology?

C. Michael Gibson, MS, MD: You’re right, Deepak. I think it could be part of the psychology. But part of it is also that patients just can’t walk. There may be so much discomfort that it’s not only your mind being told you have some pain, but you just may not be able to walk even if you want to walk. It does really limit a lot of people. I think you’re onto something there. It’s different in that regard.

Transcript Edited for Clarity