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Peripheral arterial disease

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Prevention and Screening

Smoking, hypertension, hyperlipidemia and poor diabetes control are all associated with PAD development and progression. Counsel tobacco cessation, manage diabetes and treat hypertension and hyperlipidemia to prevent and stabilize the disease. In addition to smokers, high-risk populations include African Americans and people with diabetes over age 50.

Several studies have indicated that current smoking may be the strongest factor in the development of PAD, even more so than hypertension and hyperlipidemia. When urging smoking cessation, refer smokers to a comprehensive smoking cessation program. Recommend nicotine patch and consider prescribing bupropion, or varenicline.

Although little evidence exists that control of hypertension itself improves or prevents PAD, hypertension is associated with systemic atherosclerosis and cardiovascular morbidity. Consequently, experts recommend prescribing proven cardioprotective antihypertensive agents to control blood pressure. In particular, ACE inhibitors and β-blockers (for those undergoing an operative procedure) may be of unique benefit.

Recommend a diet that is low in saturated fat and high in fiber. If diet modifications fail to reduce total cholesterol, use a statin to reduce total cholesterol and aim for a goal LDL of <100 mg/dL. Lowering LDL cholesterol can significantly reduce coronary atheromata volume, so treat high LDL, low HDL subtypes and hypertriglyceridemia aggressively. It is not known whether agents that raise HDL, such as niacin, are similarly beneficial.

Blood pressure gageTo prevent macrovascular complications, treat patients with diabetes mellitus aggressively with diet, exercise, and drug therapy to achieve a goal HbA1c of <7 mg/dL.

Screen older and high-risk populations for PAD by asking about limb pain with activity, limb fatigue, heaviness or numbness. Since as few as 11% of patients present with a classic history, obtain an ankle-brachial index (ABI). (To download a 1.5-minute, 12 MB presentation on obtaining an ABI, right-click and save-as here). A result of <0.90 indicates PAD. The most accurate method to determine PAD presence is to use the average of the (dorsalis pedis) and posterior tibial systolic pressures divided by the highest brachial pressure. For diabetics and patients with renal failure who have medial calcification of arteries and vascular noncompressibility, use a toe brachial index instead of ABI. Doppler wave form analysis, if available, is also helpful.

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