Lifestyle modification and novel pharmacological treatment options for patients with peripheral arterial disease

1. Co-chaired panel 2. University of Utah, Salt Lake City, UT 3. University of Texas, San Antonio, TX 4. Sinai Hospital/Johns Hopkins Medical Institutions, Baltimore, MD 5. GKT School of Medicine, King’s College, London, UK 6. University of Texas Health Science Center at Houston, TX 7. Sequoia Hospital, Redwood City, CA 8. Maricopa Medical Center, Phoenix, AZ 9. Tufts-New England Medical Center, Boston, MA 10. Southampton University Hospitals Trust NHS, Southampton, UK 11. Penrose–St. Francis Health Services, Colorado Springs, CO 12. Beverly Surgical Associates, Beverly, MA 13. Saint Francis Memorial Hospital, San Francisco, CA 14. Northbay Center for Wound Care, Vacaville, CA, and 15. University of California, San Francisco, CA

Sleep apnea and peripheral artery disease: Bringing each other out of the shadows

Background: Peripheral arterial disease is one among three major cardiovascular diseases and is an important contributor of death and disabilities in low and middle income countries. Symptoms of peripheral arterial disease depend upon the severity of narrowing of artery. Based on severity of disease there are various modalities of treatment is available to prevent the progress of disease and save the limb.Method: This is a prospective, observational, cross sectional study conducted in the department of general surgery. Detailed chronological clinical history is taken, after that patient was evaluated clinically for vascular abnormalities of lower extremities. All patients were followed for minimum 6 month for the evaluation of course of disease and at each visit detail examination was repeated. Result: Dorsalis pedis artery was more commonly involved in thromboangitis obliterans patients then peripheral artery disease (37.5% vs 4.34%). Regarding mode of treatment all patients in both group received medical treatment and life style modification. Lumber sympathectomy was done in 4(8.6%) patients in PAD group and 1(6.25%) in TAO group. Amputation of leg was done in 18(39.10%) in PAD group. Discussion and Conclusion: Diabetes and hypertension was common comorbid condition associated with PAD. Most of the patients have habit of tobacco use. Gangrene and ulcer are common presentation of patients and most of the patients required amputation and disarticulation. Some symptoms improved by life style modification and medical management. The mean duration of stay in hospital was longer in PAD patients then TAO patients.

Efficacy of life style modifications on severity, and operation rates for patients with peripheral artery disease.

On the rise but still underutilized - why statins are the Achilles' heel of secondary prevention in peripheral arterial disease.

Background: Peripheral artery disease (PAD) is a heritable atherosclerotic condition. With growing knowledge of the genetic basis for PAD and related risk factors, there is opportunity to identify high-risk individuals for prevention and potentially intervention based on polygenic background. Aims: To develop and validate an integrated genome-wide polygenic score for PAD (GPSPAD), evaluate association of polygenic risk with major adverse limb events (MALE), and compare predictive performance in diverse ancestral populations to previously published polygenic scores. Methods: We developed GPSPAD by integrating genetic association summary statistics for PAD and related traits stratified by ancestry. GPSPAD was trained in a sample of 96,239 European individuals from the UK Biobank, and validated in multi-ancestry cohorts, including a holdout validation UK Biobank dataset (N=304,294), and external All of Us (AoU; N=237,173) and Mass General Brigham Biobank datasets (N=37,017). GPSPAD performance was benchmarked against previously published polygenic scores and clinical risk factors. Results: GPSPAD was comprised of 603,595 variants with weights informed by association with PAD and ten PAD risk factors across five ancestry groups. GPSPAD had an OR-per SD of 1.63 in the holdout UK Biobank dataset (95% CI 1.60-1.68). GPSPAD outperformed previously published scores in non-European subgroups in the UK Biobank and achieved superior cross-population portability in external validation cohorts. GPSPAD was associated with incident PAD in the UK Biobank (HR 1.66; 95% CI 1.61-1.71) and achieved improvements in discrimination (ΔC-statistic 0.030) that were nearly equivalent to the additive performances of diabetes (ΔC-statistic 0.029) and smoking (ΔC-statistic 0.034) to the baseline model including age, sex, and 10 principal components of ancestry. Among individuals with prevalent PAD, GPSPAD was associated with incident MALE in the UK Biobank (HR 1.48; 95% CI 1.24-1.77). GPSPAD consistently identified individuals with PAD at high MALE-risk in the Mass General Brigham Biobank (HR 1.34; 95% CI 1.12-1.60), and AoU (HR 1.33; 95% CI 1.12-1.58). Conclusions: These findings contribute a polygenic score for PAD that predicts disease and MALE with cross-cohort performance and transferability to diverse ancestries. Integrated polygenic scores may be used to stratify PAD risk and target more aggressive management, lifestyle modification, and surveillance efforts.

Management of Peripheral Arterial Disease: Lifestyle Modifications and Medical Therapies.

Purpose. Atherosclerosis of arteries in the legs leads to peripheral arterial disease (PAD), increasing the risk of future cardiovascular events. Worldwide prevalence estimates indicate >200 million people have PAD, but this is likely underestimated given the variability in symptoms and lack of awareness by patients and clinicians. Antiplatelet therapy is recommended to reduce cardiovascular risk, but anticoagulation therapy may also be beneficial. This narrative review examined scientific literature for the burden and medical management of PAD, including use of anticoagulants in this population, and provides perspectives on the role of pharmacists to improve outcomes of PAD. Summary. A variety of antiplatelet therapies has been studied in patients with PAD, and treatment is recommended for those with symptomatic disease. The use of dual antiplatelet therapy is limited to patients with symptomatic PAD after revascularization. Anticoagulation with warfarin in combination with antiplatelet therapy did not improve efficacy over antiplatelet therapy alone and increased bleeding. In contrast, the direct factor Xa inhibitor rivaroxaban, when used in combination with low‐dose aspirin, has been shown to significantly reduce the risk of cardiovascular death, myocardial infarction (MI), or stroke by 28% in patients with PAD compared with aspirin alone. Similarly, in patients with PAD who have undergone revascularization, rivaroxaban plus aspirin reduced the risk of acute limb ischemia, major amputation, MI, stroke, or cardiovascular death by 15% versus aspirin alone. Major bleeding was significantly increased with rivaroxaban plus aspirin, but with no differences in fatal bleeding, nonfatal intracranial hemorrhage, or symptomatic bleeding into a critical organ between groups. Pharmacist‐led interventions for patients with PAD include identifying at‐risk patients through medication reviews and clinical assessments, education and monitoring use of prescription and over‐the‐counter medications, and appropriate counseling on lifestyle modifications. Conclusion. Rivaroxaban plus aspirin reduces the risk of major cardiovascular events, including major adverse limb events and amputation, in patients with PAD. Pharmacists can play an integral role in identifying, screening, and managing patients with PAD to achieve favorable outcomes.

Impact of peripheral artery disease on daily living: A study on knowledge, contributing factors and quality of life among patients.

The conservative treatment of peripheral arterial disease (PAD), as recommended in current guidelines, encompasses measures such as lifestyle modification and risk-factor management. In addition, in patients with vasogenic intermittent claudication (IC), it is recommended that patients first be given drugs to improve perfusion and undergo supervised gait training. Revascularization is not recommended for asymptomatic persons, but it is considered mandatory for patients with critical ischemia. In this article on conservative and revascularizing treatment strategies for IC, we address the following questions: whether all treatment options are available, how effective they are, and whether the reality of treatment for IC in Germany corresponds to what is recommended in the guidelines. In 2014, the German Society for Angiology carried out a comprehensive literature search in order to prepare a new version of the S3 guideline on PAD. This literature search was updated up to 2018, with identical methods, for the present review. The benefit of lifestyle modification and risk factor treatment is supported by high-level evidence ( evidence level I, recommendation grade A ). The distance patients are able to walk without pain is increased by drug therapy as well (evidence level IIb), but the therapeutic effect is only moderate. Supervised exercise training (SET), though supported by high-level evidence (I, A), is of limited efficacy, availability, and applicability, and patient compliance with it is also limited. In patients with IC, revascularization leads to complete relief of symptoms more rapidly than gait training, and its long-term benefit is steadily improving owing to advances in medical technology. A combination of arterial revascularization and gait training yields the best results. In a clinical trial, patients with IC who underwent combined therapy increased the distance they could walk without pain by 954 m in six months, compared to 407 m in a group that underwent gait training alone. In the treatment of vasogenic IC, SET and drugs to increase perfusion are now giving way to revascularization, which is more effective. As far as can be determined, SET is not currently implemented at all in the German health care system. It would be desirable for SET to be more available and more widely used, both to sustain the benefit of revascularization over the long term and to lower the general cardiovascular risk.

Peripheral artery disease (PAD) is a manifestation of systemic atherosclerosis where, typically, atherosclerotic plaque formation in arteries to the legs results in a decrease in limb blood flow. Symptomatically, this manifests as pain in the lower limbs upon exertion and/or at rest depending on the severity of the occlusion. Symptomatic PAD is prevalent in the elderly population and puts patients at a significantly higher risk of myocardial infarction and stroke. Those with asymptomatic PAD (up to 75% of PAD cases), which may be as prevalent as 10–15% of the adult population, are at higher risk for cardiovascular morbidity and mortality (for reviews see Hackam et al. 2005; Chi & Jaff, 2008). PAD is one of many current, urgent health problems and given risk factors that include age, diabetes mellitus, smoking, hypertension and hyperlipidemia, a higher prevalence of PAD is predicted for the future. Interventions currently employed to ease the symptoms of PAD include surgical and pharmacological options as well as a recommendation for lifestyle changes, in terms of both diet and activity. The physiological adaptations to PAD are to remodel the collateral blood vessel circuit being used in lieu of the occluded arteries by increasing both the diameter and number of vessels within the circuit. These adaptations can help restore resting blood flow levels. A paper in this issue of The Journal of Physiology by Taylor et al. (2008) shows that the collateral circuitry is not an effective substitute to accommodate the higher flows necessary during activity. Taylor et al. demonstrate that both physiological and anatomical constraints of the collateral circulation limit limb blood flow during femoral artery occlusion and highlight the potential importance of regular physical activity at overcoming both obstacles. Their first important finding was that the collateral circuit is influenced by sympathetic vasoconstriction (via α-adrenergic and neuropeptide Y1 membrane receptors) during exercise in both acute and chronic occluded states, and chronically in both sedentary and trained animals; therefore the influence of sympathetic vasoconstriction is maintained during vascular remodelling. They demonstrate further that the conductance of the collateral circuit of exercise trained animals was significantly greater than in sedentary animals. Therefore, increased sympathetic nervous activity during exercise promotes collateral vessel vasoconstriction which can limit limb blood flow, yet training can ameliorate the impact of this limitation. Their second important finding was that the low conductance of the collateral circuitry during exercise may be limited by the capacity of the circuit itself. Taylor et al. (2008) surmised that the remodelling process may render the vessels less reactive or less distensible. They showed that isolated blood vessels with chronic, restricted blood flow display a different flow-pressure relationship having a greater increase in diameter for a given perfusion pressure when compared to non-occluded controls. This structural adaptation would allow for increased blood flows in the face of lower perfusion pressures but ultimately indicates that the collateral vessels are, indeed, different in their responsiveness. Given that the collateral blood vessels are smaller in diameter than the conduit arteries they are trying to replace, even with the remodelling, they will offer more resistance and decrease the perfusion pressure of the vasculature below the collaterals. Therefore, blood flow to the lower limbs will ultimately be limited by the overall capacity of the collateral circuit. Increasing the capacity of the circuit may be an important element in the treatment of PAD, thus underscoring the importance of understanding the processes of arteriogenesis. This study also endorses the importance of regular physical activity. In observing that the conductance of the collateral circuit of exercise trained animals is significantly greater than in sedentary animals during exercise, they show that regular physical activity can overcome, in part, both the physiological (sympathetic vasoconstriction) and structural limitations (remodelling modifications) of the collateral circulation. Therefore, any prescription for the symptoms for PAD should include regular physical activity for those that are able.

An exploratory study to assess the knowledge regarding treatment and life style modification among tuberculosis patient at selected hospital of Moga, Punjab. The purpose of the present study is to explore the knowledge regarding treatment and life style modification among tuberculosis patient in selected hospital of Moga, Punjab with the objectives to assess the knowledge regarding treatment and life style modification among tuberculosis patient, to find out relationship between knowledge and selected demographic variables. To develop and distribute an information booklet regarding treatment and life style modification. Sample consists of 200 tuberculosis patients was selected by convenient sampling technique. Research setting was done in civil hospital of Moga, Punjab. The major finding shows most of 64% tuberculosis patient had average knowledge and 9% had below average knowledge regarding treatment and life style modification of tuberculosis. In the demographic variables gender of patient, religion of patient, educational status of patient, occupational status of patient, area of residence had significant impact on the knowledge score of patients. The age (in year), marital status of patient, family monthly income (in rupees) had no significant impact on knowledge score, based on findings a information booklet was developed and distributed to the patients to increase their knowledge regarding the treatment and life style modification of tuberculosis.

Type 2 Diabetes Mellitus (T2DM) is usually accompanied by various micro and macro vascular complications. Peripheral Arterial Disease (PAD) is one of the major complications of diabetes which is accountable for morbidity and mortality throughout the world. The first line of treatment in these individuals is life style modification and exercise. There is a dearth of literature on effect of supervised exercise program in PAD with T2DM on quality of life, walking impairment, change in Ankle Brachial Index (ABI) values. So, we conducted a systematic review to explore the available literature on supervised exercise program in PAD with T2DM. We conducted a systematic review (PubMed, Web of Science, CINAHL and Cochrane) to summarise the evidence on a supervised exercise program in PAD with T2DM. Randomised and nonrandomised studies were included in the review. Three studies met the inclusion criteria. The outcomes taken into accounts by the studies were the quality of life, walking impairment questionnaire, Ankle brachial index. Neither of the studies matched in their supervised exercise program nor in their outcome. In conclusion, the data evaluating the supervised exercise program in PAD with T2DM is inadequate to determine its effect on this population. Future large-scale studies can be conducted on both subjective and objective outcomes of PAD with T2DM to have a better understanding of the condition and for a universally acceptable exercise program for these individuals which the healthcare practitioners can use in their practice. Prospero registration number: CRD42018112465.

Application of the 2019 ESC/EAS dyslipidemia guidelines to a Mexican population: evaluating treatment targets for secondary prevention in clinical practice

Peripheral arterial disease (PAD) is a highly prevalent atherosclerotic condition. In patients with PAD, the presence of intermittent claudication leads to a deterioration in quality of life. In addition, even in asymptomatic cases, patients with PAD are at high risk of cardiac or cerebrovascular events. Treatment of PAD is based on lifestyle modifications; regular exercise; smoking cessation; and control of cardiovascular risk factors, including hypercholesterolemia. A growing number of studies have shown that statins reduce cardiovascular risk and improve symptoms associated with PAD. Current guidelines recommend the use of statins in all patients with PAD in order to decrease cardiovascular events and mortality. However, the prescribing of statins in patients with PAD is lower than in those with coronary heart disease. This review provides relevant information from the literature that supports the use of statins in patients with PAD and shows their potential benefit in decreasing lower limb complications as well as cardiovascular morbidity and mortality.