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American Family Physician Mar 2019Lower extremity peripheral artery disease (PAD) affects 12% to 20% of Americans 60 years and older. The most significant risk factors for PAD are hyperlipidemia,... (Review)
Review
Lower extremity peripheral artery disease (PAD) affects 12% to 20% of Americans 60 years and older. The most significant risk factors for PAD are hyperlipidemia, hypertension, diabetes mellitus, chronic kidney disease, and smoking; the presence of three or more factors confers a 10-fold increase in PAD risk. Intermittent claudication is the hallmark of atherosclerotic lower extremity PAD, but only about 10% of patients with PAD experience intermittent claudication. A variety of leg symptoms that differ from classic claudication affects 50% of patients, and 40% have no leg symptoms at all. Current guidelines recommend resting ankle-brachial index (ABI) testing for patients with history or examination findings suggesting PAD. Patients with symptoms of PAD but a normal resting ABI can be further evaluated with exercise ABI testing. Routine ABI screening for those not at increased risk of PAD is not recommended. Treatment of PAD includes lifestyle modifications-including smoking cessation and supervised exercise therapy-plus secondary prevention medications, including antiplatelet therapy, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins. Surgical revascularization should be considered for patients with lifestyle-limiting claudication who have an inadequate response to the aforementioned therapies. Patients with acute or limb-threatening limb ischemia should be referred immediately to a vascular surgeon.
Topics: Aged; Ankle Brachial Index; Exercise Therapy; Humans; Intermittent Claudication; Lower Extremity; Middle Aged; Peripheral Arterial Disease; Practice Guidelines as Topic; Risk Factors
PubMed: 30874413
DOI: No ID Found -
Journal of Vascular Surgery Jan 2007
Topics: Acute Disease; Chronic Disease; Comorbidity; Diagnostic Imaging; Humans; Intermittent Claudication; Ischemia; Leg; Peripheral Vascular Diseases; Prognosis; Risk Factors; Risk Management; Vascular Surgical Procedures
PubMed: 17223489
DOI: 10.1016/j.jvs.2006.12.037 -
Ugeskrift For Laeger May 2021Intermittent claudication is a manifestation of peripheral arterial occlusive disease. Multiple large international guidelines state that besides cardiovascular risk... (Review)
Review
Intermittent claudication is a manifestation of peripheral arterial occlusive disease. Multiple large international guidelines state that besides cardiovascular risk management, supervised exercise therapy (SET) should be offered to all patients with intermittent claudication. As described in this review, The Netherlands have already established a systemic rehabilitation program, ClaudicatioNet, where SET has been included and have shown positive outcomes. Despite all large national guidelines and the successful experience from the Netherlands, Denmark still fails to include SET to patients with intermittent claudication.
Topics: Exercise Therapy; Humans; Intermittent Claudication; Netherlands; Peripheral Arterial Disease; Treatment Outcome; Walking
PubMed: 33998446
DOI: No ID Found -
Journal of Vascular Surgery Mar 2015Peripheral arterial disease (PAD) continues to grow in global prevalence and consumes an increasing amount of resources in the United States health care system. Overall... (Review)
Review
Peripheral arterial disease (PAD) continues to grow in global prevalence and consumes an increasing amount of resources in the United States health care system. Overall rates of intervention for PAD have been rising steadily in recent years. Changing demographics, evolution of technologies, and an expanding database of outcomes studies are primary forces influencing clinical decision making in PAD. The management of PAD is multidisciplinary, involving primary care physicians and vascular specialists with varying expertise in diagnostic and treatment modalities. PAD represents a broad spectrum of disease from asymptomatic through severe limb ischemia. The Society for Vascular Surgery Lower Extremity Practice Guidelines committee reviewed the evidence supporting clinical care in the treatment of asymptomatic PAD and intermittent claudication (IC). The committee made specific practice recommendations using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system. There are limited Level I data available for many of the critical questions in the field, demonstrating the urgent need for comparative effectiveness research in PAD. Emphasis is placed on risk factor modification, medical therapies, and broader use of exercise programs to improve cardiovascular health and functional performance. Screening for PAD appears of unproven benefit at present. Revascularization for IC is an appropriate therapy for selected patients with disabling symptoms, after a careful risk-benefit analysis. Treatment should be individualized based on comorbid conditions, degree of functional impairment, and anatomic factors. Invasive treatments for IC should provide predictable functional improvements with reasonable durability. A minimum threshold of a >50% likelihood of sustained efficacy for at least 2 years is suggested as a benchmark. Anatomic patency (freedom from restenosis) is considered a prerequisite for sustained efficacy of revascularization in IC. Endovascular approaches are favored for most candidates with aortoiliac disease and for selected patients with femoropopliteal disease in whom anatomic durability is expected to meet this minimum threshold. Conversely, caution is warranted in the use of interventions for IC in anatomic settings where durability is limited (extensive calcification, small-caliber arteries, diffuse infrainguinal disease, poor runoff). Surgical bypass may be a preferred strategy in good-risk patients with these disease patterns or in those with prior endovascular failures. Common femoral artery disease should be treated surgically, and saphenous vein is the preferred conduit for infrainguinal bypass grafting. Patients who undergo invasive treatments for IC should be monitored regularly in a surveillance program to record subjective improvements, assess risk factors, optimize compliance with cardioprotective medications, and monitor hemodynamic and patency status.
Topics: Asymptomatic Diseases; Endovascular Procedures; Humans; Intermittent Claudication; Lower Extremity; Patient Selection; Peripheral Arterial Disease; Risk Factors; Severity of Illness Index; Treatment Outcome; Vascular Patency; Vascular Surgical Procedures
PubMed: 25638515
DOI: 10.1016/j.jvs.2014.12.009 -
BioMed Research International 2019Intermittent claudication is a symptom of atherosclerosis of the lower limbs (peripheral arterial disease (PAD)) and is characterized by pain and cramps of lower limb... (Review)
Review
Intermittent claudication is a symptom of atherosclerosis of the lower limbs (peripheral arterial disease (PAD)) and is characterized by pain and cramps of lower limb muscles during exercise. Claudication leads to a reduction in physical activity of patients. PAD is a systemic disease. Atherosclerotic lesions located in the arteries of the lower limbs not only pose the risk of the ischemic limb loss, but above all, they are an important prognostic factor. Patients with claudication are at significant risk of cardiovascular complications such as infarcts or strokes. Comprehensive rehabilitation of patients with intermittent claudication based on the current TASC II (Inter-Society Consensus for the Management of Peripheral Arterial Disease) guidelines, ESC (European Society of Cardiology) guidelines, and AHA (American Heart Association) guidelines includes supervised treadmill training, training on a bicycle ergometer, Nordic Walking, resistance exercises of lower limb muscles, and exercises of upper limbs. A trained, educated, and motivated patient has a chance to improve life quality as well as life expectancy.
Topics: Arteries; Cardiovascular Diseases; Exercise; Exercise Test; Humans; Infarction; Intermittent Claudication; Lower Extremity; Peripheral Arterial Disease; Physical Therapists; Physical and Rehabilitation Medicine; Quality of Life; Stroke; Walking
PubMed: 31641667
DOI: 10.1155/2019/2470801 -
European Journal of Vascular and... 2007
Topics: Acute Disease; Chronic Disease; Comorbidity; Diagnostic Imaging; Humans; Intermittent Claudication; Ischemia; Leg; Peripheral Vascular Diseases; Prognosis; Risk Factors; Risk Management; Vascular Surgical Procedures
PubMed: 17140820
DOI: 10.1016/j.ejvs.2006.09.024 -
BMJ (Clinical Research Ed.) Apr 2007
Review
Topics: Diagnosis, Differential; Humans; Intermittent Claudication; Medical History Taking; Middle Aged; Physical Examination; Referral and Consultation; Risk Assessment
PubMed: 17413176
DOI: 10.1136/bmj.39036.624306.68 -
Journal of Vascular Surgery Nov 2017The objective of this study was to provide an overview of evidence regarding exercise therapies for patients with lower extremity peripheral artery disease (PAD). (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The objective of this study was to provide an overview of evidence regarding exercise therapies for patients with lower extremity peripheral artery disease (PAD).
METHODS
This manuscript summarizes the content of a lecture delivered as part of the 2016 Crawford Critical Issues Symposium.
RESULTS
Multiple randomized clinical trials demonstrate that supervised treadmill exercise significantly improves treadmill walking performance in people with PAD and intermittent claudication symptoms. A meta-analysis of 25 randomized trials demonstrated a 180-meter increase in treadmill walking distance in response to supervised exercise interventions compared with a nonexercising control group. Supervised treadmill exercise has been inaccessible to many patients with PAD because of lack of medical insurance coverage. However, in 2017, the Centers for Medicare and Medicaid Services issued a decision memorandum to support health insurance coverage of 12 weeks of supervised treadmill exercise for patients with walking impairment due to PAD. Recent evidence also supports home-based walking exercise to improve walking performance in people with PAD. Effective home-exercise programs incorporate behavioral change interventions such as a remote coach, goal setting, and self-monitoring. Supervised treadmill exercise programs preferentially improve treadmill walking performance, whereas home-based walking exercise programs preferentially improve corridor walking, such as the 6-minute walk test. Clinical trial evidence also supports arm or leg ergometry exercise to improve walking endurance in people with PAD. Treadmill walking exercise appears superior to resistance training alone for improving walking endurance.
CONCLUSIONS
Supervised treadmill exercise significantly improves treadmill walking performance in people with PAD by approximately 180 meters compared with no exercise. Recent evidence suggests that home-based exercise is also effective and preferentially improves over-ground walking performance, such as the 6-minute walk test.
Topics: Evidence-Based Medicine; Exercise Therapy; Exercise Tolerance; Health Care Costs; Home Care Services; Humans; Insurance Coverage; Intermittent Claudication; Lower Extremity; Peripheral Arterial Disease; Randomized Controlled Trials as Topic; Recovery of Function; Resistance Training; Treatment Outcome; Walk Test; Walking
PubMed: 28874320
DOI: 10.1016/j.jvs.2017.05.111 -
Journal of Vascular Surgery Mar 2017
Topics: Amputation, Surgical; Cost Savings; Cost-Benefit Analysis; Endovascular Procedures; Exercise Therapy; Health Care Costs; Humans; Intermittent Claudication; Limb Salvage; Peripheral Arterial Disease; Societies, Medical; Treatment Outcome; Vascular Surgical Procedures
PubMed: 28236913
DOI: 10.1016/j.jvs.2016.11.027 -
Journal of Vascular Surgery Jul 2017Peripheral artery disease (PAD) is common and associated with significant morbidity and mortality. Optimal medical management of PAD is required for each patient,... (Review)
Review
Peripheral artery disease (PAD) is common and associated with significant morbidity and mortality. Optimal medical management of PAD is required for each patient, irrespective of the decision regarding lower extremity revascularization. The goals include reducing cardiovascular morbidity and mortality and improving quality of life. The approach should consist of aggressive and individualized risk factor modification including smoking cessation, antiplatelet therapy, a statin, and an angiotensin-converting enzyme inhibitor. Exercise is critical for cardiovascular health and highly effective for improving claudication symptoms. Cilostazol may be considered for symptomatic treatment in certain patients.
Topics: Cardiovascular Agents; Comorbidity; Drug Therapy, Combination; Humans; Intermittent Claudication; Life Style; Lower Extremity; Peripheral Arterial Disease; Quality of Life; Risk Factors; Risk Reduction Behavior; Treatment Outcome
PubMed: 28533077
DOI: 10.1016/j.jvs.2017.02.040