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From Research to Practice/Cardiovascular Disease and Diabetes

Management of Peripheral Arterial Disease

  1. Lyn M. Steffen, PhD, MPH, RD,
  2. Daniel A. Duprez, MD, PhD,
  3. Jackie L. Boucher, MS, RD, CDE,
  4. Abby G. Ershow, ScD, RD, FAHA and
  5. Alan T. Hirsch, MD
Diabetes Spectrum 2008 Jul; 21(3): 171-177. https://doi.org/10.2337/diaspect.21.3.171
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Abstract

In Brief

Peripheral arterial disease (PAD) is a common atherosclerotic disease affecting the quality of life of > 8 million Americans. PAD is characterized by atherosclerotic stenoses of arteries that supply the lower extremities and is associated with a marked increase in the short-term risk of heart attack, stroke, amputation, and death. Adherence to pharmacological therapies and modification of lifestyle factors, including increasing moderate physical activity along with supervised exercise, smoking cessation, and a healthy dietary intake, are central to the successful management of PAD. The improvement of an adverse cardiovascular risk profile is a proven and crucial strategy to lower the risk of major morbid and mortal events for individuals with PAD.

Peripheral arterial disease (PAD) is a serious condition that increases individual and population-based risk of heart attack, stroke, death, and amputation and decreases quality of life and functional independence. It affects millions of Americans, especially those with diabetes. Furthermore, the economic burden of PAD is substantial.1

What Is Lower-Extremity PAD?

Lower-extremity PAD is most commonly caused by atherosclerosis, a blockage of the inner lining of an artery by fatty deposits that results in poor perfusion of the skin, muscles, and limb.2 The diagnosis of lower-extremity PAD is commonly established by the resting ankle-brachial index (ABI; calculated as the systolic blood pressure in the right or left ankle divided by the higher of the two brachial artery pressures, with values < 0.90 diagnostic of PAD).

PAD most often affects the arteries that supply the legs, but it may also occur in any non-coronary circulation, including the arms, brain, stomach, kidney, or any vital organ. The blockage that occurs in the legs or feet may cause an intermittent fatigue, cramping sensation, or pain that is called intermittent claudication, which is the most recognized symptomatic subset of lower-extremity PAD.

Evidence-based guidelines for the diagnosis, treatment, and management of PAD have been developed and published by vascular health physicians and unanimously approved by associated cardiovascular health professional organizations and the National Heart, Lung, and Blood Institute.2 These guidelines are available online at www.acc.org and www.americanheart.org.

Prevalence of PAD

PAD affects 8–12 million adults ≥ 40 years of age in the United States and affects similar proportions of men and women.2,3 About 20–30% of individuals with PAD have diabetes.4–7 Compared to whites, the likelihood of PAD is 50% greater among African Americans 2,3,8 and 55% lower among Chinese.8 The National Health and Nutrition Examination Survey (NHANES) for 1999–2000 showed that the age-adjusted prevalence of PAD was 11.7% in non-Hispanic whites, 19.5% in non-Hispanic blacks, and 15.6% in Hispanic men and women.9 The risk of PAD increases substantially with age.1–3 The prevalence of PAD is 4.8, 12.0, and 22.0% for men and women aged 60–69 years, 70–79 years, and ≥ 80 years, respectively.9 The prevalence of claudication, as a less sensitive symptomatic marker of PAD, is 0, 2.4, and 2.7% for men and women aged < 60 years, 60–69 years, and ≥ 70 years or more, respectively.10

PAD is associated with significant morbidity and mortality. A low ABI (< 0.90) has been associated with an increased risk of all-cause mortality (relative risk [RR] 1.60; 95% confidence interval [CI] 1.32–1.95); cardiovascular mortality (RR 1.96; 95% CI 1.46–2.64); fatal and non-fatal coronary heart disease (RR 1.45; 95% CI 1.08–1.93); and fatal and non-fatal stroke (RR 1.35; 95% CI 1.10–1.65).11 In a cross-sectional study that evaluated both walking impairment and quality of life among individuals with both PAD and other cardiovascular diseases, the impact of PAD on functional status was equal to or worse than that of individuals of comparable age with coronary and other cardiovascular diseases.12

Patients with diabetes are more likely to develop symptomatic PAD. In a cross-sectional study, lower-extremity function was assessed in 460 male and female patients with PAD, 147 of whom also had diabetes.13 Individuals with PAD and diabetes had worse lower-extremity function with shorter distances walked and at a slower pace than those with PAD alone, which may be explained by diabetes-related neuropathy.13 Patients with both PAD and diabetes are at higher risk than PAD patients without diabetes for the progression of their PAD, as well as developing manifestations of coronary heart disease.7 Further, the presence of concomitant diabetes in individuals with PAD may result in more severe anatomic arterial disease, as well as a distribution of disease in more distal leg arterial segments, which is associated with higher rates of lower-extremity amputation.14,15

The prevalence of amputation in PAD varies regionally, but overall risk is < 3–4% of the total PAD population. It is important to note that rates of leg amputation in individuals with PAD and diabetes are associated with great regional variation. These disparate rates are likely the result of differing care pathways offered to individuals at risk, further amplifying the national PAD outcomes health disparity.16

Risk Factors for Development of PAD

The risk factors for PAD are similar to those for other atherosclerotic diseases, including age, smoking, diabetes, high blood pressure, and dyslipidemia. Recently low-grade inflammation was identified as an independent risk factor for development and progression of PAD. Specifically, elevated levels of C-reactive protein are associated with risk of developing PAD.17 Smokers have 2.5 times the risk of developing PAD of nonsmokers, 2,13,18 and individuals with diabetes have 2–4 times the risk of developing PAD.13,19 To prevent microvascular complications, the American Diabetes Association recommends for individuals with diabetes a target hemoglobin A1c (A1C) level of < 7.0%.19 However, data to support more aggressive control of glycemia to prevent macrovascular arterial endpoints, including amputation, are lacking.13 In the Reduction of Atherothrombosis for Continued Health (REACH) study, an international registry of 69,055 atherothrombotic patients aged ≥ 45 years to monitor risk factor control and use of risk reduction strategies, 44.2% of 8,273 patients with PAD also had diabetes.20 Cardiovascular ischemic event rates in individuals with PAD were higher than those with coronary disease alone.21

About 33% of U.S. adults (≥ 18 years of age) have high blood pressure; however, only 35% of hypertensive individuals have achieved target goals for the treatment of their blood pressure.3 In the REACH registry, > 80% of PAD patients aged ≥ 45 years were hypertensive, and 92% were taking at least one antihypertensive medication.20 The prevalence of high LDL cholesterol (≥ 160 mg/dl) among U.S. adults >18 years of age was 25.3% according to NHANES 1999-2004.3 Among PAD patients in this registry, 66.7% had been diagnosed with hypercholesterolemia; of these, 70% were prescribed at least one lipid-lowering medication (64% were taking statins).20 Beyond these international registry data, undertreatment of risk factors and lower use of risk reduction therapies have been demonstrated from the NHANES population-based data and other studies.5,22

Awareness of PAD as a prevalent cardiovascular disease, and its associated risk, is very low as demonstrated by a recent population-based national survey of > 2,500 white, Hispanic, and African-American adults with a mean age of 67 years.23 Less than one in four Americans > 50 years of age—a group characterized by high rates of risk factors and leg pain—were at all aware of the existence of PAD. Fifty percent of individuals did not know that diabetes and smoking increased the risk for PAD, and less than one-fourth of the cohort that had heard of PAD was aware that PAD increased the risk of heart attack and stroke. Less than one in seven of the “PAD-aware” cohort was knowledgeable that PAD was the major cause of leg amputation. Awareness of PAD was lower among individuals with lower income and education levels.

In the PAD Awareness, Risk and Treatment: New Resources for Survival study of PAD treatment in a primary care setting, most patients with PAD were aware of their diagnosis; however, many of their primary care physicians were not.5 As might be anticipated, atherosclerosis risk factors were treated less frequently in those whose PAD diagnosis was not previously established. However, treatment intensity was also less in those PAD patients who had a prior PAD diagnosis established compared to CAD patients in the same practice setting. This undertreatment of PAD likely contributes to the high rates of heart attack, stroke, amputation, hospitalization, and death. Establishment of a prompt PAD diagnosis provides a compelling opportunity to provide cost-effective prevention of disability and death.

Diagnosis

PAD symptoms

About 50% of individuals with PAD are asymptomatic. Among individuals experiencing symptoms, the most common one is claudication, which is the fatigue, aching, cramping, or frank pain that is provoked in leg muscles during activity and that resolves with rest.2,19 At least half of individuals with PAD experience leg discomfort both at rest and with exercise as a result of the presence of multiple illnesses that impair leg function. This clinical presentation is known as “atypical leg pain.” Manifestations of severe PAD include ischemic leg pain that occurs at rest or the development of a nonhealing skin ulcer or gangrene. This constellation of severe ischemic symptoms is known as “critical limb ischemia” and is a medical emergency. More rarely, acute limb ischemia may occur when leg arterial blood flow is suddenly obstructed by an embolic or in situ thrombus.

Establishing the diagnosis

The resting ABI is used to establish the lower-extremity PAD diagnosis in patients suspected of PAD symptoms, defined as individuals with exertional leg symptoms, with nonhealing wounds, who are ≥ 70 years of age, or who are ≥ 50 years of age with a history of smoking or diabetes.2,5 The ABI should be measured in both legs in all new patients with PAD of any severity to confirm the diagnosis of lower-extremity PAD and establish a baseline. The toe-brachial index should be used to establish a lower-extremity PAD diagnosis in patients in whom lower-extremity PAD is clinically suspected but in whom the ABI test is not reliable because of non-compressible vessels. Leg segmental pressure measurements are useful to establish a lower-extremity PAD diagnosis when anatomical localization of lower-extremity PAD is required to create a therapeutic plan.

Exercise treadmill tests are recommended to provide the most objective evidence of the magnitude of the functional limitation of claudication and to measure the response to therapy. A standardized exercise protocol (either fixed or graded) with a motorized treadmill should be used to ensure reproducibility of measurements of pain-free walking distance and maximal walking distance. Exercise treadmill tests with measurement of pre-exercise and post-exercise ABI values are recommended to provide diagnostic data useful in differentiating arterial claudication from non-arterial causes of leg pain. Duplex ultrasound of the extremities is useful to diagnose the anatomic location and degree of stenosis of PAD. More advanced imaging techniques, such as computed tomography or magnetic resonance angiography, may also be useful for individuals who require an arterial revascularization procedure to improve symptoms when medical therapies are ineffective or when limb survival is threatened. For these individuals, use of percutaneous transluminal angioplasty or open vascular surgical revascularization may be beneficial, and both noninvasive and invasive arterial imaging can effectively guide the revascularization approach.

Treatment

The goals of treatment in PAD are 1) to improve leg ischemic symptoms and 2) to reduce the risk of heart attack, stroke, amputation, and death.2 Optimal PAD care is always best achieved by the combined use of pharmacological treatment and lifestyle changes,24 with more limited use of revascularization procedures (e.g., angioplasty or surgery) when medical therapy alone is not effective in improving claudication symptoms or in preventing amputation.

Lifestyle intervention

PAD symptoms may be reduced and managed through lifestyle modification, including exercise and physical activity, smoking cessation, and a healthy diet.1,24

Exercise and physical activity. Physical activity is known to promote and maintain health, including lower blood pressure, inflammation markers, and lipids; reduced prevalence of overweight and depression; and improved exercise capacity and blood rheology.2,25 For individuals with diabetes and PAD, physical activity is recommended because success in treatment of PAD may be measured in distance walked without pain.17,25 In a systematic review of 10 randomized clinical trials of exercise programs in patients with symptomatic claudication, supervised exercise therapy was effective in increasing walking time compared to standard care.26 Higher level or longer duration of physical activity is related to longer survival and lower risk of death from cardiovascular disease among PAD patients.2,19,25–27 For more detailed information on recommendations for supervised exercise, please see the article by Stewart et al.28

Smoking cessation. Smoking cessation is a key modifiable risk factor for increasing survival and reducing the potential for disease progression. Smoking increases the risk of leg amputation, the risk of developing coronary heart disease or stroke, and mortality among PAD patients.2,18,19

Dietary intake. Few published studies have investigated the relation between dietary intake and risk of development of PAD. Cross-sectional studies of the relationship between nutrient intakes and PAD have shown a lower risk of PAD with a higher intake of vegetable fatty acids (i.e., olive oil and canola oil) ≥ 34.4 g/day (odds ratio [OR] 0.39; 95% CI 0.16, 0.97) and vitamin E intake ≥ 7.7 mg/day (OR 0.37; 95% CI 0.16, 0.84).29 The main vegetable fat consumed in this study was olive oil, which is rich in both monounsaturated and polyunsaturated fatty acids, as well as flavonoids and terpenes. It is known that polyunsaturated fatty acids favorably influence serum cholesterol concentrations and endothelial function,30 while flavonoids and terpenes function as antioxidants.31

Vitamin E, found mainly in cooking oils, also contains antioxidant and anti-inflammatory properties and inhibits platelet aggregation.32 In a case-control study of antioxidant intake and PAD, lower vitamin C intake was reported in PAD cases compared to control subjects.33 Lower levels of ascorbic acid and higher C-reactive protein levels were observed in PAD patients compared to hypertensive individuals or healthy control subjects.34

It is possible that intakes of vegetable oil (i.e., olive oil), vitamin E, and vitamin C are markers for the Mediterranean diet pattern, which has been associated with lower risk of chronic disease in numerous studies.35-37 We note that data that attempt to define atherosclerosis risk derived from both prospective and cross-sectional population surveys has unknown relevance to the treatment of established PAD. Given that dietary intervention trials have yet to be performed in a PAD population, the potential benefit and risk of altered dietary fat, vitamin C, or vitamin E consumption is not known.

Adverse levels of risk factors for PAD, including high blood pressure, diabetes, and dyslipidemia, however, all may be improved with dietary intake. Cardioprotective nutrition interventions, which include reduction in saturated fat, trans fats, and dietary cholesterol, and interventions to improve blood pressure should be a part of the treatment plan.38 The cardioprotective dietary pattern should be individualized to provide a fat intake of 25–35% of total calories, < 7% of total calories from saturated fat and trans fatty acids, and < 200 mg of cholesterol per day. This pattern can lower LDL cholesterol up to 16% and decrease risk of cardiovascular disease. The Dietary Approaches to Stop Hypertension diet39 demonstrated a reduction in blood pressure of 8–14 mmHg. It is rich in fruits and vegetables and includes low-fat dairy products, nuts, and whole grains and is low in sodium, total fat, and saturated fat. In observational studies of young and middle-aged adults, greater intakes of fruit, vegetables, and whole-grain products were associated with a lower risk of developing elevated blood pressure.40,41

In epidemiological studies, low to moderate alcohol intake has been protective for development of PAD, coronary heart disease, and type 2 diabetes.42–44 Alcohol may promote its beneficial effect on cardiovascular disease and risk factors through beneficial modification of lipids, hemostatic factors and fibrinolysis, inflammatory markers, and glucose control parameters.43,45

Eating a healthy diet pattern based on the Dietary Guidelines for Americans46 or following the American Diabetes Association47 nutrition recommendations for individuals with diabetes is known to prevent or improve adverse cardiovascular disease risk factors and to promote vascular health. According to the Dietary Guidelines for Americans, adults should eat a sufficient number and variety of foods from the fruit, vegetables, dairy, grain, and meat groups each day while staying within individual energy needs.46 In particular, selection of fruit and vegetables from all subgroups is recommended, including dark green, orange, legume, starchy, and other vegetables, as well citrus, berries, melons, and other fruit. In addition, intake of 1–2 servings of fish per week is associated with improved vascular health.46,48 The Dietary Guidelines for Americans, first developed in 1980 and updated in 2005 by the U.S. Department of Agriculture (USDA) and the Department of Health and Human Services, provides science-based advice to promote health and reduce risk for major chronic disease through diet and physical activity. 46 In addition, the USDA developed a tool called the Food Guide Pyramid (found at www.mypyramid.gov), which translates the Dietary Guidelines for Americans into messages that may assist consumers in improving their eating habits.49

Medical therapies

To reduce adverse cardiovascular event rates associated with PAD, lifelong treatment should include modification or elimination of atherosclerotic risk factors, such as smoking, diabetes, dyslipidemia, and hypertension and promotion of daily exercise and adoption of a nonatherogenic diet.2 Medical therapy (pharmacotherapy) is mandatory when target levels of blood pressure, LDL cholesterol, and plasma glucose cannot be achieved by lifestyle changes alone.

Antiplatelet therapy is indicated to reduce the risk of myocardial infarction (MI), stroke, or vascular death in individuals with PAD. Aspirin, in daily doses of 75–325 mg, is recommended as a safe and effective therapy to reduce this risk. Clopidogrel, 75 mg per day, is recommended as an effective alternative antiplatelet therapy.50 Oral anticoagulation therapy with warfarin is not indicated to reduce the risk of adverse cardiovascular ischemic events in these patients.51

Statin therapy is indicated for all patients with PAD to achieve a target LDL cholesterol level of < 100 mg/dl. In very-high-risk PAD patients (those with any poorly controlled risk factor, such as diabetes), statin therapy is indicated to achieve a target LDL cholesterol of < 70 mg/dl. Treatment with a fibric acid derivative can be useful for PAD patients with low HDL cholesterol and elevated triglycerides.

Antihypertensive therapy should be administered to hypertensive patients with PAD to achieve a goal of < 140/90 mmHg (for individuals without diabetes) or < 130/80 mmHg (for individuals with diabetes or chronic renal disease) to reduce the risk of MI, stroke, congestive heart failure, and cardiovascular death.52,53 Treatment of diabetes with medical nutrition therapy, exercise, and medications targeting glycemic control is essential to achieve an A1C of < 7%.

Claudication treatment

Pharmacotherapy to improve walking distance is proven to increase pain-free walking, and use of cilostazol is recommended as a first-line treatment for all individuals with PAD and claudication (though this medication is contraindicated for use in the rare individuals who have PAD and concomitant heart failure).54 Endovascular procedures, including balloon angioplasty and stenting, are indicated for individuals with a vocational or lifestyle disability resulting from intermittent claudication; when clinical features suggest a likelihood of symptomatic improvement, there has been an inadequate response to exercise or pharmacological therapy, and there is a very favorable risk-benefit ratio. Surgical interventions are indicated in PAD patients in whom an endovascular procedure would be less suitable and successful.2

Summary and Conclusion

PAD is a major and common health problem affecting many individuals with or at risk for developing diabetes. Like diabetes and pre-diabetes, PAD often goes undiagnosed until the disease has progressed. It is important that diabetes health professionals understand the diagnosis and treatment of PAD, as defined by current treatment guidelines, so they can support individuals with diabetes who are affected by this disease. Diabetes professionals are in a key position to identify individuals at risk for developing PAD, provide education, and refer individuals for appropriate care.

Addressing health behaviors (i.e., tobacco use, diet, physical activity, and supervised exercise) and adherence to pharmacological therapies is crucial to the successful management of both diabetes and PAD. Table 1 provides information about two organizations that provide useful information for health care professionals and patients.

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Table 1.

PAD Resources

Footnotes

  • Lyn M. Steffen, PhD, MPH, RD, is an associate professor of epidemiology at the University of Minnesota School of Public Health, Division of Epidemiology and Community Health, in Minneapolis. Daniel A. Duprez, MD, PhD, holds the Donald and Patricia Garofalo Chair in Preventive Cardiology as a professor of medicine, director of research at the Rasmussen Center for Cardiovascular Disease Prevention Center, and is associate director of the Cardiovascular Clinical Trial Center Cardiovascular Division at the University of Minnesota School of Medicine in Minneapolis. Jackie L. Boucher, MS, RD, CDE, is vice president, education, at the Minneapolis Heart Institute Foundation in Minneapolis and an associate editor of Diabetes Spectrum. Abby G. Ershow, ScD, RD, FAHA, is program director (nutrition) in the Division of Cardiovascular Diseases of the National Heart, Lung, and Blood Institute in Bethesda, Md. Alan T. Hirsch, MD, is a professor of epidemiology and community health at the University of Minnesota School of Public Health, Division of Epidemiology and Community Health, and director of the vascular medicine program at the Minneapolis Heart Institute Foundation in Minneapolis.

  • American Diabetes Association

References

  1. ↵
    Hirsch AT, Hartman L, Town RJ, Virnig BA: National healthcare costs of peripheral arterial disease in the USA Medicare population. Vasc Med In press
  2. ↵
    Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WRC, Olin JW, Puschett JB, Kenneth A. Rosenfield, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA: ACC/AHA guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). Circulation 113:1474 –547, 2006
    OpenUrlFREE Full Text
  3. ↵
    Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, Hailpern M, Ho M, Howard V, Kissela B, Kittner S, Lloyd-Jones D, McDermott M, Meigs J, Moy C, Nichol G, O'Donnell C, Roger V, Sorlie P, Steinberger J, Thom T, Wilson M, Hong Y: Heart disease and stroke statistics – 2008 update: a report form the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 117:e25 -e146, 2008
    OpenUrlFREE Full Text
  4. ↵
    Elhadd TA, Robb R, Jung RT, Stonebridge PA, Belch JJF: Pilot study of prevalence of asymptomatic peripheral arterial occlusive disease inpatients with diabetes attending a hospital clinic. Pract Diabetes Int16 : 153-166,1999
    OpenUrl
  5. ↵
    Hirsch AT, Criqui MH, Treat-Jacobson D, Regensteiner JG, Creager MA, Olin JW, Krook SH, Hunninghake DB, Comerota AJ, Walsh ME, McDermott MM, Hiatt WR: Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA 286:1317 –1324, 2001
    OpenUrlCrossRefPubMedWeb of Science
  6. Beks PJ, Mackaay AJ, de Neeling JN, de Bries H, Bouter LM, Heine RJ: Peripheral arterial disease in relation to glycaemic level in an elderly Caucasian population: the Hoorn study. Diabetologia 38:86 –96, 1995
    OpenUrlCrossRefPubMedWeb of Science
  7. ↵
    Marso S, Hiatt WR: Peripheral arterial disease in patients with diabetes. J Am Coll Cardiol 47:921 -929, 2006
    OpenUrlCrossRefPubMedWeb of Science
  8. ↵
    Allison MA, Criqui MH, McClelland RL, Scott JM, McDermott MM, Liu K, Folsom AR, Bertoni AG, Sharrett AR, Homma S, Kori S: The effect of novel cardiovascular risk factors on the ethnic-specific odds for peripheral arterial disease in the Multi-Ethnic Study of Atherosclerosis (MESA). J Am Coll Cardiol 48:1190 –1197, 2006
    OpenUrlCrossRefPubMedWeb of Science
  9. ↵
    Ostchega Y, Paulose-Ram R, Dillon CF, Gu Q, Hughes JP:. Prevelence of peridpheral arterial disease and risk factors in persons aged 60 and older: Data from the National Health and Nutrition Examination Survey 1999-2004. J Am Eriart Soc 55:583 –589, 2007
    OpenUrl
  10. ↵
    Criqui MH, Fronek A, Barrett-Connor E, Klauber MR, Gabriel S, Goodman D: The prevalence of peripheral arterial disease in a defined population. Circulation 71:510 –515, 1985
    OpenUrlAbstract/FREE Full Text
  11. ↵
    Heald CL, Fowkes FG, Murray GD, Price JF, Ankle Brachial Index Collaboration: Risk of mortality and cardiovascular disease associated with the ankle-brachial index: systematic review. Atherosclerosis189 : 61–69,2006
    OpenUrlCrossRefPubMedWeb of Science
  12. ↵
    Regensteiner JG, Hiatt WR, Coll JR, Criqui MH, Treat-Jacobson D, McDermott MM, Hirsch AT: The impact of peripheral arterial disease on health-related quality of life in the Peripheral Arterial Disease Awareness, Risk, and Treatment: New Resources for Survival (PARTNERS) program. Vasc Med13 : 15–24,2008
    OpenUrlAbstract/FREE Full Text
  13. ↵
    Dolan NC, Liu K, Criqui MH, Greenland P, Guralnik JM, Chan C, Schneider JR, Mandapat AL, Martin G, McDermott MM: Peripheral artery disease, diabetes, and reduced lower extremity functioning. Diabetes Care25 : 113–120,2002
    OpenUrlAbstract/FREE Full Text
  14. ↵
    Adler AI, Boyko EJ, Ahroni JH, Smith DG: Lower-extremity amputation in diabetes: the independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers. Diabetes Care, 22:1029 –1035, 1999
    OpenUrlAbstract/FREE Full Text
  15. ↵
    Bird CE, Criqui MH, Fronek A, Denenberg JO, Klauber MR, Langer RD: Quantitative and qualitative progression of peripheral arterial disease by non-invasive testing. Vasc Med 4:15 –21, 1999
    OpenUrlAbstract/FREE Full Text
  16. ↵
    Wrobel JS, Mayfield JA, Reiber GE: Geographic variation of lower-extremity major amputation in individuals with and without diabetes in the Medicare population. Diabetes Care 24:860 –864, 2001
    OpenUrlAbstract/FREE Full Text
  17. ↵
    Ridker PM, Cushman M, Stampfer MJ, Tracy RP, Hennekens CH: Plasma concentrations of C-reactive protein and risk of developing peripheral vascular disease. Circulation 97:425 –428, 1998
    OpenUrlAbstract/FREE Full Text
  18. ↵
    Navas-Acien A, Selvin E, Sharrett AR, Calderon-Aranda E, Silbergeld E, Guallar E: Lead, cadmium, smoking, and increased risk of peripheral arterial disease. Circulation 109:3196 –3201, 2004
    OpenUrlAbstract/FREE Full Text
  19. ↵
    American Diabetes Association: Peripheral arterial disease in people with diabetes. Diabetes Care 26:3333 –3341, 2003
    OpenUrlFREE Full Text
  20. ↵
    Bhatt DL, Steg PG, Ohman EM, Hirsch AT, Ikeda Y, Mas JL, Gota S, Liau CS, Richard AJ, Rother J, Wilson PWF for the REACH Registry Investigators: International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA 295:180 –189, 2006
    OpenUrlCrossRefPubMedWeb of Science
  21. ↵
    Steg G, Bhatt DL, Wilson PWF, D'Agostino R, Ohman EM, Rother J, Liau CS, Hirsch AT, Mas JL, Ikeda Y, Pencina MJ, Goto S, for the REACH Registry Investigators: One-year cardiovascular event rates in outpatients with atherothrombosis. JAMA 297:1197 –1206, 2007
    OpenUrlCrossRefPubMedWeb of Science
  22. ↵
    Selvin E, Hirsch AT: Contemporary risk factor control and walking dysfunction in individuals with peripheral arterial disease: NHANES 1999–2004. Atherosclerosis 2008 [Epub ahead of print. doi:10.1016/j.atherosclerosis.2008.02.002 ]
  23. ↵
    Hirsch AT, Murphy TP, Lovell MB, Twillman G, Treat-Jacobson D, Harwood EM, Mohler ER, Creager MA, Hobson RW, Robertson RM, Howard WJ, Schroeder P, Criqui MH for the Peripheral Arterial Disease Coalition: Gaps in public knowledge of peripheral arterial disease: the first national PAD public awareness survey. Circulation 116:2086 –2094, 2007
    OpenUrlAbstract/FREE Full Text
  24. ↵
    Hankey GJ, Norman PE, Eikelboom JW: Medical treatment of peripheral arterial disease. JAMA 295:547 –553, 2006
    OpenUrlCrossRefPubMedWeb of Science
  25. ↵
    Milani RV, Lavie CJ: The role of exercise training in peripheral arterial disease. Vasc Med 12:351 –358, 2007
    OpenUrlAbstract/FREE Full Text
  26. ↵
    Leng GC, Fowler B, Ernst E: Exercise for intermittent claudication [Review]. Cochrane Database Syst Revs Issue 2. Art. No.: CD000990, 2000
  27. ↵
    Garg PK, Tian L, Criqui MH, Liu K, Ferrucci L, Gulalnik JM, Tan J, McDermott MM: Physical activity during daily life and mortality in patients with peripheral artery disease. Circulation 114:242 –248, 2006
    OpenUrlAbstract/FREE Full Text
  28. ↵
    Stewart KJ, Hiatt WR, Regensteiner JG, Hirsch AT: Exercise training for claudication. N Engl J Med 347:1941 –1951, 2002
    OpenUrlCrossRefPubMedWeb of Science
  29. ↵
    Antonelli-IncalziR, Pedone C, McDermott MM, Bandinelli S, Miniati B, Lova RM, Lauretani F, Ferrucci L: Association between nutrient intake and peripheral artery disease: results from the InCHIANTI study. Atherosclerosis 186:200 –206, 2006
    OpenUrlCrossRefPubMed
  30. ↵
    Leng GC, Taylor GS, Lee AJ, Fowkes FGR, Horrobin D: Essential fatty acids and cardiovascular disease: the Edinburgh Artery Study. Vasc Med4 : 219-226,1999
    OpenUrlAbstract/FREE Full Text
  31. ↵
    Arts IC, Hollman PC: Polyphenols and disease risk in epidemiologic studies. Am J Clin Nutr 81(Suppl):317S –325S, 2005
    OpenUrlAbstract/FREE Full Text
  32. ↵
    Munteanu A, Zingg JM, Azzi A: Anti-atherosclerotic effects of Vitamin E: myth or reality? J Cell Mol Med 8:59 –76, 2004
    OpenUrlPubMedWeb of Science
  33. ↵
    Leng GC, Fowkes FGR, Smith FB, Lowe GDO, Donnan PT, Ells K: Plasma essential fatty acids, cigarette smoking and dietary antioxidants in peripheral artery disease: a population-based case-control study. Arterioscler Thromb 14:471 –478, 1994
    OpenUrlAbstract/FREE Full Text
  34. ↵
    Langlois M, Duprez D, Delanghe J, De Buyzere M, Clement DL: Serum vitamin C concentration is low in peripheral arterial disease and is associated with inflammation and severity of atherosclerosis. Circulation103 : 1863–1868,2001
    OpenUrlAbstract/FREE Full Text
  35. ↵
    Ciccarone E, Di Castelnuovo A, Salcuni M, Siani A, Giacco A, Donati MB, De Gaetano G, Capani F, Iacoviello L, on behalf of the Gendiabe Investigators: A high-score Mediterranean dietary pattern is associated with a reduced risk of peripheral arterial disease in Italian patients with Type 2 diabetes. Thromb Haemost 1:1744 –1752, 2003
    OpenUrl
  36. Mitrou PN, Kipnis V, Thiebaut AC, Reedy J, Subar AF, Wirfalt E, Flood A, Mouw T, Hollenbeck AR, Leitzmann MF, Schatzkin A: Mediterranean dietary pattern and prediction of all-cause mortality in a US population: results from the NIH-AARP Diet and Health Study. Arch Intern Med167 : 2461–2468,2007
    OpenUrlCrossRefPubMedWeb of Science
  37. ↵
    Panagiotakos DB, Tzima N, Pitsavos C, Chrysohoou C, Zampelas A, Toussoulis D, Stefanadis C: The association between adherence to the Mediterranean diet and fasting indices of glucose homoeostasis: the ATTICA Study. J Am Coll Nutr26 : 32–38,2007
    OpenUrlPubMedWeb of Science
  38. ↵
    American Dietetic Association: Type 1 and type 2 diabetes evidence-based nutrition practice guidelines for adults [article online]. Available from http://www.adaevidencelibrary.com/topic.cfm?=3252
  39. ↵
    Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, Bray GA, Vogt TM, Cutler JA, Windhauser MM, Lin PH. Karanja N, of the DASH Collaborative Research Group: A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med 336:1117 –1124, 1997
    OpenUrlCrossRefPubMedWeb of Science
  40. ↵
    Steffen LM, Kroenke CH, Yu X, Pereira MA, Slattery ML, Van Horn L, Gross MD, Jacobs DR Jr: Associations of plant food, dairy product, and meat intake with 15-y incidence of elevated blood pressure in young black and white adults: the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Am J Clin Nutr 82:1169 –1177, 2005
    OpenUrlAbstract/FREE Full Text
  41. ↵
    Miura K, Greenland P, Stamler J, Liu K, Daviglus ML, Makagawa H: Relation of vegetable, fruit, and meat intake to 7-year blood pressure change in middle-aged men: The Chicago Western Electric Study. Am J Epidemiol159 : 572–580,2004
    OpenUrlAbstract/FREE Full Text
  42. ↵
    Djousse L, Levy D, Lurabito JM, Cupples LA, Ellison RC: Alcohol consumption and risk of intermittent claudication in the Framingham Heart Study. Circulation 102:3092 –3097, 2000
    OpenUrlAbstract/FREE Full Text
  43. ↵
    Rimm EB, Moats C: Alcohol and coronary heart disease: drinking patterns and mediators of effect. Ann Epidemiol 17:S3 –S7, 2007
    OpenUrlCrossRefWeb of Science
  44. ↵
    Athyros VG, Liberopoulos EN, Mikhailidis DP, Papageorgiou AA, Ganotakis ES, Tziomalos K, Kakafika AI, Karagiannis A, Lambropoulos S, Elisaf M: Association of drinking pattern and alcohol beverage type with the prevalence of metabolic syndrome, diabetes, coronary heart disease, stroke, and peripheral arterial disease in a Mediterranean cohort. Angiology58 : 689–697,2008
    OpenUrlAbstract/FREE Full Text
  45. ↵
    Booyse FM, Pan W, Grenett HE, Parks DA, Darley-Usmar VM, Bradley KM, Tabengwa EM: Mechanism by which alcohol and wine polyphenols affect coronary heart disease risk. Ann Epidemiol 17:S24 –S31, 2007
    OpenUrlCrossRefPubMed
  46. ↵
    U.S. Department of Health and Human Services and U.S. Department of Agriculture: Dietary Guidelines for Americans, 6th ed. Washington, D.C.. U.S. Government Printing Office, 2005
  47. ↵
    American Diabetes Association: Nutrition recommendations and interventions for diabetes [Position Statement]. Diabetes Care 31 (Suppl. 1): S61–S78,2008
    OpenUrlFREE Full Text
  48. ↵
    Steffen LM, Folsom AR, Cushman M, Jacobs DR Jr, Rosamond WD: Greater fish, fruit, and vegetable intakes are related to lower incidence of venous thromboembolism. Circulation 115:188 –195, 2007
    OpenUrlAbstract/FREE Full Text
  49. ↵
    Haven J, Burns A, Herring D, Britten P: MyPryamid.gov provides consumers with practical nutrition information at their fingertips. J Nutr Educ Behav 38:S153 –S154, 2006
    OpenUrlCrossRefPubMed
  50. ↵
    Duprez DA, De Buyzere ML, Hirsch AT: Developing pharmaceutical treatments for peripheral artery disease. Expert Opin Invest Drugs12 : 101–108,2003
    OpenUrlCrossRefPubMed
  51. ↵
    Warfarin Antiplatelet Vascular Evaluation Trial investigators: Oral anticoagulant and antiplatelet therapy and peripheral arterial disease. N Engl J Med357 : 217–227,2007
    OpenUrlCrossRefPubMedWeb of Science
  52. ↵
    Clement DL, De Buyzere ML, Duprez DA: Hypertension in peripheral arterial disease. Curr Pharm Des 10:3615 –3620, 2004
    OpenUrlCrossRefPubMedWeb of Science
  53. ↵
    Hirsch AT, Duprez D: The potential role of angiotensin-converting enzyme inhibition in peripheral arterial disease. Vasc Med8 : 273–278,2003
    OpenUrlAbstract/FREE Full Text
  54. ↵
    Duprez DA: Pharmacological interventions for peripheral artery disease. Expert Opin Pharmacother 8:1 –12, 2007
    OpenUrlCrossRefPubMedWeb of Science
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July 2008, 21(3)
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Management of Peripheral Arterial Disease
Lyn M. Steffen, Daniel A. Duprez, Jackie L. Boucher, Abby G. Ershow, Alan T. Hirsch
Diabetes Spectrum Jul 2008, 21 (3) 171-177; DOI: 10.2337/diaspect.21.3.171

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Management of Peripheral Arterial Disease
Lyn M. Steffen, Daniel A. Duprez, Jackie L. Boucher, Abby G. Ershow, Alan T. Hirsch
Diabetes Spectrum Jul 2008, 21 (3) 171-177; DOI: 10.2337/diaspect.21.3.171
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    • Abstract
    • What Is Lower-Extremity PAD?
    • Prevalence of PAD
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    • Lifestyle intervention
    • Medical therapies
    • Claudication treatment
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