Vascular Disease Foundation - Fighting Vascular Disease... Improving Vascular Health.

Interactive Learning : Ask the Expert

 

Ask the Expert Live Chat Transcript - Tuesday, August 3, 2010

Elizabeth Ratchford, MD


Assistant Professor, Department of Medicine, Division of Cardiology, Johns Hopkins Heart & Vascular Institute

 

 

Dr. Ratchford generously donated her time to answer our patients' general questions about vascular disease. The below transcript details all of the questions asked by our participants as well as her answers.

Moderator- VDF: Welcome everyone! Thanks for joining us today, we're glad you're here! You may now go ahead and type your questions for Dr. Ratchford to answer. We appreciate everyone's patience as she works to answers everyone's questions.


Doris W: Are there PAD therapy programs available? Are there printed pamphlets that can be handed out at doctors' offices?

Speaker Dr. Ratchford: Hi Doris - We at Johns Hopkins have a dedicated PAD rehab program which is relatively unique among medical centers but there are a few across the country.

Doris W: Are there any stem cell treatments?

Speaker Dr. Ratchford: Doris: I am not aware of any clinical use of stem cells for PAD but much vascular biology research is going on.

Doris W: I live in Portland, Texas, a bedroom community of Corpus Christi. We have many residents who do not understand English, and no info. That I am aware of on PAD, How do we get this condition publicized?

VDF Moderator:  Hi Doris, thanks for your question. You can order brochures from VDF's online store: http://www.vdf.org/estore/ they are free for patients and we ask for a small shipping and handling fee for professionals.

Doris W: I have a treadmill. Are there specific guidelines for exercise? I have 5 stents in my legs, done at PVA in San Antonio, with circulation restored to about 75 percent. But I just sort of set my own guidelines for exercise.

Speaker Dr. Ratchford: Doris: I would recommend walking using the protocol in the CLEVER trial where you walk to achieve MODERATE (7/10) pain within 5 minutes, get off and sit down till the pain subsides, and then get back on, for a total of 30-60 minutes daily of walking.

Doris W: Is water aerobics helpful in exercise for PAD? I do it 2 days a week and walk 1 mile on treadmill the other 3 days.

Speaker Dr. Ratchford:  Doris: I am not aware of any studies on water aerobics for PAD but it is an interesting thought. The general rule is that if you want to be able to walk farther, then you need to walk. If the goal is to increase your water aerobics ability, then water aerobics would be great! Any kind of exercise is good for improving your cardiovascular risk.

Doris W: Are there many clinical trials for PAD?

Speaker Dr. Ratchford:  Doris: Yes there are many clinical trials including CLEVER; you can check http://www.clinicaltrials.gov

Doris W: I had two procedures for stents using the Foxhollow (sort of a roto-rooter) device, which were both successful for me.

VDF Moderator:  Great Doris thanks for sharing about your success!


Sharon B: I've heard of a treatment/prevention that wraps air cuffs around the legs for awhile each day to improve circulation. Do you know if this has some proven benefit?

Speaker Dr. Ratchford: Sharon: I have heard about this device but I don't think it has been proven to be beneficial in PAD, although a similar device is useful for venous disease and/or lymphedema.

Sharon B: Does Ginkgo biloba help circulation? Would it hurt to take it? Are there other supplements that might help PAD?

VDF Moderator:  Hi Sharon, thanks for your interest in Ginkgo and other supplements. Unfortunately this is not an area that Dr. Ratchford has expertise in. I also can not stress enough the importance of talking to your doctor about any supplements that you are taking. There are many prescription medications that interact with herbal supplements and can cause more harm than good.

Sharon B: I think my dad had PAD - definitely had circulation problems. I am trying to prevent them (hence my question about supplements). My legs ache a lot - almost all of the time when standing or sitting. I don't want PAD - how can I prevent it? Is there something to help the achy legs?

Speaker Dr. Ratchford: Sharon: Perhaps the most important thing you can do is to exercise regularly (30 min/day every day) and focus on controlling your cardiovascular disease risk factors.


Caley M:  I think my father has PAD - what supplements (if any) help?

Speaker Dr. Ratchford: Caley and Sharon - I do not believe there is any data to support the use of supplements (including Ginkgo biloba) for PAD.

VDF Moderator:  For those interested in studies surrounding Ginkgo bilbo. I just ran a quick search and found this article online from PubMed: http://www.ncbi.nlm.nih.gov/pubmed/18628657


Arlene N: Are there any medications on the market that help improve PAD? I am asking about medications your Dr. can give?

Speaker Dr. Ratchford: Arlene: Medications for PAD include: aspirin (or clopidogrel) for reducing the risk of heart attack and stroke. Statins also reduce that risk. Cilostazol can increase walking ability. ACE inhibitors are good for reducing blood pressure in PAD patients.

Arlene N: Exactly what do you do in the rehab programs besides treadmill walking?

Speaker Dr. Ratchford: Arlene: The rehab program is at the Clinical Exercise Center and most of the work is focused on walking since this is the best studied treatment but it is also a comprehensive approach with emphasis on lifestyle changes as well as some strength training.

Arlene N: Strength training in legs only? I know eating certain foods like fat isn't good for PAD patients, what else is there?

Speaker Dr. Ratchford: Arlene: The strength training is overall (not just for the legs) but is not geared specifically towards increasing walking distance but rather in improving overall health. I generally recommend a heart-healthy diet low in saturated fats, and high in fruits/vegetables and whole grains. Also, everything in moderation including portion sizes!!

Arlene N: Are there any new procedures other than angioplasty; are there any new ideas for bypass surgery other than using my veins or artificial ones?

Speaker Dr. Ratchford:  Arlene: The procedures done in the cath lab vary depending on the situation; some interventionalists will use other techniques such as atherectomy or cryoplasty or laser treatment. Bypass surgery is generally a last resort. We like to use endovascular revascularization (with balloons and stents) if possible because it is lower risk.

Arlene N: I realize it is a last resort but I have had two surgeries using my veins to bypass my artery. After several angioplasties it looks like I may have to have it done again and there aren't anymore viable veins.

Speaker Dr. Ratchford:  Arlene: It sounds like a PTFE (synthetic) graft may be the next step.


Jeannette F:  Approximately what percentage of 55 year old diabetics (say with a ten year history of DM) and a past history of smoking should have PAD testing done?

Speaker Dr. Ratchford: This is a great question Jeannette. First, anyone with symptoms and those risk factors should have an ABI and it will be covered by insurance. The question regarding people without symptoms is less clear, mainly because it is not typically covered by insurance in the absence of symptoms. Many would advocate for screening all people with DM over age 50. However, any time you order a diagnostic test, it is important to ask how it would change your management. Patients with diabetes should already be treated as if they have known atherosclerosis because it is considered a coronary heart disease equivalent.


Denis R: Hi Dr. Ratchford as a DVT survivor (3 years post diagnose) I often wonder why thrombectomy is not one of the first treatment offered? Is this more of a vascular/hematology discussion.

Speaker Dr. Ratchford: Denis: Thrombectomy is definitely used in some cases of large iliofemoral DVTs, in fact I saw someone with that this morning that had thrombolysis done. But there are risks associated with it so we don't use it for most people.

Denis R: Does the danger of the procedure (thrombectomy/thrombilysis) outweigh the danger of getting PTS and further skin ulcers?

Speaker Dr. Ratchford:  Denis: Yes the risk can outweigh the benefit if there is life-threatening bleeding.


Irene: I am someone who is at risk for PAD and I also have FMD how do I know if my leg pain is the start of PAD or if the arteries in my leg are affected by FMD?

Speaker Dr. Ratchford:  Irene: A simple ABI can help to answer that question.

VDF Moderator:  Hi Irene, for more information about the ABI you can visit this link: http://www.vdf.org/diseaseinfo/pad/anklebrachial.php  You can also request a free ABI brochure by contacting us at http://www.vdf.org or 888.833.4463.


Hany: I have pain in femoral/groin when walking, relieved by rest, cold limbs, weak femoral pulse, strong family history of PAD (father, uncle, grandmother). I have had Doppler ultrasound and CTA however they do not show disease. Is there a more definitive diagnosis for PAD. Is an arteriogram 100% accurate test? I also have microvascular angina.

Speaker Dr. Ratchford:  Hany: Have you had an ABI?

Hany: Yes ABI ankles normal but my pain is in femoral.

Speaker Dr. Ratchford:  Hany: The ABI is the best screening test for PAD and the likelihood of PAD is quite low if the ABI is normal. There is probably another cause for the pain?

Hany: Thanks, I have had nerves and bones tested. I heard ABI can still be normal if problem is in femoral. My father and uncle have exact same symptoms with PAD in femoral.

Speaker Dr. Ratchford:  Hany: The ABI can be normal but it is very unlikely. The CTA is also a pretty accurate test so I doubt it is arterial but perhaps venous?

Hany: Is arteriogram 100% accurate test? I will ask my cardiologist about venous, thank you.

Speaker Dr. Ratchford:  Hany: Yes an angiogram is the gold standard but based on what you have said, I don't think you need one.

Hany:  Is L-arginine good for PAD/circulation?

Speaker Dr. Ratchford:  Hany: Unfortunately the data are somewhat mixed but L-arginine has not definitively been shown to improve claudication symptoms.

VDF Moderator:  Hi Hany, there was a study that showed that L-arginine had no benefit and could possible cause harm for PAD. I found two articles online: http://www.ncbi.nlm.nih.gov/pubmed/17592080 and the whole study may be found here (it's pretty technical!): http://circ.ahajournals.org/cgi/content/fu…

Hany: Is rebounding /trampette good exercise for PAD/circulation?

Speaker Dr. Ratchford:  Hany: As I mentioned above, walking is the best thing if the goal is to walk farther but any type of exercise is good

Hany:  Is pain in femoral, groin, genital indicative of illiac or femoral disease?

Speaker Dr. Ratchford:  Hany: No, not usually. Pain is usually beyond (further down the leg) from the blockage so femoral disease usually causes calf pain. Iliac disease can cause hip, buttock, or thigh pain.


Craig H: I've worked with and had read papers by Dr. Emile Mohler and heard the podcast by Dr. Meyerson and Dr. Stewart when they asked that more Primary Care Physicians should perform the ABI on patients with signs and symptoms. Why do you feel they do not?

Speaker Dr. Ratchford:  Hi Craig. I think the level of awareness is improving among primary care providers but their time is limited and it is not covered by insurance.

Craig H:  I believe the difficulty with screening is insurance does not pay for screening; there must be signs and symptoms to pay for the testing.

Speaker Dr. Ratchford:  Craig - yes that is correct.

Craig H:  If the procedure used in the CV Lab could be migrated to the PCP's office so they got paid under curent CPT and ICD-9 coding help with diagnosis, treatment and awareness?

Speaker Dr. Ratchford:  Craig: Yes absolutely

Craig H: Thanks Dr Ratchford, I know how this can be done using Information Technology to instruct, educate patients and communicate the study to the cardiologist for reading. It also can interface with any EMR.

Speaker Dr. Ratchford:  Craig: That would be great


VDF Moderator:  This next question was e-mailed to us ahead of time: Every few nights in bed I develop painful cramps in both feet. By standing on the cold bathroom tiles and massaging the feet it eventually disappears, only to return again once I return to bed. Is there anything that can relieve these painful cramps?

Speaker Dr. Ratchford:  Re: the cramps in the feet: This could be a sign of poor circulation or PAD so an ABI test may be a good idea depending on your other risk factors. Sometimes people have "nocturnal leg cramps" which are worsened by magnesium or other electrolyte deficiencies. It may improve with stretching prior to bed, and quinine was used in the past but is no longer prescribed due to cardiac side effects.

VDF Moderator:  This next question was also e-mail to us ahead of time: Does any one pay much attention to the High Thigh Index (HTI) when doing segmental pressures?

Speaker Dr. Ratchford:  Re: High Thigh pressures - We used a contoured thigh cuff because it is more comfortable. Thus, we don't use the high thigh pressure since a femoral pulse can usually help us distinguish between iliac and femoral disease.


VDF Moderator:  Thank you for joining us today! We appreciate your time and interest. Please join us for our next chat on 9/7 with Jean White. We thank Dr. Ratchford for her time today. Have a healthy day!


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