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Interactive Learning : HealthCast Transcripts

Episode 15 : More about PAD

Release Date: April 17, 2007

Dr. David Meyerson:  Hi, I'm Dr. David Meyerson, cardiologist at Johns Hopkins and your host for this edition of Vascular Disease Foundation's HealthCast.  We are very excited to be able to bring excellent, easy to understand science to you on all topics relating to heart and blood vessel diseases as a public service. As a public education forum, the Vascular Disease Foundation is made up of representatives of the premiere medical and science advisory groups in the country that relate to vascular diseases.  These are groups that use peer-reviewed science to verify that the information you are getting is nationally recognized as the very best and most reliable data available. Prior episodes in this series have dealt with carotid artery disease, that's the narrowing of the arteries in the neck that nourish the brain which can cause stroke and threaten strokes called TIA's or transient ischemic attacks.  We've talked about coronary artery disease, narrowings of the arteries that nourish the heart muscle that can cause angina, the chest pain you get when too little blood supply and oxygen gets to your heart muscle or also cause heart attacks.  We're talking about abdominal aortic aneurysm, the bulging and weakening of the major blood vessel of the abdomen which can cause life threatening blood loss and finally we've talked about peripheral arterial disease, narrowings or blockages in the arteries that nourish the legs which can limit your ability to walk, cause pain and ulcers of the legs and in extreme situations, can even cause one to risk amputation.  These are largely preventable diseases. Once developed, they are very treatable diseases and the early recognition and treatments can prevent your disability, promote your physical well-being and helpyou maintain the healthiest and most active lifestyle you possibly can.  We have used the analogy of the sixty-year-old house.  If the plumber tells you that certain of the pipes in the basement are corroded and clogged, it wouldn't, it shouldn't surprise you that the pipes on the second floor are also at risk  Today we have some very special information which tells us that identifying certain conditions of the circulation to the legs may be a critical window on potential disease lurking in other parts of the circulation. This special information comes from a very special guest.  He is  Dr. Alan Hirsch.  He's the Director of the Vascular Medicine Program at the Minneapolis Heart Institute.  Like me, he's a card-carrying cardiologist. He's also Professor of Epidemiology and Community Health at the University of Minnesota School of Public Health.  He's also past president of the Vascular Disease Foundation.  Dr. Hirsch welcome to the VDF HealthCast microphones.

Dr. Alan Hirsch:  David, it's absolutely delightful to join you and our colleagues who are listening in.

Dr. David Meyerson:  Thank you very much and Alan, we know each other personally, so no disrespect from the first name.  We wanted to begin to talk about how to recognize peripheral arterial disease and why is it so important.  And maybe I should ask you to take about a minute to tell us, what is peripheral arterial disease and why is it so critical?

Dr. Alan Hirsch:  Well, it's absolutely fabulous that these podcasts have been able to offer the public a focus on the broad range of arterial blockage diseases that affect life and limb.  For those who are not yet aware of the major significance of peripheral arterial disease, this is defined as the illness that blocks arteries outside the heart.  Where we use this term, we primarily are suggesting that this is a disease that affects the aorta, the main pipe that leads to the heart, all the other organs and to the lower extremities, although it can affect any artery in the body.  So peripheral arterial disease is a very, very common manifestation of atherosclerosis or the artery clogging disease.

Dr. David Meyerson:  And as we said in the beginning, this disease can limit your ability to walk, it causes pain of the legs, ulcers of the legs and in extreme situations can even risk amputation, right?

Dr. Alan Hirsch:  Absolutely.  But to take all three of those things you said and amplify them, they -- clearly this illness limits people's ability to move and enjoy the sort of independence that we really cherish as we go through activities of daily living. It certainly is a major cause of heart attack and stroke which people should know.  And finally as you said, it's the primary cause of loss of legs in this country.

Dr. David Meyerson:  And you know we've heard from our colleague, Dr. Kerry Stewart is a member of the VDF Foundation and also actually the producer of these healthcasts, that exercise is so critical and when you can't do exercise, all of your cardiovascular health fails.

Dr. Alan Hirsch:  That's correct.

Dr. David Meyerson:  Your blood pressure is not as well controlled, your cholesterol is not as well controlled and your heart health is not as well controlled.  I think everybody, all humans from the age of childhood all the way through the adult years realizes that we are meant to be mobile.  Our ability to be with our families, our loved ones, to work and to play is dependent upon that fully one half of our body, our legs, that let us to be ambulatory.

Dr. David Meyerson:  So Alan --

Dr. Alan Hirsch:  Certainly want to preserve that.

Dr. David Meyerson:  Let's talk about this. When a new patient comes to us as cardiologist, it would be invariable that we would have some vital signs and we would often have a baseline electrocardiogram. It would be every patient's expectations that you go to a cardiologist, you get an electrocardiogram.  But you have another concept.  There's a test that we do to look for peripheral arterial disease, which should almost be as reflexly done by the doctor.  Is that right?

Dr. Alan Hirsch:  Yes and that would be the ankle-brachial index and as you leave here David, you know, in the 1930's, `40's and `50's, it became common for patients to expect the doctor to listen to their heart because the heart was the organ that permitted the blood to flow, but you're right.  In 2007 and in the years ahead, it's clearly recognized that blood flow to all parts of the body, including to the legs, must be measured.  That's clearly part of every national and international guideline that preserves cardiovascular health, so as we get into this, clearly both patients, physicians need to measure some aspect of leg blood flow.  That would be the ankle-brachial index.

Dr. David Meyerson:  Do you think that it's - if a cardiologist were to do a careful physical examination which included a careful examination of all of the pulses of the lower extremities and looked for a sensation, looked for absence of ulcers in the lower extremities, look for hair distribution on the lower extremities and you could verify that those pulses were excellent and intact, would that be good enough or do you think that this actual ankle-brachial index should be performed on almost everyone?

Dr. Alan Hirsch:  For those listeners who can't see me, I'm smiling.  Would it be good enough to drive without headlights?  It's acceptable.  The examination --

Dr. David Meyerson:  Depends on the time of the day, right?

Dr. Alan Hirsch:  -- not just by cardiologist since most individuals won't be seeing a cardiologist, but by their primary care physician, their nurse practitioner, their physician assistant.  Because this disease is so common, affecting well over eight million Americans and probably over twenty-seven to thirty million throughout Western Europe and North America, it's not enough to merely feel pulses, but one must feel them.  So by feeling the pulse, if they're normal, they're certainly less risk of the disease being present, but our fingers simply aren't, even with twenty or thirty years of clinical practice, they're not precise enough to measure blood flow.

Dr. David Meyerson:  So you would like -- which providers should be doing ankle-brachial index?

Dr. Alan Hirsch:  I think if a provider is seeing adults over fifty, taking care of adult populations, then if we care as a society about preventing the most common cause of death and morbidity, we care about preventing heart attack and stroke and stay mobile, every provider needs to be aware, as you know --

Dr. David Meyerson:  So a family practitioner?

Dr. Alan Hirsch:  -- must feel pulses andmeasure the ankle blood pressure.

Dr. David Meyerson:  A family practitioner, an internist, a cardiologist, vascular surgeon should be doing that study.

Dr. Alan Hirsch:  Well, for any illness that affects such a high fraction of the population for which people are unaware of your risk, yes you turn the headlights on and you look ahead before you hit the deer.

Dr. David Meyerson:  Excellent.  Now I'm thinking from the point of view of our listeners, we've mentioned the ankle-brachial index now several times. Exactly what is done and how is it performed?

Dr. Alan Hirsch:  Let me kind of put this in perspective.  You and I have talked about this.  I think again, we're starting to live in a world where almost no matter where you are, people realize that if you want to understand the heart function, you can do more than simply place a stethoscope on the chest. Everyone is aware that you can do an electrocardiogram or ECG.  It's a measure really very important aspect of heart function and it's inexpensive and every physician can do it.  Therefore if you have unusual chest discomfort, ECG can unmask with really quite good precision danger that lurks.  For the legs, the ankle- brachial index, ankle for leg, brachial as a word for arm, the ankle-brachial index is the ratio of the higher blood pressure at the ankle as compared to the arm.

Dr. David Meyerson:  So tell, our listeners really want to know, what's the doctor going to do?

Dr. Alan Hirsch:  Well, the ABI is  the ECG of the legs.

Dr. David Meyerson:  Right.

Dr. Alan Hirsch:  The doctor is going to do something very simple either in their office --

Dr. David Meyerson:  Right.

Dr. Alan Hirsch:  -- the blood pressure cuff that is used for the arm pressure will measure both arm pressures and usually the same cuff will be rotated both legs and the ankle pulses and the ankle blood pressure will also be measured.

Dr. David Meyerson:  Where should the patient expect the doctor to put the blood pressure cuff?  Most of them know where on the upper arm we put it.  There's a new way, by the way that we've talked about on occasion of taking blood pressure for people who wear glasses, you can put the blood pressure cuff around the neck and pump it up until the eyeballs put back of the lenses.  That's just to get our listeners to smile and listen and we don't do that.  We all do know that you put the blood pressure cuff around the upper arm generally and the doctor will listen with a stethoscope or sometimes it's done with an automated machine. Exactly where does the blood pressure go when they put it on the leg and what do they measure.

Dr. Alan Hirsch:  Right.  I think people should be able to picture this in their minds.  So upper arm and above the ankle and so, you know, really this is a very easy, comfortable, inexpensive, cost- affective and accurate test, so a simple blood pressure cuff at the arm and the ankle --

Dr. David Meyerson:  Uh-huh [affirmative].

Dr. Alan Hirsch:  -- they have a high rate of detection of a life threatening disease.

Dr. David Meyerson:  Now you're two steps ahead.  So the doctor --

Dr. Alan Hirsch:  I am.

Dr. David Meyerson:  -- the doctor has the blood pressure cuff on the calf somewhere, right?  Just above the ankle, right?

Dr. Alan Hirsch:  Right.

Dr. David Meyerson:  And is the doctor going to listen with the stethoscope to the arteries of the lower leg by the ankle or is the doctor going to feel for that pulse and find out what the pressure is?

Dr. Alan Hirsch:  Well, the doctor or the physician's nurse or assistant, does not have to be the physician, we use an electronic stethoscope called the doppler device --

Dr. David Meyerson:  Okay.

Dr. Alan Hirsch:  -- it is more accurate in detecting blood flow than a mere stethoscope and its accuracy is important, but easy to achieve so using a handheld electronic stethoscope at the arm and the ankle, over about ten minutes, fifteen minutes at most will have four measurements of arm and ankle pressure and as you're about to ask me, the ankle pressure should be essentially the same as the arm pressure if there's no blockage in the pipes and obviously if there's a decline in the ankle pressure, it means there's something preventing blood flow from getting to the legs which is usually a sign of P.A.D. or peripheral arterial disease.

Dr. David Meyerson:  So this could be one of the early signs, even before you get symptoms.

Dr. Alan Hirsch:  Yes and actually that raises a really critical point for listeners which is this concept of early disease detection.  If a patient, a member of the public, someone at risk of heart attack and stroke wants, with a smile, get a leg ahead on a cardiovascular risk, measurement of an abnormal ankle blood pressure may be clear.  It's not really an early sign of risk.  How that ankle pressure decline?

Dr. David Meyerson:  It's actually quite an intermediate or late sign.

Dr. Alan Hirsch:  Well, it's actually quite late, right.  So that once that ankle pressure is low, that risk is imminent.  The rate of heart attack and stroke is increased three to five-fold within the first year.  As we'll talk about later, the risk of heart attack, stroke, death or leg loss is really right in front of you, in fact the headlights are on and the deer is within the stopping distance, but just barely.

Dr. David Meyerson:  Uh-huh [affirmative]. Let me ask you this Alan.  So we do the blood pressure usually -- the best way to do it is to do it on both arms and compare it and because there can be a differential in the flow that goes from leg or another or peripheral arterial disease can affect one side and not the other, it's important to do it on both sides, right?

Dr. Alan Hirsch:  Both sides and you're right, one does not have to feel leg pain to have this be abnormal and it's challenging to occur in the physician's office.  You know, there are many vascular laboratories and certainly every community in this country where this can be measured easily and simply and accurately as well.

Dr. David Meyerson:  Let me ask you this, who are the patients who should most get an ankle-brachial index?  We could certainly begin with all of our diabetics, all of our smokers, who else?

Dr. Alan Hirsch:  Well, I'll rank these easily for you.  Certainly individuals with symptoms are at the highest risk so if a person has exertional leg muscle discomfort that comes on reproducibly at a distance, a fatigue, a cramp, frank pain in the prior calf muscles that goes away and resolves with rest, that's a symptom of peripheral arterial disease. That's a symptom called claudication which I think you've talked about on other podcasts.  These individuals clearly need to be immediately tested.  But you've also made the comment --

Dr. David Meyerson:  And let's be clear.  If they're getting those symptoms and the test is not -- they need more than that test.  Those people need a vascular evaluation.

Dr. Alan Hirsch:  Well that is his physician's judgement.  Many will need a vascular evaluation, but I would be happy in this country if we got that far down the road.

Dr. David Meyerson:  Uh-huh [affirmative].

Dr. Alan Hirsch:  But you're right.  Some of those individuals may need more.

Dr. David Meyerson:  How about the ones are not having symptoms who are really in the prevention mode?

Dr. Alan Hirsch:  Well, you know this has been on the one hand, was controversial until about one year ago.  It was a question as to whether individual with a significant high grade artery blockage in a leg artery that cause no symptoms should be tested, and this is absolutely non-controversial at this point.  If your best friend, spouse or brother had no symptoms, but was over the age of seventy for which this disease is common or over the age of fifty with a history of any major risk factor, but certainly diabetes or those who smoke.  There has been both a U.S. national consensus in a guideline that was published last year as well as international consensus, colleagues around the world that these individuals should undergo the test.

Dr. David Meyerson:  I'm going to get to a question on that in just a minute.  Why do you think this is not done more commonly?  Are physicians not aware enough?  Are patients not aware enough to ask for it?  Is it an insurance issue where it's not a reimbursable thing when it should be?  Where's the rate limiting step here?

Dr. Alan Hirsch:  Well, it's a series of steps.  You know whenever we try to gain the wisdom of society, it's important to answer your question.  You know, patients and physicians are wise and want to do the right thing.  Clearly, there is a relative lack of awareness.  I bet you most of our listeners haven't heard this before, although the message is getting out and frankly again, five or ten years ago, most physicians didn't really understand the high risk of peripheral arterial disease.  It was felt to be an unimportant disease.  So that's changing.   That's changing rapidly with national P.A.D. awareness program, but you raise a good point which is, you know, what we do in our society is definitely linked to powers that pass between insurance companies and Medicare and we value what we do with reimbursement so that heretofore, it has been easier to obtain these ABI tests if you have symptoms than if you're asymptomatic. That is slowly changing, but needs to change much quicker if there is a goal to decrease rates of heart attack and stroke, so there remains some reimbursement barriers and I'm actually hopeful that the public will understand that because I believe we do live in an important democracy where the public has demanded access to things that prevent breast cancer, like mammography where the database is actually quite robust, demanded access to colon endoscopic screening because it is sad to watch a loved one die of colon cancer.  That would be imminently preventable. Compared to other preventative strategies in place, there is little doubt amongst vascular experts that performing this ankle-brachial index as sort of the ECG of the legs, could clearly save legs and save lives, so I'm sure we'll see change shortly.

Dr. David Meyerson:  This is just a reminder to our listeners, we're talking with Dr. Alan Hirsch. He's Director of the Vascular Medicine Program at the Minneapolis Heart Institute and he's also past president of the Vascular Disease Foundation.  Alan, let's talk about this.  A recent study of almost sixty- eight thousand patients from forty-four countries gave us some critical information that peripheral arterial disease as a window to what's going on in other areas of the circulation and this, if you're a listener right now, you really want to -- this brings home why looking at P.A.D. is so important and why it becomes a window to what's going on.  So Alan, why is this study called the Reach study, R-E-A-C-H.  Why is it so important? Why does it correlate the risk of peripheral arterial disease with cardiovascular disease?

Dr. Alan Hirsch:  Well, thank you very much. I'm actually very pleased to discuss this, but it was just published in the Journal of the American Medical Association.  As a listener, Reach, --

Dr. David Meyerson:  I might add, you're also a coauthor.

Dr. Alan Hirsch:  Yes, I was pleased to be able to participate with Dr.'s Deepak Bot [phonetic] and Gabrielle Steg, Dr.'s Ohlmen [phonetic], Roser [phonetic] and Wilson in a really stellar group of international clinicians representing cardiology, neurology, vascular medicine in other domains who could reach --

Dr. David Meyerson:  This study is telling us that people with P.A.D. are at very high risk for other critical cardiovascular events, isn't it?

Dr. Alan Hirsch:  Right.  So the Reach Registry stands for Reduction of Athrothrombosis for Continued Health.  It was really a prevention study in the sense that we, as a group in forty-four countries throughout the world recruited sixty-eight thousand individuals in primary care practices and this included over twenty-four thousand in the United States.  And the individual chose to join Reach on the advice of their physician, this registry, so that we could simply ask them their risk factors and follow their risk of having a heart attack, stroke, heart and leg procedures or death and you entered Reach, it's important for listeners to know, if you had risk factors or atherosclerosis or if you had known coronary disease or a prior stroke or peripheral arterial disease and the inclusion of a P.A.D. group, a leg artery blockage group was very important in Reach as it has been recognized that this is a high risk cohort.

Dr. David Meyerson:  I don't want the time to evaporate, so I really need to press you on this issue. Why is it so critical for people with P.A.D. to be aware of this?  What does it mean in terms of their outcome?

Dr. Alan Hirsch:  Here's the headline.  I want everyone to listen carefully.  There is no cardiovascular disease that is more common that is more dangerous and that is more under treated.  In Reach, of those individuals with P.A.D., one in five and this is current, modern, up-to-date data, suffered a chance of dying, having a heart attack or stroke or being hospitalized for a cardiovascular reason within the first year.

Dr. David Meyerson:  So as a marker, as a marker for important disease, for important heart disease and potential for stroke, the peripheral arterial disease, once it is found tells you, you must be careful, you must be fully evaluated and this is a plumbing problem not just in the basement, but in the entire building as the analogy goes.

Dr. Alan Hirsch:  That's right, so this one in five risk and the individual risk of heart attack, stroke or death was as high with a patient with a heart attack, as I said the deer in the headlights is right ahead of you.  It really isn't time to be complacent and I think Reach makes that case very, very well.

Dr. David Meyerson:  Alan, why do you think that is?  Do you think that this is -- once we can produce enough athroschlerotic narrowing of the large arteries going to the lower extremities, do you envision that as a more advanced case of generalized atherosclerosis?  Why is it such a potent marker?

Dr. Alan Hirsch:  You know, for me as a cardiovascular investigator, I think it's important to say, "I don't know" when I don't know.  That should provoke younger investigators to do more research and it may be because we wait so long to make the diagnosis, the disease is widespread.  It's sort of a metastatic athroschlerotic cancer in a sense.  There's more disease and more locations and we're just pretty late.  Frankly, it may be that this is a slightly different manifestation of the common disease and it is more aggressive and I suspect it's a combination of both, but we don't really know.  We do know the risk is there and we know how to treat that risk.

Dr. David Meyerson:  Let's bring this point home again because it's so important.  The study showed that if you had peripheral arterial disease, your risk of having a heart attack or stroke or dying was far greater than anybody ever believed and Alan, would you say that if somebody is being evaluated or is being treated for peripheral arterial disease, that they should be seeing a cardiovascular specialist to know exactly what their entire vascular health is doing?

Dr. Alan Hirsch:  Well, I don't know about that.  I think that what's key is that they need counseling from an experienced clinician and sometimes to be frank that can be a primary care physician and there is a role for every vascular specialist whether it's a cardiologist, a vaso surgeon, a radiologist participate, but I think the key is what you said, you want expertise.  I want to leave people with a real sense of optimism and hope.  We keep trying to get people's attention with a high rate of bad things that happen, but these are preventable, so that wherever they need to seek care, want to get care, develop a trusting relationship, there are so many good choices to make.  This idea of therapeutic choice that once the diagnosis is present, yes, it changes your life, but a good clinician, a good patient can make a great partnership to stay healthy.

Dr. David Meyerson:  As we said before, the early recognition and treatment can prevent disability, promote physical well-being, help people maintain the healthiest and most active lifestyles they can.  We can prevent heart attacks, we can prevent strokes, we can prevent peripheral arterial disease from getting worse, but you got to -- you can't be the deer in the headlights, you must recognize that this problem exists.  Alan, what are the critical things that people should look for?  Diabetics need to be critically controlled.  That is very important.  What recommendations do you have about blood cholesterol?

Dr. Alan Hirsch:  Well, I'm going to take that question in two parts.  One is individuals again with exertional leg pain or a poorly healing wound that's not explained should obviously seek immediate attention, but beyond that, I think you sort of said it.  Individuals who are in their adult years who smoke or have diabetes already fall in the category where this ankle-brachial index test should be performed. I'm not sure how to answer further.  If we could get that done in the next one year in this country, I would be a very happy clinician.

Dr. David Meyerson:  And again, the ankle- brachial index, taking the blood pressure of the arm, comparing it to the blood pressure of the lower leg, doing that on both sides is a very good index of whether there is peripheral arterial disease and that simple test is a wonderful index to tell you, is there cardiovascular risk in other areas of your circulation. Isn't that the case Alan?

Dr. Alan Hirsch:  Yeah.  You know I do think in pictures sometimes.  I think it's helpful for our listeners.  I trust individuals to do the right thing. If you knew the well was poisoned, you wouldn't drink. The ABI does permit people to see clearly, listen clearly to know what artery blood flow is.  With that, it certainly is easy to have a healthier lifestyle and find fresh water that you need to survive.

Dr. David Meyerson:  Excellent.  My special guest has been Dr. Alan Hirsch.  He's Director of the Vascular Medicine Program at the Minneapolis Heart Institute, Professor of Epidemiology and Community Health at the University of Minnesota School of Public Health.  He is past president of the Vascular Disease Foundation and as all our listeners have heard incidentally, he's a hell of a guy.  For Dr. Hirsch, for the Vascular Disease Foundation, for my sidekick engineer and producer, Dr. Kerry Stewart, I'm Dr. David Meyerson, we'll see you next time and thanks for listening.

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