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Interactive Learning : HealthCast Transcripts

Episode 22 : P.A.D.: Are You Aware of It?

Release Date: October 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're very excited to bring you excellent, easy to understand science 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 premier medical and science 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.  We've had the privilege of talking about carotid artery disease, that's the narrowing of the arteries in the neck that nourish the brain.  Damage here can cause strokes and threaten strokes which we call TIA's or transient ischemic attacks.  We've talked about coronary artery disease, narrowing of the arteries that nourish the heart muscle that can cause angina, the chest pain you get when too little blood and oxygen get to your heart muscle. Further damage also causes heart attacks.  Heart attack is actually the death and destruction of heart muscle. We've talked about abdominal aortic aneurysms, the bulging and weakening of the major blood vessels of the abdomen which can cause life-threatening blood loss, and finally, finally, we've talked about peripheral arterial disease.  This is getting more and more important and we really want your attention here because PAD is a narrowing or blockage in the arteries that nourish the legs which can limit your ability to walk, cause pain and ulcers in the legs and in extreme situations, can even cause one to risk amputations. Why is PAD so important?  Because it's also, it also tells us who is at risk for having a heart attack and a stroke.  It's critical that you listen to this because these are largely preventable diseases and once developed, they are very treatable diseases and the early recognition and treatments can prevent your disability, promote your physical well being and help you maintain the healthiest and most active lifestyle you possibly can.

Today again, my special guest in studio is Dr. Kerry Stewart.  He's Director of Clinical and Research Exercise Physiology at Johns Hopkins.  He's a member of the Board of Directors of the Vascular Disease Foundation and he's been my sidekick and engineer and the person whose driving force behind the podcasts has really created this work for the Vascular Disease Foundation and for the public.  So Kerry, thanks so much for being here today.  Where do you want to get started?  Three out of four adults surveyed have no idea what PAD is and then if they have no idea what it is, they can't use it as a warning sign, can they?

Dr. Kerry Stewart:  Well, I think this is a critically important topic that we're going to discuss today.  Through a survey organized by the Vascular Disease Foundation and the Peripheral Arterial Disease Coalition, a survey was conducted over twenty-two hundred individuals to determine how much they actually know about PAD.  One of our goals in these podcasts is to spread the word about vascular disease.  We've obviously focused on peripheral arterial disease, but this survey I think, has shown some striking results in the sense that we, even though we've started, we have a long way to go.

Dr. David Meyerson:  Kerry, I'm looking at a graph that was published by the PAD Coalition and it's striking.  It says that ninety percent of the population know about high blood pressure and how important it is to treat to prevent strokes and heart failure and heart attacks.  Eight-five percent of the population is well schooled in issues relating to cholesterol, then the numbers are similarly high for recognition of the importance of diabetes and stroke and coronary artery disease and congestion heart failure.  But there's a striking little box at the very end of the graph which is in red, which is peripheral arterial disease.  Now, why is it so critical that patients recognize when they have peripheral arterial disease and share this with their doctor?

Dr. Kerry Stewart:  Well, there's several reasons.  First of all, all these other risk factors that you mentioned, high cholesterol, high blood pressure were unknown fifteen, twenty years ago in terms of the potential adverse health affects that they have and through various public awareness campaigns organized through the National Institutes of Health, the American Heart Association and other organizations, the public in fact, is much more aware of these problems.

Dr. David Meyerson:  So in other words, these were important issues, but really we're not on the public radar until groups like the American Heart Association and other groups got together and really put together a public education campaign much like the PAD Coalition is doing with peripheral arterial disease.

Dr. Kerry Stewart:  That's exactly right and an important next step is, in fact, that these – many of these are the risk factors that lead to PAD and PAD only registers, in terms of awareness, in about twenty- six percent of the population that we've surveyed, so it's either less than half to a third of what people know about these other risk factors that, in fact, cause PAD.

Dr. David Meyerson:  Now let's talk just a minute why this is so important.  It turns out that if you have peripheral arterial disease, you are much, much more likely in the next year or two to have a significant heart attack, stroke or even death and so, it's not that, don't misunderstand please, it's not that if you have PAD the fact that you have the PAD is going to give you a heart attack or give you a stroke, but we talked about the plumbing once in the sixty-year- old house, for example and if the plumber came to fix a corroded pipe in the basement and then the plumber said, "Well, let me survey the house because sometimes we see damage in other pipes of a house the same age." And the plumber went up to the second floor and found equivalent corrosion, that wouldn't surprise anyone. It's all the plumbing in a sixty-year-old house.  It turns out though, that because the legs and the arteries of the lower abdomen and in the legs, when they get occluded, they're fairly large vessels and when they have enough blockage, enough plaque deposition and cholesterol and hardening and calcification of the arteries, when those arteries are damaged enough, it's signaling that there is a high likelihood that there's damage in other places in the body, so that actually many people have their first heart attack, is a fatal one.  They don't get a warning.  Their first disabling stroke is a fatal, or a totally disabling one and they don't get a warning. It's very fortunate when somebody gets a TIA which is little threatened mini stroke which goes away and then if they seek medical help right away, it can get treated and if they -- if a patient gets angina and they see the cardiologists and they get treated, it does not have to progress to a heart attack.  If you have peripheral arterial disease and it gets treated, not only can you prevent ulcers in the legs and disability from walking and the risk of amputation, but if your doctor and you take the signal the right way, you then know that you must be looking at other places in the vascular, in the plumbing, of that sixty or so year old house because it's a signal that if we have enough disease downstairs to hurt the legs, the peripheral arteries, then we have enough disease in other areas of the body that you must attend to it, you must be evaluated for it and I think that's what this study is telling us Kerry, don't you think?  It's a critical public awareness issue.

Dr. Kerry Stewart:  Well, that's part of the need for awareness and as you said, the disease -- underlying disease process, atherosclerosis or building up of the plaque is the underlying cause of all these cardiovascular conditions including PAD, including heart attack, including stroke.  And, in fact, if you have one as you said, you're most likely to have the other.  In certain ways, having PAD first, you in fact, might be lucky because PAD by itself doesn't kill whereas if your first event is a heart attack or is a stroke, you're more likely to die, so by making the public much more aware of PAD, we're hoping to raise awareness of the fact that the individual has atherosclerosis, atherosclerosis needs to be treated, the treatment for preventing atherosclerosis in the legs is the same as treating atherosclerosis in the heart and atherosclerosis to the arteries to the brain, so it's all one process with the overall goal of preventing these cardiovascular diseases from becoming major clinical problems that cause disability and death.

Dr. David Meyerson:  And if somebody could tell you that the car you were driving was going to have potentially a severe accident in a quarter of a mile or a half a mile, you could take adequate steps to avoid that accident and if you have had PAD or if you have a leg ulcer that's not healing, if you have pain when you're walking called claudication, if you've had the doctor says that you might need a bypass operation to your legs, that is the signal that there's enough disease of the blood vessels that you must be evaluated for the potential for heart attack and stroke.  So Kerry, let me take this a step further.  The fascinating thing and why this public education issue is so important to you and me is that this same study -- tell us a little bit about surprisingly where people who do know about PAD found out.  It turns out, all too often, it's not from their doctor.

Dr. Kerry Stewart:  Well, it's not from their doctor and unfortunately it's not from the radio or these podcasts although they just recently started, so one of the purposes of the PAD survey is that, in fact, establish a baseline of what people know and hopefully in two or three years when the survey is repeated, we'll see that these efforts that we're doing will make a difference.  But in fact, most people do learn about PAD from the media, from television and advertising. In most cases, advertising by commercial companies that are trying to sell drugs which in fact, is a good thing.

Dr. David Meyerson:  In a way it is because the doctor -- the patient is not going to just go buy the drug, they may ask the doctor about it and then getting into medical care and then asking those questions is very important.

Dr. Kerry Stewart:  Unfortunately, you know, preventive medicine is not well funded and we don't have the kinds of dollars that the drug companies have to promote their drugs.  We don't have the kinds of dollars that the fast food restaurants have to promote their foods, but if there's a good spinoff of some of this advertising and people learn about PAD, ask their doctor about it and get a diagnosis, then some benefit has come from it.

Dr. David Meyerson:  So I'm looking at another graph from a -- presented at a PAD Coalition meeting and it turned out that about, of the people who do know about this, about a quarter of them saw it somewhere on TV.  Maybe fifteen percent saw it in a magazine.  Seventeen percent got information about it from family and friends.  A small percentage heard it on radio.  A small percentage looked at it on the internet and maybe a slightly larger, five percent saw it in a newspaper, but the interesting thing and what troubles you and me is that only nineteen percent have, less than -- about one in five, heard it from their healthcare provider and it would seem that our healthcare providers ought to be a bigger outlet because so many people are seeing healthcare providers and I wonder if the doctors and nurses don't either have the time or the inclination or you know what would be a fascinating study Kerry, it would be very fascinating to take this exact same study and see how comfortable healthcare providers were about PAD and whether it was just internists that had a highly level of training in cardiovascular medicine or cardiologists or perhaps family doctors that had a very, very specialized interest in preventing heart and blood vessel disease.  Maybe they would be more knowledgeable, but I wonder if the American healthcare system is not giving doctors enough time to really do any patient education.

Dr. Kerry Stewart:  Well, I think doctors are not having enough time to do lots of things, particularly patient education and counseling on lifestyle changes like smoking and diet and exercise which is what I focus on.  But let me say that I think there are actually changes that are going to take place over the next few years.  Most recently, there were published guidelines on the treatment and management of PAD and I'm actually on several writing committees that will be publishing performance standards.  And what these standards are designed to do is set the goals for physicians in terms of making the proper diagnosis and choosing the proper treatments for dealing with this disease and over time, the quality of a healthcare system will be judged by the extent to which they adhere to these standards.  So, even though I think we're lagging far behind, I think we're slowly catching up and hopefully in a couple of years, a lot of these trends will reverse themselves.

Dr. David Meyerson:  So it's been said that health professionals, the media, the healthcare industry and government agencies all share a responsibility to work together to inform the public about this very common cardiovascular disease that affects essentially every American family.  This is really important.  There is no one, there is no family member that does not have a family member that does not have this to one degree or another.

Dr. Kerry Stewart:  Well that's true, and in fact if you want to know some specific statistics --

Dr. David Meyerson:  Say that three times fast.

Dr. Kerry Stewart:  -- I had a hard time saying it one time fast, so three times is really a challenge.  But lower extremity peripheral arterial disease, which is in the past called peripheral vascular disease although we've recently standed on peripheral arterial disease,  in fact --

Dr. David Meyerson:  That's because people can have -- we talk about blood clots in the lower extremities--

Dr. Kerry Stewart:  Right.

Dr. David Meyerson:  -- deep vein thrombosis and those -- that's a problem with the veins of the legs, the thin-walled blood vessels that take blood back up toward the heart --

Dr. Kerry Stewart:  Right.

Dr. David Meyerson:  -- and it's the arterial supply which is the more thick-walled vessels that bring the red oxygenated blood under pressure to the muscles and all areas of the lower extremities, in fact, to all areas of the body and that's why they just break it up into peripheral arterial disease and peripheral -- there can be peripheral arterial disease, peripheral venous disease.  So arterial would be one, venous would be the other and peripheral vascular disease would be a big umbrella --

Dr. Kerry Stewart:  Right.

Dr. David Meyerson:  -- that encompasses all three.

Dr. Kerry Stewart:  Exactly, but getting back to PAD specifically and I did say that okay this time. It's been estimated --

Dr. David Meyerson:  These are your specific statistics?

Dr. Kerry Stewart:  Absolutely.  Effects up to twelve to twenty-nine percent of the elderly, so that's the best estimates we have and it clearly affects more people as they get older and that translates in to somewhere about ten million Americans. This survey also --

Dr. David Meyerson:  But let me back up. This is not just a disease of the elderly.  This is a disease --

Dr. Kerry Stewart:  Well, it's not just a disease in the elderly --

Dr. David Meyerson:  This begins in diabetic people who are forty years old.

Dr. Kerry Stewart:  Well, right.  And to the extent that younger people have risk factors and the most important risk factors for developing PAD are smoking and diabetes, but to the extent that younger people have those risk factors, they're at risk for disease, but it is still more common in older people, as many as ten million Americans overall, maybe even more and approximately about a million Canadians.  So in North America, it affects us somewhere between ten and twelve million people.

Dr. David Meyerson:  But the fact of the matter is, we don't have to go that far to let our audience feel the flavor of this.

Dr. Kerry Stewart:  No.

Dr. David Meyerson:  If you look to your uncle, to your aunt, someone, father, your mother, your brother, there is someone in your family that's got some degree of peripheral arterial disease and it's so important.  Kerry, what should we be asking our listeners that when they go to the doctor next time, they should arrange to get ankle-brachial index?

Dr. Kerry Stewart:  Well, we recommend that particularly if you have these risk factors.

Dr. David Meyerson:  Now don't go so far, you know I'm trying to serve you up a softball here.  Tell them what it is.

Dr. Kerry Stewart:  Well, I'm sorry.  The ankle-brachial index is actually simply a measure of blood pressure in the arm relative to blood pressure in the leg and if the -- the blood pressure should be the same throughout the entire body and if the blood pressure in the leg falls off, that could be an indication of lack of blood flow due to the blockages caused by peripheral arterial disease.

Dr. David Meyerson:  And a small change in the ankle-brachial index is a big hint that there's plumbing, significant arterial disease going on and I'll bet -- I'm hoping, I'm hoping at this moment that the people listening to this podcast are saying to themselves, "I can't remember.  I've been to the doctor so many times, they've never, ever, ever once checked the blood pressure in my legs."  It's a very simple thing to compare the blood pressure in the arms to the blood pressure in the legs and it gives a lot of potential screening information, doesn't it?

Dr. Kerry Stewart:  It gives a tremendous amount of screening information.  Unfortunately, one of the problems with healthcare reimbursement, is that in most cases the ABI or ankle-brachial index is not reimbursed so doctors often are reluctant to do it because it takes about ten minutes and they don't get paid for it, so often it gets skipped.

Dr. David Meyerson:  So because it's so important then because it may really be a window to a real opportunity to find disease and prevent it from progressing and then again, here the key to this is if you find peripheral arterial disease, it is a hallmark, it is a landmark, it is a red flag that there is additional disease lurking elsewhere in the body and/or that that person is likely to develop it in the very foreseeable future.  This is a great time in your life, in your medical life to say, "What do I have to do to turn this around?"  If you're a diabetic, you must be meticulous with your diabetes control.  If you're a smoker, you must stop.  You need to know what your blood pressure is in your arms and your legs.  You need to know what your cholesterol is.  Unfortunately you cannot change your family genetics.  If your father and mother had high cholesterol or vascular disease developing in early ages, that just means that you have to be even more vigilant, but knowing when PAD is in your -- when you have PAD, when you have PAD, it is your signal to say to your doctor, "I think I need to be checked for other things.  I think I need to know that my blood pressure, my cholesterol are great and I need to know that my heart is doing well and I need to know that I'm not at risk for having a heart attack or a stroke."

Dr. Kerry Stewart:  Let me add one other thing is the fact that intermittent claudication is the most frequent symptom of PAD.  This is the aching, the cramping, the pain that one gets in the leg when they walk and it goes away when they stop.  But unfortunately, only about half the patients who have PAD, in fact, have these symptoms of PAD.  So that, if you're at risk for PAD, the testing still should be done even if you don't have the symptom because even if you have asymptomatic PAD, in other words you have PAD, but you don't have the classical pain, you're still at just the high risk for having a heart attack or stroke. The symptom itself while important and considered a very important warning sign, is often undetected – or often doesn't exist in about forty to fifty percent of individuals.

Dr. David Meyerson:  It's the same way we talk about high blood pressure.  It -- high blood pressure has almost no symptoms.  Oh occasionally somebody may have headaches or be headachy from it or be fatigued, but otherwise high blood pressure by itself has few to no symptoms until it causes horrendous disease like heart failure or stroke or heart attack and something just like that may be, as Dr. Stewart was saying, so with peripheral arterial disease.  You don't need the -- doctor when I walk to the mailbox, when I get to that same place on the hill, every time my calf will hurt terribly or I feel a pain in my buttock and then when I stop and rest for a while, it goes away and then when I walk, another equivalent distance and especially up a hill, it comes back.  Now those people should absolutely be checked and you should tell the doctor, "I'm having symptoms that sound like claudication."  And if you don't wantto give the medical name for it, tell them that every time you walk, you're getting -- and the doctor will help you differentiate between that pain that comes from a blood supply limitation verses that pain that comes from arthritis and other problems of the lower spine.  So I think we've told them some very important things today, Kerry, that PAD is a very important hallmark for other disease and it may prevent before the other disease is severe and it may actually save their functional capacity and prolong their life.

Dr. Kerry Stewart:  Absolutely.  And before we end, I have a couple of things I'd just actually like to add about this study.  First of all, this study was published in Circulation which is a major journal of the American Heart Association.  It was published online on September 17, 2007 and should be in press in the next couple of months.

Dr. David Meyerson:  Again, Circulation for any cardiologist or internal medicine doctor or researcher in cardiovascular disease of any sort, Circulation is one of the premiere journals --

Dr. Kerry Stewart:  Right.

Dr. David Meyerson:  -- it is among the most well thought of and if you are a researcher in an area relating to cardiac, cardiovascular medicine and you can get your paper published in Circulation, you know that it's been peer-reviewed by the highest level groups of scientists in multiple, multiple disciplines and it's a publication venue that we take very, very seriously in medicine.

Dr. Kerry Stewart:  Before we end, let me point that one I thought was an amazing statistics about the awareness of PAD.  So we mentioned earlier that in this survey, only twenty-six percent of those individuals who surveyed knew about PAD, but forty-two percent knew about multiple sclerosis, thirty-six percent knew about Lou Gehrig's disease and twenty-nine percent knew about cystic fibrosis.  Now these are certainly very important diseases --

Dr. David Meyerson:  If you're affected by any one of these diseases, it changes your whole life around, that's for certain.

Dr. Kerry Stewart:  If you're affected by them, they're terrible diseases.  But in terms of how many people they actually affect, multiple sclerosis only affects about three hundred thousand people a year, Lou Gehrig's disease only affects about twenty thousand people a year and cystic -- I'm having trouble with cystic fibrosis like I did with specific -- affects about thirty thousand people a year, whereas PAD, as I said earlier, affects about ten million people a year, so --

Dr. David Meyerson:  The numbers are striking.

Dr. Kerry Stewart:  The numbers are striking, there's a huge discrepancy between awareness and what's actually affecting the public and I think it just emphasizes to us David, that we really have a lot of challenges ahead with these podcasts to continue to get this message out.

Dr. David Meyerson:  Well, I guess a patient should be asking their doctor, "Doctor, what's the blood pressure in my legs compared to that in my arms?" And, "If I have symptoms of PAD, I understand that this can be a warning that I should be spending extra time and effort in preventing a heart attack and stroke."  I think that's the clear message here.

Dr. Kerry Stewart:  Absolutely.

Dr. David Meyerson:  I'm so glad that we had the opportunity.  It sounds like simple information, but this little kernel of public awareness can actually save lives and prolong functional capacity for anybody that has this disease or who may develop it.  And again, thank you so much for listening for the Vascular Disease Foundation at www.vdf.org if you'd like further information, that's www.vdf.org and for my sidekick and friend Dr. Kerry Stewart, I'm Dr. David Meyerson, thanks so much for listening.  Till next time, have a good day.

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