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Interactive Learning : HealthCast Transcripts

Episode 1 : Introduction to VDF; What is PAD?

Release Date: September 9, 2006

Dr. David Meyerson: I'm Dr. David Meyerson, a Cardiologist at Johns Hopkins, a national spokesperson for the American Heart Association and your host for this edition of Vascular Disease Foundation's HealthCast. We're very excited about the opportunity to bring excellent digestible science to you on all of the blood vessel diseases as a public service. As a public education coalition, the Vascular Disease Foundation is made up of those organizations already known to many of you as premiere public education sources of quality data that you can rely on.

Some of those societies include: The American Association of Cardiovascular and PulmonaryRehabilitation, the American College of Cardiology, the American Heart Association, American Venous Forum, Society for Clinical Vascular Surgery, Society for Vascular Medicine and Biology, The Society Vascular Nursing, the Society for Vascular Surgery, the Society for Vascular Ultrasound and the Society of International Radiology to name just a few.

Let me introduce it this way. If you had a sixty-year-old house and some plumber told you that the bathroom on the second floor had a corroded pipe, you wouldn't at all be surprised if plumbing in other areas of the house was affected, now would you? So what's so very important about the sixty-year-old house analogy is that finding a problem in one portion of the circulatory system means it is foreseeable that there will be diseases in others. Being aware of these diseases can save lives, being aware can prevent disability, being aware can promote your best functional capacity and your future health.

I'm joined today by Dr. Kerry Stewart. He's Professor of Medicine at Johns Hopkins, Director of

Clinical Research in Exercise Physiology and a member of the Board of Directors of the Vascular Disease Foundation. Today's edition will focus primarily on peripheral arterial disease, but this topic is just one from a long list of issues that we'll bring you in this special forum.

Let me now welcome to our HealthCast microphone, Dr. Kerry Stewart. Dr. Stewart, thank you for being with us today.

Dr. Kerry Stewart: And thank you Dr. Meyerson for hosting this show. The Vascular Disease is very proud to be able to present this important public education service through pod casting and we look forward to you continue to be our host.

Dr. David Meyerson: It's my privilege, Dr. Stewart. Tell me a little bit about the Vascular Disease Foundation. I'd like our audience to know where they're getting their information from and why it's so reliable.

Dr. Kerry Stewart: Well, the Vascular Disease Foundation is a multi-disciplinary, nonprofit organization that's focused on all the vascular diseases and our sole purpose is to provide public education and improve awareness of vascular diseases. The Board of Directors are made up of healthcare professionals, physicians, nurses, exercise physiologists, scientists who all are experts in their individual field and we've come together again, for the sole purpose of bringing this type of public education.

Dr. David Meyerson: And perhaps one more remark about the level of credibility of the sister organizations that support the Vascular Disease Foundation.

Dr. Kerry Stewart: Well, the list of organizations that you read are the leading professional organizations in their respective fields and our Board of Directors and the people who provide this type of information for VDF are all experts in their field. They're leading individuals at academic health centers, hospitals, and in private practice, so we have experts from a wide range of disciplines.

Dr. David Meyerson: And I as a cardiologist at Johns Hopkins would look at the list and say, yes I am familiar with the American College of Cardiology, a critical organization in my professional development. American Heart Association and anyone in the field has representation with a level of education to the public that is reliable and in the forefront of science. Wouldn't you say that?

Dr. Kerry Stewart: Absolutely. And we have a particular point in -- that we emphasize in the Vascular Disease Foundation is that all the information comes from these experts and it's reviewed by other experts so everything that we put out to the public, all these messages are peer-reviewed.

Dr. David Meyerson: And let us mention for the moment that there is a Web site that people can go to and that is www.vdf -- that vdf stands for Vascular Disease Foundation, so it's www.vdf.org. It's not dot com, it's dot org, O-R-G. So let me repeat it one last time, www.vdf.org. Wonderful educational information for both the lay public and professionals.

Dr. Kerry Stewart: Absolutely and since 2000, through its newsletters, the  Web site, brochures, flyers, various meetings and television and public service announcements, VDF has kept track of actually how many people we've been in contact with and it's approaching fourteen million individuals in over thirty states and throughout Canada.

Dr. David Meyerson: Oh that's wonderful. And this HealthCast, PodCast if you will, is now phase two of the educational programs that are being offered by the Vascular Disease Foundation.

Dr. Kerry Stewart: That's correct. We're keeping up with the times in addition to the Web site which was one of our first phases, this is the way to go with bringing public messages and we're doing it.

Dr. David Meyerson: Wonderful. Let's switch gears now. Now that the public knows who they're getting the information from and that it's wonderful and reliable information. Let's go on to peripheral arterial disease or PAD. Dr. Stewart, what is PAD, peripheral arterial disease?

Dr. Kerry Stewart: Peripheral arterial disease is a form of atherosclerosis or hardening of the arteries in which there are blockages that prevent blood flow to the muscles. Peripheral arterial disease specifically deals with lower limb disease. There are other forms of atherosclerosis in vessels, such as those that feed the brain, the carotid arteries, but when we talk about peripheral arterial disease, most people think of blockages in the legs and in many individuals they will get symptoms when they walk, claudication, the symptom associated with peripheral arterial disease.

Dr. David Meyerson: What is claudication? Let's hit that point once again.

Dr. Kerry Stewart: Well, claudication refers specifically to the pain that occurs when individuals walk.

Dr. David Meyerson: Let's go back and use the word ischemia. Ischemia for our public means any area of the body that doesn't get enough blood supply for its purpose of its well being is said to be ischemic. It means to little blood supply and ischemia of the brain is too little blood supply upstairs, ischemia of the heart can cause angina and ischemia of the lower extremities, the legs, can cause --

Dr. Kerry Stewart: Claudication.

Dr. David Meyerson: Okay and what is --

Dr. Kerry Stewart: Claudication comes from the Latin word claudica which means to limp. And many people who get claudication will have such severe pain in their legs that they will limp because it hurts.

Dr. David Meyerson: And some patients will tell us that I have a long, long walk to the mailbox or down a hill or up a hill and they know about what place they will stop walking and rest because it hurts, won't they?

Dr. Kerry Stewart: Absolutely. In some cases it could be just one or two blocks and you have to stop and rest. Let me emphasize though when we talk about peripheral arterial disease, only about half the patients actually have symptoms for some reason, so that many people will have peripheral arterial disease, but they may not even know it because they may not be getting the classical symptom of claudication.

Dr. David Meyerson: Could a non-healing ulcer for example could be a symptom of such a disease?

Dr. Kerry Stewart: That's one -- that's another symptom and that would be more likely to occur in people with more severe forms of the disease.

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

Dr. Kerry Stewart: Also cold feet and loss of hair.

Dr. David Meyerson: Let me just ask, why all of the activity with peripheral arterial disease now? Is this an especially under recognized and under treated problem?

Dr. Kerry Stewart: Peripheral arterial disease, in fact, is probably one of the most prevalent diseases among individuals and probably one of the least diagnosed. It's a form of atherosclerosis. It's often considered a marker for more severe disease throughout the body. People who have peripheral arterial disease are about twice as likely to develop a heart attack or have a heart attack or acquire some cardiac intervention over the next several years compared to someone who doesn't have peripheral arterial disease.

Dr. David Meyerson: I so totally agree with that. I do think of these are markers for other diseases in the body. Again, it's the sixty-year-old home. And you know, we see problems in thirty-year- olds and forty-year-olds, so it's not a disease of only the older cross section of the population and are diabetics and are smokers are particularly at risk. But Dr. Stewart, who is at greatest risk for peripheral arterial disease?

Dr. Kerry Stewart: Well, I think you just hit on the key categories. The risk factors for

peripheral arterial disease are identical to those for coronary artery disease and includes --

Dr. David Meyerson: So you're not selling me that what makes the pipe corrode on the second floor bathroom pipe is the same thing that's going to make the pipe corrode in the kitchen and in other areas of the house, then that's not surprising, is it?

Dr. Kerry Stewart: That's not surprising at all to those who know about it.

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

Dr. Kerry Stewart: -- and again one of the purposes of this PodCast along with all the other messages of the Vascular Disease Foundation is to get that message out, but the process is the same.

Dr. David Meyerson: So this is a really know your plumbing type of PodCast, isn't it?

Dr. Kerry Stewart: Absolutely.

Dr. David Meyerson: What about diabetes and peripheral arterial disease? Are those folks especially at risk?

Dr. Kerry Stewart: Diabetes is – after smoking, diabetes is probably the other major risk factor for peripheral arterial disease and we know that diabetics are at very high risk.

Dr. David Meyerson: And so if you were to say today, what can our average listener do immediately to begin to lessen their risk, I think both of us would in concert say if you are a smoker, please stop. It is so worthwhile.

Dr. Kerry Stewart: Absolutely. If you're a smoker and if you're over the age of sixty, if you have high cholesterol and high blood pressure, it's probably a good idea to talk to your doctor about doing some simple testing which can diagnose peripheral arterial disease.

Dr. David Meyerson: Well, what exactly do you ask the doctor? How do you broach the subject with him or her?

Dr. Kerry Stewart: Well, you can say, I heart it on this PodCast and that's one of the things we're trying to accomplish. Besides educating the public, there are also multiple efforts going on trying to educate physicians to be more aware that their patients may have peripheral arterial disease and do some testing to diagnose it.

Dr. David Meyerson: And we're obviously thinking in the future that if you can delay or totally prevent these diseases, we can prevent amputation, we can promote high levels of physical activity for our patients well into their latter years and what we're trying to prevent are the ravages of these diseases which include amputations and ulcers and all kinds of nasty things.

Dr. Kerry Stewart: Absolutely and like most illnesses or diseases, the earlier you know about it, the more opportunity there is to do something about it and hopefully it will prevent the complications that you just mentioned.

Dr. David Meyerson: So you would advise patients that if they have had, for example, angina or a heart attack and they are followed by their cardiologist and internist or if they've known to have high cholesterol, or if they have problems of the lungs from incessant smoking, those people should -- or if they've had either what we call transient ischemic attacks or maybe mini threatened strokes or if they've had a stroke, these are all markers for them to then go back to their doctor saying, "Doctor, I have had either heart or blood vessel disease and as you pointed out earlier as a marker for these diseases, should I now be evaluated for peripheral arterial disease?"

Dr. Kerry Stewart: We believe so and I think the evidence that's in the scientific literature would suggest that. Again, peripheral arterial disease is a form of atherosclerosis and if you have it in one part of the body, you're certainly at risk at having it in another part of the body. We don't know why some people have heart attacks before they develop PAD or why they have a stroke before they have a heart attack, but once you have one of those atherosclerotic diseases, you're at risk for all the others.

Dr. David Meyerson: And these diseases are preventable. If somebody's had angina, we like to be able to prevent them from having a heart attack. If they've had a threatened stroke, we want to be able to prevent them from having a fixed deficit where they don't speak well or their arm doesn't move any more, things like that. This is largely preventable disease as is the peripheral arterial disease, is not?

Dr. Kerry Stewart: Absolutely. And the treatments for all those diseases are not that different from each other. It means modifying the known risk factors such as lowering cholesterol, lowering blood pressure, stopping smoking, physical activity, increasing physical activity -- that's a key factor.

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

Dr. Kerry Stewart: And watching diet.

Dr. David Meyerson: In fact, those -- patients that we see that are healthy and active in their eighties were healthy and active in their fifties and sixties and seventies and those people who let the peripheral arterial disease go, they become disabled by their peripheral arterial disease, they gain weight and their overall cardiovascular health declines. And I think you would like to join me in telling our public that this is largely preventable disease.

Dr. Kerry Stewart: It's largely preventable and I think you raised a good point about when you have something like peripheral arterial disease and you stop physical activity because you're getting pain that kind of creates what we call the cycle of disability. So the pain causes inactivity, the inactivity raises risk factors. You gain weight and then you become even less active and the peripheral arterial disease continues to progress.

Dr. David Meyerson: What test would the doctor commonly order?

Dr. Kerry Stewart: Well, a simple test and the most effective for screening is probably the ankle- brachial index. The ankle-brachial index sounds like a long complicated test, but in fact, what it is is comparing the blood pressure in the arms to the blood pressure in the legs. And if the blood pressure in the legs are significantly lower than the blood pressure in the arms, you're likely to have peripheral arterial disease.

Dr. David Meyerson: So that would suggest that there's some sort of blockage arteries that feed the lower extremities, the legs and because there are blockages, the blood pressure that's downstairs, if you will, measures lower than the blood pressure upstairs, or in the arms.

Dr. Kerry Stewart: That's exactly right and once the diagnosis is made, it may be necessary to do other types of tests to specifically locate where the blockage is and in some cases people will need surgical intervention such as angioplasties or stents, similar to what's done in the heart or even bypass.

Dr. David Meyerson: So patients don't get too worried too quickly, a lot of the therapies that are available for this type of problem are procedure based or if you will, catheter based. Doesn't have to do with cutting and surgery per say, although for the more complicated peripheral arterial disease situations, surgery sometimes is the proper therapy, is it not?

Dr. Kerry Stewart: Absolutely and that decision needs to be made after very careful evaluation by a vascular specialist. But let me also emphasize that the percentage of people needing those interventions, those invasive interventions initially is pretty low. It's a very slow progressing disease and it's only when you get to the very severe stages and a level of what we call critical leg ischemia that people need these major surgical interventions.

Dr. David Meyerson: And some of the therapies that we spoke about may be as simple as changing lifestyle, changing eating habits, smoking cessation interventions are critical, maybe weight control, controlling cholesterol rigorously, much more so than you would if the disease was not present. Isn't that right?

Dr. Kerry Stewart: That's exactly right. And you mentioned the lifestyle ways of accomplishing that which is diet, weight loss and exercise and it also may mean taking medicines to lower blood pressure, to lower cholesterol and get the disease under control. With people who have claudication, actually one of the best therapies is exercise training. That's my specialty, And it's very, very clear and compelling evidence that the first line of treatment for most patients who have peripheral arterial disease is to actually go out and walk. Walk until you get some pain, which sounds a little unusual, and you would never do that for heart disease. If you get pain, you typically are told to stop. But with peripheral arterial disease, we want you --

Dr. David Meyerson: Speak to your doctor, speak to your doctor, speak to your doctor.

Dr. Kerry Stewart: Speak to your doctor, speak to your doctor, obviously.

Dr. David Meyerson: Stop smoking, stop smoking.

Dr. Kerry Stewart: But we want you to walk enough to get some pain, then stop, let the pain go away and then continue and this cycle of rest, getting some pain, rest, getting some pain actually leaves those favorable adaptations that will lessen the symptoms of the disease.

Dr. David Meyerson: Now for certain of our patients that have blockages in the arteries that nourish the heart muscle, the coronary arteries. Sometimes they're fortunate enough to have these little budding collateral vessels, almost like when you put a plant cutting in water and you look at the cutting about a week later and you see these nice filament roots developing -- lightly less ample blood supply.

Dr. Kerry Stewart: Well, the scientific evidence would suggest that the major mechanism we call it, would be an improvement in the muscles ability to do work with less blood, blood carries oxygen. There's some evidence although not overwhelming in humans, there is some evidence from animal studies that there is also some collateral circulation, in other words, the growth of new blood vessels although that is not considered the major reason why people feel better. They feel better primarily because their muscles are in much better shape.

Dr. David Meyerson: So in summary, this is preventable disease, this is imminently treatable disease. You really need to begin a dialogue with your doctor if you're in one of the risk groups that we've mentioned. What else would you like to tell our listeners, Dr. Stewart?

Dr. Kerry Stewart: Again, I'd like to tell the listeners to look at our Web site, www.vdf.org and learn about this disease and as you said, it is preventable in many cases or at least the progression of it can be markedly delayed and people who have symptoms will feel better if they follow the therapies that are available to them. That's what they need to do.

Dr. David Meyerson: And that's it for today. Our brief introduction to peripheral arterial disease. On behalf of the Vascular Disease Foundation, my guest has been Dr. Kerry Stewart of Johns Hopkins. On behalf of the Vascular Disease Foundation, I'm Dr. David Meyerson, thanks for listening.

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