Counsel Patients on Peripheral Artery Disease Management

Peripheral artery disease (PAD) is a vascular disease that affects the extremities and tends to affect the legs more than the arms. It occurs when fatty plaque deposits build up inside the arteries that carry oxygenated blood to the extremities. This causes stenosis of the arteries, reducing blood flow and resulting in cramping, numbness, pain, and difficulty healing. This may also lead to amputation, heart attack, or stroke.¹

PAD affects more than 12 million individuals in the United States. It is more prevalent in patients over age 50 years, and the risk increases with age.² Risk factors for PAD include smoking, hypertension, atherosclerosis, diabetes, hypercholesterolemia, more advanced age, and African American race. This disease affects both men and women and is itself a risk factor for coronary artery disease and cerebrovascular disease.³

LIFESTYLE MODIFICATIONS

Treatment for PAD focuses on the reduction of symptoms and the prevention of further progression of the disease. In most cases, claudication medications and lifestyle changes such as exercise and a healthy diet are enough to slow the progression or even reverse the symptoms of PAD. Key areas for patient counsel are listed below:

• Smoking cessation: Tobacco smoke is a major, preventable risk factor for PAD. Combustible cigarettes release several harmful products into tobacco smoke that stimulate endothelial injury, thrombosis development, and atherothrombosis.⁴ Quitting smoking is difficult for most individuals, but recommendations of effective tools may help the patient quit. Some options are behavior modification techniques, nicotine replacement products, and medications designed to curb cravings.
• Exercise: Regular physical activity is an effective treatment for the symptoms of PAD. Patients should always consult their primary care physician before starting any exercise program. Simple walking regimens can consist of alternating walking and resting to increase the amount of time before intermittent claudication pain sets in. Initially, this should take place in a controlled setting such as a rehabilitation center or other structured program.⁵
• Diet: Although dietary improvements may slow the progression of PAD, they cannot reverse it. Patients should follow a diet that includes mainly vegetables, fruits, and whole grains. They should include low-fat dairy products, poultry, fish, legumes, nuts, seeds, and olive or avocado oils. They should also limit intake of sugar (including sugary beverages such as sodas), red meat, and saturated and trans fats.⁵

Some predetermined diets can help slow the progression of PAD. These include the Mediterranean diet, the Dietary Approaches to Stop Hypertension diet, a low-carbohydrate (keto) diet, and an anti-inflammatory diet.⁶

PHARMACOLOGIC OPTIONS FOR PAD

Several classes of medications may be prescribed for patients with PAD, including medications to lower cholesterol levels, antihypertensive medications, antithrombotic medications, and medications to help manage the leg pain that is common in PAD. Patients must take any medications as prescribed to prevent worsening of PAD and to decrease the risk of heart attack and stroke.⁷

More detailed information on the commonly prescribed medications for PAD is as follows^2,7,8:

• Cholesterol medications: Statin medications are the most commonly used options to treat PAD due to their ability to lower low-density lipoprotein cholesterol, reducing arterial plaque buildup and stabilizing existing plaques to keep them from forming clots.
• Antihypertensives: Uncontrolled hypertension can cause the arteries to become stiff and hard. This lack of flexibility lends itself to slow blood flow, which makes it easier for plaque to form. According to the American Heart Association, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are recommended for the treatment of PAD.²
• Antithrombotic medications: Anticoagulants can help prevent blood clots from forming by slowing the blood-clotting process. They do this by allowing the body to break down existing clots and by preventing new clot formation. Current guidelines for anticoagulant use in PAD recommend the combination of rivaroxaban (Xarelto; Janssen) and low-dose aspirin for patients with a low risk of bleeding and clopidogrel (Plavix; Sanofi-Aventis) in patients with a high risk of bleeding.⁸
• Medication for leg pain: Cilostazol (Pletal; Otsuka America Pharmaceutical) is an antiplatelet drug and a vasodilator. This thins the blood and widens blood vessels to allow increased blood flow. This helps treat limb pain in patients with PAD. Pentoxifylline (Trental; Upsher-Smith) is an alternative, but it generally does not work as well as cilostazol.⁷

SURGICAL PROCEDURES FOR PAD

In some cases, the following physical procedures may be necessary to treat PAD causing claudication^7,9,10:

• Angioplasty and stent placement: Peripheral artery angioplasty is a minimally invasive procedure that widens arteries in patients with PAD. During the procedure, a catheter with a small balloon is inserted into the artery and inflated to break up plaque and widen the artery. The balloon compresses the plaque against the arterial wall, restoring blood flow and improving circulation. This may be coupled with stent placement during the same procedure. A metal stent can be inserted into the artery wall to prevent renarrowing.
• Bypass surgery: Peripheral artery bypass surgery redirects blood flow around a blocked artery in the leg. The procedure uses a synthetic graft or a vein from the patient’s body to create a new pathway for blood flow. The surgery usually lasts 3 to 4 hours and requires a few days spent in the hospital. The physician may also recommend physical therapy during the recovery period.
• Thrombolytic therapy: Intra-arterial thrombolysis involves the administration of agents directly into an artery to break down thrombus. Although many agents are available, those used for intraarterial thrombolysis are classified as plasminogen activators. Plasminogen activators provide thrombolysis by activating plasminogen to its active form, plasmin, which then degrades the fibrin blood clot.¹⁰

PHARMACISTS’ ROLE

Pharmacists play a vital role in the treatment of PAD. They can identify patients at risk and educate them on lifestyle changes, medications, and available procedures. Pharmacists can also monitor for antiplatelet and statin therapy, ensure patients have the education and guidance to take their medications safely and correctly, promote healthy lifestyles, recommend smoking cessation tools, and encourage medication adherence.

Additionally, because PAD is a painful disease that can disrupt quality of life, pharmacists can monitor patients for depression and anxiety. When appropriate, pharmacists can work with patients to recommend psychotherapy and/or choose medications to help them manage the associated symptoms.

REFERENCES

1. Peripheral artery disease. Foundation to Advance Vascular Cures. Accessed April 11, 2024. https://www.vascularcures.org/peripheralartery-disease/

2. Allison MA, Armstrong DG, Goodney PP, et al. Health disparities in peripheral artery disease: a scientific statement from the American Heart Association. Circulation. 2023;148(3):286-296. doi:10.1161/CIR0000000000001153

3. Peripheral arterial disease (PAD). CDC. Updated December 19, 2022. Accessed April 11, 2024. https://www.cdc.gov/heartdisease/PAD.htm

4. Behrooz L, Abumoawad A, Rizvi SHM, Hamburg NM. A modern day perspective on smoking in peripheral artery disease. Front Cardiovasc Med. 2023;10:1154708. doi:10.3389/fcvm.2023.1154708

5. Cafasso J. What foods help manage peripheral artery disease? Healthline. February 6, 2024. Accessed April 11, 2024. https://www.healthline.com/health/peripheral-artery-disease-diet

6. Peripheral artery disease (PAD). Mayo Clinic. June 21, 2022. Accessed April 11, 2024. https://www.mayoclinic.org/diseases-conditions/peripheral-artery-disease/diagnosis-treatment/drc-20350563

7. Espinola-Klein C, Weißer G, Schmitt V, Schwaderlapp M, Munzel T. Antithrombotic therapy in peripheral arterial disease. Front Cardiovasc Med. 2022;9:927645. doi:10.3389/fcvm.2022.927645

8. Angioplasty and stent placement – peripheral arteries. MedlinePlus. Updated January 18, 2023. Accessed April 11, 2024. https://medlineplus.gov/ency/article/007393.htm

9. Güneş Y, Sincer I, Erdal E. Catheter-directed intra-arterial thrombolysis for lower extremity arterial occlusions. Anatol J Cardiol. 2019;22(2):54-59. doi:10.14744/AnatolJCardiol.2019.63296

10. Rivera-Bou WL. Thrombolytic therapy. Medscape. Updated August 4, 2021. Accessed April 11, 2024. https://emedicine.medscape.com/article/811234-overview