Essay on Peripheral Artery Disease: Unraveling Epidemiology, Pathogenesis, and Patient Management

Introduction

Peripheral Artery Disease (PAD) encompasses various diseases that affect non-cardiac arteries. PAD is commonly caused by atherosclerosis as well as inflammatory disorders of the arterial wall. It is the leading cause of atherosclerotic vascular morbidity. Globally, the importance of PAD has risen, given the number of people living with the disease has increased. The causes of the increase include the aging populations as well as the increased exposure to risk factors (Sampson et al., 2017). The disease is undiagnosed, undertreated, and poorly understood. It is caused by atherosclerosis of the abnormal aorta as well as lower extremity arteries which results in occlusion.

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Most people affected by the disease include individuals older than 70 years and older. For instance, over 30% of patients in the United States are older than 70 years (Sampson et al., 2017). However, individuals older than 50 years with a history of smoking or diabetes are affected by the disease. The diagnosis of Peripheral Artery Disease has been overlooked due to the lack of treatment of cardiovascular risk factors in patients with cardiovascular disease (Olin & Sealove, 2010). Overlooking the diagnosis of PAD leads to a low quality of life as well as a high rate of depression with poor functional performance. Besides, patients with PAD may experience a myocardial infarction, stroke as well as cardiovascular death, and a high rate of mortality.

Objectives of this Paper

This study aims to discuss the epidemiology of PAD based on evidence that provides updates on the number of people living with the disease. The paper explores the etiology, pathogenesis, morphological changes, clinical significance, medical management consideration, and patient teaching as it relates to peripheral artery disease.

Etiology

Peripheral Artery Disease is caused by atherosclerosis. Atherosclerosis results in the reduction of significant organ blood flow. The process of atherosclerosis is complex and involves numerous cells, proteins as well as modifiable pathways, thus contributing to risk factors in the advancement of atherosclerosis. However, there are other causes of the disease, including the inflammation of the blood vessels, injury as well as radiation exposure. The risk factors for Peripheral Artery Disease include diabetes, obesity as well as high blood pressure, and high cholesterol with increasing age, especially after the age of 50 years (Sampson et al., 2017). Peripheral Artery Disease can also be caused by a family of the disease as well as heart disease and stroke. Of all the risk factors, smoking is associated with a high risk of PAD development.

PAD affects about 250 million adults across the globe, and the incidence of PAD has increased to about 20% in people over the age of 70 (Dhaliwal & Mukherjee, 2007). Although PAD was seen as a disease for men, it has been found to impact both men and women. Underdiagnoses of PAD have become a significant issue as most of the patients with the disease do not present the stereotypical symptoms of claudication. Tobacco use heavily contributes to the high risk of PAD and contributes to the disease severity. As compared to non-smokers, smokers with PAD experience a shorter life span as they frequently process amputation and limb ischemia.

Pathogenesis

Peripheral Artery Disease is driven by the progression of atherosclerosis disease and leads to macrovascular dysfunction. The disease typically impacts the lower extremity vascular bed as well as, the larger arteries including the abdominal aorta as well as the iliac arteries. A severe disease involved can lead to the diffusion of the disease. The atherosclerosis pathophysiology entails a complex inflammatory response as it consists of several vascular cells as well as factors for thrombosis and cholesterol. Atherosclerosis progresses from the accumulation of lipoprotein in the intimal layer of large arteries. The presence of lipoprotein leads to lipid oxidation as well as cytokine response with lymphocyte infiltration (Dhaliwal & Mukherjee, 2007). The macrophages consume the oxidized lipids forming foam cells that lead to the development of fatty streaks that develop into advanced plaques with necrotic lipid core. They also include the smooth muscle cells that secrete cytokines and growth factors, thus leading to the migration of the smooth muscle cells to the luminal side.

Formation of the atherosclerotic plaque takes different years—the accumulation results in vascular stenosis that maximizes the end-organ perfusion. The plaque might continue to accumulate due to the vessel dilation, thus compromising the lumen occasionally and leading to the narrowing of the artery. The narrowing of the artery results in the development of collateral beds that do not match the supply of blood for the healthy vessel (Olin & Sealove, 2010). The severe form of PAD includes limb ischemia defined as limb pain which may ensue if vascular thrombosis occurs. Arterial thrombosis leads to the atherosclerosis disease.

The rapture of atherosclerosis leads to exposure of sub-endothelial as well as inflammatory cells, thus causing platelet adhesion and aggregation. Therefore, the hemodynamic consequence of atherosclerosis depends on arterial narrowing, which obstructs the artery with the flow of blood with the shift to the arteries that are smaller and parallel to the diseased artery (Gul & Janzer, 2020). The network of the smaller vessels does not carry as much blood as the main artery. The restriction of the blood flow represents the typical symptoms of PAD. Patients with PAD might have enough collateral blood flow with the symptoms arising when there is an increase in energy demand. As a result, the PAD becomes severe when the blood does not meet the metabolic needs of the lower extremities.

Morphological Changes

Morphological changes of Peripheral Artery Disease based on arterial duplex ultrasonography technique. The technique uses the B-mode imagining with a continuous-wave Doppler display. The sensitivity of duplex ultrasonography detects the occlusions and stenosis through imaging that evaluates the tandem stenosis as well as vessel imaging. Duplex Doppler examines the lower extremity based on the femoral artery as well as the distal and popliteal artery. Stenosis is localized with color Doppler which asses the velocities at several arterial sites. It has the forward flow systolic peak with a reversal of flow in early diastole.

The progressive PAD leads to the elimination of reverse flow with the systolic peak decreasing (Losordo et al., 2016). The use of duplex ultrasound in patients with saphenous vein grafts increases the risk of developing stenosis. The detection of stenosis and its repair is crucial to preserving the patency of bypass grafts. Modalities define arterial anatomy. The imaging modalities are essential for controlling IC failure in patients with acute limb ischemia. Since management involves specific interventions, the imaging modalities provide the road map defining the distribution and severity of the disease.

Clinical Significance

The diagnosis of PAD is confounded by the increased prevalence of commodities which causes lower extremity pain. As a result, there is a high degree of clinical suspicion with the provider based on patient risk factors. The symptomatic and asymptomatic PAD predict a functional decline. With a small minority of patients with PAD developing critical leg ischemia, the impact of lower extremity atherosclerosis is considered (Losordo et al., 2016). The presence of PAD has prognostic significance for coronary heart disease and death as it enables follow-up as well as multivariate adjustment for the relative risk for all-cause mortality. Besides, the relationship between the ankle-brachial index as well as cardiovascular disease reveals a population cohort of adults above 65 years with models for handling stroke and cardiovascular death.

Medical and Nursing Management Considerations

Management of PAD entails lowering cardiovascular risk while improving walking ability. Patients with PAD have an increased risk of myocardial infarction as well as thrombosis. Therefore, all the patients diagnosed with PAD should undertake lifestyle changes that lower the cardiovascular risk profile. The lifestyle changes entail reducing the use of tobacco while lowering cholesterol as well as diabetes control. The management of PAD starts with modifying individuals’ lifestyles while preventing the progression of medical and interventional therapy. It entails improving the symptomatic control of cardiovascular event risk reduction. The treatment options should aim at improving the walking ability based on the symptoms of the patient as well as the severity of the disease. Exercise therapy involves walking until the patient reaches the pain tolerance with a brief rest for the pain to resolve. The walking sessions should be about 30 minutes, three times per week for 12 weeks (Losordo et al., 2016).

Pharmacotherapy is also essential for treating PAD and involves the use of cilostazol, a medication that promotes vasodilation while suppressing the proliferation of vascular smooth muscle cells (Dhaliwal & Mukherjee, 2007). Pentoxifylline is another medication that improves oxygen delivery by its hemolytic effect. The endovascular treatment achieves the best results leading to technical success as well as the durability of endovascular therapy decrease in patients. Surgery should be reserved for patients with effective treatment with bypass grafts that divert flow around the blockage and remove obstructive plaque. The patients diagnosed with Peripheral Artery Disease required a practical approach that accounts for the risk factors.

Patient Teaching

Patient education is essential for managing Peripheral Artery Disease. Making an adequate diagnosis of PAD entails learning the history of the patient, the physical exam as well as the objective test result. The patient, therefore, has a responsibility to provide accurate history based on walking ability. Most of the patients with PAD do not show symptoms of the classic claudication; thus, the a need to be informed on reporting the physical ailments and imitations (Olin & Sealove, 2010). They have to be encouraged to be volunteers in giving information about walking as well as the essential aspects of history, including cardiovascular risk factors such as smoking and hypertension. The ABI entails several mistakes involving the failure to measure the brachial pressure (Mazhari & Hsia, 2005). The patients should ensure the ABI is not underestimated with upper extremity blood pressure discrepancy. Increasing the measure of ABI entails allowing the patient to rest supine for about five minutes which would enable pressure to stabilize while choosing an appropriate-sized blood pressure cuff. The blood work reveals altered renal function. Therefore, there is a need to determine the site for the flow of blood as well as the velocities of flow that are essential for determining the occlusion sites while assessing if the patient requires angioplasty. Patients with ulcers should be evaluated through perfusion.

Peripheral Artery Disease is a progressive disease and has poor long-term outcomes. The symptoms of PAD have been stable for several years with patients being at a high risk of cardiovascular events. As a result, patients are advised to seek inter-professional coordination which is capable of identifying the risk of the disease while preventing secondary progression. It will also present patients with various options for the disease (Losordo et al., 2016).