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By MICHELLE BRANDT While aches and pains go hand-in-hand with getting older, one type of cramp in the calves or thighs could be a sign of something more serious – peripheral arterial disease (PAD). Yet a multi-center study involving Stanford shows that PAD, which causes leg pain and is linked to heart attack and stroke, is often overlooked by physicians. Many PAD patients aren't even aware that they have the condition.The study, known as PARTNERS (PAD Awareness Risk and Treatment: New Resources for Survival), involved nearly 7,000 patients, including 300 at Stanford. It was the largest program ever conducted on PAD in the primary care setting. The study found that almost 30 percent of the participants had PAD and more than half were unaware of it. "This study documents that PAD is a prevalent disease that is not being recognized by medical professionals or patients," said John Cooke, MD, PhD, associate professor of medicine and an investigator in the study, which was published in the Sept. 19 issue of the Journal of the American Medical Association. PAD, which affects between eight and 12 million Americans, involves the buildup of fatty plaque deposits in the arteries of the arms and legs. Patients with PAD may experience fatigue or cramps in their calves or thighs, but two-thirds of patients are asymptomatic. Left untreated, PAD can lead to atherothrombosis (clogging of the arteries) and an increased risk of cardiovascular disease. Past studies have shown that patients with PAD are six times more likely to die from cardiovascular disease within 10 years than patients without PAD. "PAD itself is not going to kill these patients – heart attack and stroke are," said Cooke. "Patients with PAD have a 50 percent to 75 percent chance of having coronary artery disease." Cooke said that steps can be taken to minimize PAD patients' risk of heart attack and stroke. Once diagnosed, physicians can work with their patients to modify their diets, implement exercise programs, quit smoking, control their blood pressure and use medications that lower cholesterol and prevent blood clotting. Mindful of the risks of this disease, and the importance of treatment, Cooke and fellow investigators sought to assess awareness of PAD among patients and health care professionals. They evaluated 6,979 at-risk patients – patients age 70 or older, or between the ages of 50 and 69 with a history of smoking or diabetes – and 350 primary care practices for five months in 1999. The investigators recorded the patients' medical histories and then tested them with the ankle-brachial index (ABI) – a noninvasive procedure that detects PAD by comparing the systolic blood pressure in the legs and arms. If the patients had been previously diagnosed with PAD the researchers made note of the ways they had been treated. Researchers found that 29 percent had PAD, and that half had not been previously diagnosed by their physicians, leading investigators to conclude that the ABI test is underused. The study also found that patients who had been previously diagnosed had not been treated as aggressively as patients with atherosclerosis of the heart and brain arteries. PAD patients were found to be less likely to be prescribed cholesterol-lowering or anti-clotting medications, for example. Cooke expressed surprise at the prevalence of the disease. "It was higher than I thought it would be," he said. "There is a perception that there is nothing we can do about it, but certain therapies have been shown to reduce patients' risk of heart attack and stroke," he said. Investigators in the study said that the under-diagnosis of PAD in primary care practice may be a barrier to minimizing cardiovascular risk for patients. They said the study confirms the need to raise awareness about PAD and for physicians to more frequently test for and aggressively treat the disorder.
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Stanford Report, October 31, 2001
