Peripheral Artery Disease
Dr. Anthony Patrello discusses Peripheral Artery Disease (also known as PAD), the signs and symptoms, and how to protect limbs that have been potentially affected.
Featured Speaker:
Anthony Patrello, MD
Dr. Anthony Patrello is an interventional cardiologist at The Hudson Valley Heart Center and the Director of Cardiovascular Services at St. Lukes Cornwall Hospital. He has particular expertise at treating complex coronary artery disease, peripheral vascular disease, heart valve disease, as well as preventative medicine. He is board certified in cardiovascular disease, nuclear cardiology, echocardiography, interventional cardiology, and internal medicine. He has received the honor of being elected a Fellow of the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions. Dr. Patrello began his medical training at The Mount Sinai School of medicine, where he received his medical degree with honors. He completed a residency in internal medicine at The Columbia University Medical Center. He then moved to Chicago where he was fellowship trained at Northwestern University. Dr. Patrello then returned to New York City and completed a fellowship in interventional cardiology at The Mount Sinai Medical Center. Dr. Patrello is married to a visual effects artist and they have two young children. The Hudson valley native is excited to provide cutting edge care to the community where he was raised. Transcription:
Peripheral Artery Disease
Prakash Chandran: With peripheral artery disease or PAD affecting 8 to 12 million people in the United States, it's important not only to know about the signs and symptoms, but also how to protect potential limbs that have been affected. We're going to talk about it today with Dr. Anthony Patrello, the Medical Director of Cardiovascular Services at Montefiore St. Luke's Cornwall.
This is Doc Talk, the podcast from Montefiore St. Luke's Cornwall. My name is Prakash Chandran. So first of all, Dr. Patrello, great to have you here today. Let's get right into it. What exactly is peripheral artery disease?
Dr. Anthony Patrello: Peripheral arterial disease is narrowing typically through atherosclerosis or cholesterol buildup in the arteries, usually of the lower extremities.
Prakash Chandran: And what exactly does this disease cause? Or how does it present itself?
Dr. Anthony Patrello: Peripheral arterial disease can cause a wide range of presentations. The vast majority of people are asymptomatic, which means that they do not have any symptoms. But even if you do not have any symptoms, it doesn't mean that it's benign. The cholesterol buildup is a systemic process. If it's happening in the arteries of the lower extremities, it is probably happening in the other artery beds as well, including the arteries in the heart, which can cause coronary artery disease and the arteries in the brain, which can lead to stroke. So even patients who have asymptomatic peripheral arterial disease are at higher risk of having cardiovascular events.
After that, the next step would be that the peripheral disease can cause mild symptoms typically through walking. And those symptoms can cause pain either in the hip or in the buttocks, down in the back of the calf and the back of the thigh or even sometimes in the foot. And then the next stage after that, the most advanced stage would be where somebody has a threatened limb or critical limb ischemia, and those patients often have pain at rest or even tissue loss and ulcerations in their feet. So it's a wide range of presentations.
Prakash Chandran: Okay. So pain in the limb or buttocks as you use them, but also when more extreme cases, pain at rest. One of the things that I've actually read about this disease is that it can get severe enough to where you need to amputate the affected limb. Is that true?
Dr. Anthony Patrello: That is correct. The most extreme stage of this, the critical limb ischemia often can lead to amputation. In fact, that happens about 25% of the time in the patients who have critical limb ischemia. So most of our treatment algorithms are aimed at catching this early and trying to prescribe an algorithm to prevent progression of disease.
Prakash Chandran: Yes. And just before we start talking about some of these prevention measures, I'd love to understand a little bit more around who's most at risk.
Dr. Anthony Patrello: So the patients who are at risk of developing peripheral artery disease is the same risk factors for people who develop coronary artery disease. And those risk factors are fairly well-established. Their number one risk factor by far is smoking. Patients who smoke are the number one risk of developing peripheral artery disease. And if you have peripheral artery disease and you smoke, you're at the highest risk of progressing.
Other risk factors include diabetes, high cholesterol, high blood pressure, chronic kidney disease, and age. The older you are, the more likely that this is to occur. The age that it starts typically is at age 40. But the further along you get on in age, the more likely it is that you can develop peripheral artery disease. But smoking is still the number one cause.
Prakash Chandran: And Dr. Petrello, how do people know that this is something that they should start getting looked at? Are there certain symptoms that people should be aware of?
Dr. Anthony Patrello: Certainly if you have any symptoms, you should be evaluated for it. And symptoms would be sort of what we discussed, either having some vague symptoms in the hip or in the buttocks back into the lower part of the thigh and the calf or in the foot. Sometimes this is due to arthritis and oftentimes people assume that it's from arthritis, but not always.
There's certainly been cases where patients have gone for years without having this diagnosed, because they just assume that it was either back pain or arthritis that was causing their hip pain when really it's from peripheral artery disease. So if you're having any leg discomfort at all, I think it would be reasonable to get evaluated.
And for people who are not having any symptoms, if you have risk factors, so if you're above the age of 40 and have some of these risk factors that we talked about, smoking, diabetes, high blood pressure, high cholesterol, it would be reasonable to be screened.
Prakash Chandran: Okay. So let's talk a little bit about that screening process and getting diagnosed. So you're saying if you're above the age of 40 and you have some of these risk factors, is that something that you go to your primary care physician for? Or do you go to a certain facility to get that done?
Dr. Anthony Patrello: I would first start by initiating the discussion with your primary care physician. Oftentimes, primary care physicians will have enough understanding of the disease process that they'd be able to order the testing on their own. If they don't, they can refer you either to a cardiologist or to a vascular specialist, and they can order the testing for you.
The initial round of testing is very straightforward. It's a test that's called an ABI or an ankle brachial index. And basically, all you're doing is taking blood pressure in the arms and blood pressure in several points down the leg. And you compare the blood pressure in the arm and the blood pressure in the legs. And if there's a significant drop in blood pressure in the legs, that means that there's some blockage or some narrowing of the arteries in the legs. And the lower that ratio is, the worse the blockage is.
Prakash Chandran: Okay. That makes a lot of sense. You know, we talked about like the different presentations of peripheral artery disease and, you know, the extreme cases where when you have pain at rest, then you could potentially even lose a limb. I'm assuming that happens when it goes ignored and not diagnosed for a long time. Would I be correct in saying that?
Dr. Anthony Patrello: You would be correct. But mostly, it's because those risk factors that caused that were not addressed. So for people who are smoking, it wasn't brought to their attention that they're causing some damage to their peripheral artery system and they haven't been motivated to quit smoking. Diabetics, they let their blood sugars run rampant and they're not motivated to control it. Whereas if they knew that they were developing some blockage in the lower extremities, they may be more motivated. People letting their high blood pressure go, people letting their diet run wild and letting their cholesterol go. So mostly, it's because those risk factors are not controlled. There are some dedicated treatments that we can do to help prevent some of that progression. But mostly, it's aggressive risk factor modification.
Prakash Chandran: Okay. So let's actually get into some of the different treatment options available to people. What do you generally tell people is available to them?
Dr. Anthony Patrello: So certainly, as we talked about, the primary treatment is to address all those risk factors. And if you smoke, you need to stop smoking. If you're a diabetic, you need to control your blood sugar better. After that, the primary treatment is very aggressive cholesterol control. Since this is cholesterol blockage and cholesterol buildup in the arteries, we want to drive your cholesterol down as low as we can get it, usually beyond what can be done through diet alone. So that's typically through medication.
In addition, and after that, we recommend active walking. The more walking that you do, the more that your legs can accommodate blood flow. Symptoms from peripheral artery disease are all about a supply-demand mismatch. So if you're able to do some more walking, you can help improve the supply and reduce the demand on the legs.
There are also some medications that can be variably effective that can help dilate the arteries. So if there's a fixed blockage there, they can dilate the arteries and improve blood flow a little bit and help on the supply side, those are variably effective, and sometimes we use them in cases where the initial round of therapy wasn't particularly helpful.
Prakash Chandran: Okay. So if someone listening to this isn't experiencing any symptoms, but has some of the risk factors that we've discussed, if they stopped smoking and they get their diet under control, is this disease something that is reversible? Or is this something that just halts the development of the blockages in those arteries?
Dr. Anthony Patrello: The primary goal is to halt it in its tracks. There can be a little bit of regression. But mostly, if you're able to keep things where they are and increase your walking, your body's actually able to compensate for that blockage better and your pain can actually improve over time. And if it doesn't and if you reach a plateau, there are minimally invasive procedures that can be done as well that we can offer that can help improve symptoms, where we either balloon open an artery where we improve the blood flow that way or put a stent in an artery and improve blood flow. In very extreme cases, we can consider a surgical procedure where we actually bypass blood flow around that blockage, but that's the rarity and very extreme situations.
Prakash Chandran: So as I'm listening to this, it seems like the key is to really be proactive to, as you said, halt the development of some of the blockages in the limbs. And by way of being proactive, are there any vitamins or foods that people can ingest to help prevent the onset of this disease?
Dr. Anthony Patrello: I think what you said being proactive is super important. I think recognition is super important. This is a very under-recognized disease process. It's estimated as much as 30 to 50 people who have it don't even recognize that they have it. So it's hard to fix it and address it if you don't know that you have it
in terms of foods, it's mostly the same kind of foods that you would use for other types of blockage in terms of the arteries of the heart. So it would be mostly a "heart-healthy diet", so more of a Mediterranean kind of a diet, olive oil-based diet or fruits, nuts, grains, vegetables, lean chicken. Some fish oil in the diet can increase your good cholesterol and lower your triglyceride levels. But no vitamin supplement has really been proven to be particularly effective in cleaning out the arteries.
Prakash Chandran: So just before we close here today, if you could leave the audience with one piece of advice before they came to see you, what might that be?
Dr. Anthony Patrello: The single piece of advice would be to stay vigilant, to try to recognize symptoms, to discuss the symptoms with your physician. And if you smoke, please stop smoking. Like I mentioned before, it's the number one cause of peripheral artery disease. And it is very difficult to treat the disease process for people who continue to smoke.
Prakash Chandran: Well, Dr. Patrello, that is very good advice. And I think the perfect place to end. Thank you so much for your time today.
Dr. Anthony Patrello: Thank you for having me.
Prakash Chandran: That's Dr. Anthony patrello, the Medical Director of Cardiovascular Services at Montefiore St. Luke's Cornwall. For more information, please visit MontefioreSLC.org. That's M-O-N-T-E-F-I-O-R-E-S-L-C dot org.
Please remember to subscribe, rate and review this podcast and all other Montefiore St. Luke's Cornwall podcasts. Thanks for listening to this episode of Doc Talk presented by Montefiore St. Louis Cornwall. My name is Prakash and we'll talk next time.
Peripheral Artery Disease
Prakash Chandran: With peripheral artery disease or PAD affecting 8 to 12 million people in the United States, it's important not only to know about the signs and symptoms, but also how to protect potential limbs that have been affected. We're going to talk about it today with Dr. Anthony Patrello, the Medical Director of Cardiovascular Services at Montefiore St. Luke's Cornwall.
This is Doc Talk, the podcast from Montefiore St. Luke's Cornwall. My name is Prakash Chandran. So first of all, Dr. Patrello, great to have you here today. Let's get right into it. What exactly is peripheral artery disease?
Dr. Anthony Patrello: Peripheral arterial disease is narrowing typically through atherosclerosis or cholesterol buildup in the arteries, usually of the lower extremities.
Prakash Chandran: And what exactly does this disease cause? Or how does it present itself?
Dr. Anthony Patrello: Peripheral arterial disease can cause a wide range of presentations. The vast majority of people are asymptomatic, which means that they do not have any symptoms. But even if you do not have any symptoms, it doesn't mean that it's benign. The cholesterol buildup is a systemic process. If it's happening in the arteries of the lower extremities, it is probably happening in the other artery beds as well, including the arteries in the heart, which can cause coronary artery disease and the arteries in the brain, which can lead to stroke. So even patients who have asymptomatic peripheral arterial disease are at higher risk of having cardiovascular events.
After that, the next step would be that the peripheral disease can cause mild symptoms typically through walking. And those symptoms can cause pain either in the hip or in the buttocks, down in the back of the calf and the back of the thigh or even sometimes in the foot. And then the next stage after that, the most advanced stage would be where somebody has a threatened limb or critical limb ischemia, and those patients often have pain at rest or even tissue loss and ulcerations in their feet. So it's a wide range of presentations.
Prakash Chandran: Okay. So pain in the limb or buttocks as you use them, but also when more extreme cases, pain at rest. One of the things that I've actually read about this disease is that it can get severe enough to where you need to amputate the affected limb. Is that true?
Dr. Anthony Patrello: That is correct. The most extreme stage of this, the critical limb ischemia often can lead to amputation. In fact, that happens about 25% of the time in the patients who have critical limb ischemia. So most of our treatment algorithms are aimed at catching this early and trying to prescribe an algorithm to prevent progression of disease.
Prakash Chandran: Yes. And just before we start talking about some of these prevention measures, I'd love to understand a little bit more around who's most at risk.
Dr. Anthony Patrello: So the patients who are at risk of developing peripheral artery disease is the same risk factors for people who develop coronary artery disease. And those risk factors are fairly well-established. Their number one risk factor by far is smoking. Patients who smoke are the number one risk of developing peripheral artery disease. And if you have peripheral artery disease and you smoke, you're at the highest risk of progressing.
Other risk factors include diabetes, high cholesterol, high blood pressure, chronic kidney disease, and age. The older you are, the more likely that this is to occur. The age that it starts typically is at age 40. But the further along you get on in age, the more likely it is that you can develop peripheral artery disease. But smoking is still the number one cause.
Prakash Chandran: And Dr. Petrello, how do people know that this is something that they should start getting looked at? Are there certain symptoms that people should be aware of?
Dr. Anthony Patrello: Certainly if you have any symptoms, you should be evaluated for it. And symptoms would be sort of what we discussed, either having some vague symptoms in the hip or in the buttocks back into the lower part of the thigh and the calf or in the foot. Sometimes this is due to arthritis and oftentimes people assume that it's from arthritis, but not always.
There's certainly been cases where patients have gone for years without having this diagnosed, because they just assume that it was either back pain or arthritis that was causing their hip pain when really it's from peripheral artery disease. So if you're having any leg discomfort at all, I think it would be reasonable to get evaluated.
And for people who are not having any symptoms, if you have risk factors, so if you're above the age of 40 and have some of these risk factors that we talked about, smoking, diabetes, high blood pressure, high cholesterol, it would be reasonable to be screened.
Prakash Chandran: Okay. So let's talk a little bit about that screening process and getting diagnosed. So you're saying if you're above the age of 40 and you have some of these risk factors, is that something that you go to your primary care physician for? Or do you go to a certain facility to get that done?
Dr. Anthony Patrello: I would first start by initiating the discussion with your primary care physician. Oftentimes, primary care physicians will have enough understanding of the disease process that they'd be able to order the testing on their own. If they don't, they can refer you either to a cardiologist or to a vascular specialist, and they can order the testing for you.
The initial round of testing is very straightforward. It's a test that's called an ABI or an ankle brachial index. And basically, all you're doing is taking blood pressure in the arms and blood pressure in several points down the leg. And you compare the blood pressure in the arm and the blood pressure in the legs. And if there's a significant drop in blood pressure in the legs, that means that there's some blockage or some narrowing of the arteries in the legs. And the lower that ratio is, the worse the blockage is.
Prakash Chandran: Okay. That makes a lot of sense. You know, we talked about like the different presentations of peripheral artery disease and, you know, the extreme cases where when you have pain at rest, then you could potentially even lose a limb. I'm assuming that happens when it goes ignored and not diagnosed for a long time. Would I be correct in saying that?
Dr. Anthony Patrello: You would be correct. But mostly, it's because those risk factors that caused that were not addressed. So for people who are smoking, it wasn't brought to their attention that they're causing some damage to their peripheral artery system and they haven't been motivated to quit smoking. Diabetics, they let their blood sugars run rampant and they're not motivated to control it. Whereas if they knew that they were developing some blockage in the lower extremities, they may be more motivated. People letting their high blood pressure go, people letting their diet run wild and letting their cholesterol go. So mostly, it's because those risk factors are not controlled. There are some dedicated treatments that we can do to help prevent some of that progression. But mostly, it's aggressive risk factor modification.
Prakash Chandran: Okay. So let's actually get into some of the different treatment options available to people. What do you generally tell people is available to them?
Dr. Anthony Patrello: So certainly, as we talked about, the primary treatment is to address all those risk factors. And if you smoke, you need to stop smoking. If you're a diabetic, you need to control your blood sugar better. After that, the primary treatment is very aggressive cholesterol control. Since this is cholesterol blockage and cholesterol buildup in the arteries, we want to drive your cholesterol down as low as we can get it, usually beyond what can be done through diet alone. So that's typically through medication.
In addition, and after that, we recommend active walking. The more walking that you do, the more that your legs can accommodate blood flow. Symptoms from peripheral artery disease are all about a supply-demand mismatch. So if you're able to do some more walking, you can help improve the supply and reduce the demand on the legs.
There are also some medications that can be variably effective that can help dilate the arteries. So if there's a fixed blockage there, they can dilate the arteries and improve blood flow a little bit and help on the supply side, those are variably effective, and sometimes we use them in cases where the initial round of therapy wasn't particularly helpful.
Prakash Chandran: Okay. So if someone listening to this isn't experiencing any symptoms, but has some of the risk factors that we've discussed, if they stopped smoking and they get their diet under control, is this disease something that is reversible? Or is this something that just halts the development of the blockages in those arteries?
Dr. Anthony Patrello: The primary goal is to halt it in its tracks. There can be a little bit of regression. But mostly, if you're able to keep things where they are and increase your walking, your body's actually able to compensate for that blockage better and your pain can actually improve over time. And if it doesn't and if you reach a plateau, there are minimally invasive procedures that can be done as well that we can offer that can help improve symptoms, where we either balloon open an artery where we improve the blood flow that way or put a stent in an artery and improve blood flow. In very extreme cases, we can consider a surgical procedure where we actually bypass blood flow around that blockage, but that's the rarity and very extreme situations.
Prakash Chandran: So as I'm listening to this, it seems like the key is to really be proactive to, as you said, halt the development of some of the blockages in the limbs. And by way of being proactive, are there any vitamins or foods that people can ingest to help prevent the onset of this disease?
Dr. Anthony Patrello: I think what you said being proactive is super important. I think recognition is super important. This is a very under-recognized disease process. It's estimated as much as 30 to 50 people who have it don't even recognize that they have it. So it's hard to fix it and address it if you don't know that you have it
in terms of foods, it's mostly the same kind of foods that you would use for other types of blockage in terms of the arteries of the heart. So it would be mostly a "heart-healthy diet", so more of a Mediterranean kind of a diet, olive oil-based diet or fruits, nuts, grains, vegetables, lean chicken. Some fish oil in the diet can increase your good cholesterol and lower your triglyceride levels. But no vitamin supplement has really been proven to be particularly effective in cleaning out the arteries.
Prakash Chandran: So just before we close here today, if you could leave the audience with one piece of advice before they came to see you, what might that be?
Dr. Anthony Patrello: The single piece of advice would be to stay vigilant, to try to recognize symptoms, to discuss the symptoms with your physician. And if you smoke, please stop smoking. Like I mentioned before, it's the number one cause of peripheral artery disease. And it is very difficult to treat the disease process for people who continue to smoke.
Prakash Chandran: Well, Dr. Patrello, that is very good advice. And I think the perfect place to end. Thank you so much for your time today.
Dr. Anthony Patrello: Thank you for having me.
Prakash Chandran: That's Dr. Anthony patrello, the Medical Director of Cardiovascular Services at Montefiore St. Luke's Cornwall. For more information, please visit MontefioreSLC.org. That's M-O-N-T-E-F-I-O-R-E-S-L-C dot org.
Please remember to subscribe, rate and review this podcast and all other Montefiore St. Luke's Cornwall podcasts. Thanks for listening to this episode of Doc Talk presented by Montefiore St. Louis Cornwall. My name is Prakash and we'll talk next time.