Evo Terra (Host): Welcome to DocTalk, presented by Montefiore St. Luke's Cornwall. I'm Evo Terra. And with me today is Dr. Ahmad B. Hadid, an interventional cardiologist at Montefiore St. Luke's Cornwall, as we talk about peripheral artery disease, what it is, how it's diagnosed, and the options patients have to stay active and protect their long-term health. Thanks for joining me, Dr. Hadid.

Ahmad B. Hadid, MD: Thank you for having me today.

Host: So for those of us unfamiliar, what is peripheral artery disease?

Ahmad B. Hadid, MD: Peripheral vascular disease is a common condition that affect blood circulation outside the heart and the brain, specifically in the legs. It's a very important topic because it's a public health issue. It can reduce mobility, can impair quality of life, can increase the risk of heart attack, stroke, and limb loss.

The good news is it is easy to detect, can be treated if it's caught early, and it will require the physician to ask some questions and concentrate during exam to find some abnormalities and proceed from there. So in general, basically, what's happening here, the arteries, especially in the lower extremities, they become more stiff. That's what in general you hear about hardening of the arteries by having plaque and cholesterol buildup there and calcium, and you get less blood flow into the legs.

Host: Got it. That makes sense to me. So clearly, there are some warning signs and some symptoms of this that patients and families should not ignore. Can you tell me about those?

Ahmad B. Hadid, MD: Yeah. The interesting thing about this topic is the early signs are really very vague and not very specific. And major symptoms happen when there is a significant blockage there. So, people who had those hardening of the arteries or plaque in their lower extremities, in their, in the limbs, they present with a vague complaint, "My legs feel tired when I walk. My legs feel heavy sometimes. Every time, I walk or I climb stairs, I have this tightness in my calf. I have tightness on my thigh." This is the beginning. This is how it starts. Obviously, this is why it's very important from the physician to pay attention to those early symptoms, specifically in somebody who's at risk of having that disease. We're talking about elderly people. We're talking about a patient who had diabetes, somebody who smokes, somebody who has some risk of plaque into other arteries or maybe they have heart disease already. So, this is something to pay attention to.

Further up, when the blockages become significant, a patient can develop more symptoms, and they develop more complicated situation where they can have like a wound taking longer to heal. A small cut on the lower leg that happened accidentally, it takes longer time to heal. That's a message saying that area did not get enough blood to heal. And most of the time, that's how we get involved with treating the patient. But we'd like to detect these little bit earlier in patients who are at risk and treat them before they get further down this path.

Host: Absolutely. Early detection is always a good thing. Now, I did a little bit of research coming into this, and I learned about these tests, the way we diagnose this, things like the ankle brachial index and the angio—all of these things. Maybe you can tell me how are we diagnosing this today?

Ahmad B. Hadid, MD: So as I say before, I'll start by questioning the patient about any of those symptoms that we think he is at risk of having by having a good conversation. "When you walk, do you have any cramp in your legs? Does your calf bother you when you walk?" That comes from just talking to the patient.

Second thing, during a good physical exam, we have to see how the limb looks. You check the pulse, check if there is enough blood flow at multiple levels: in the groin area, behind the knee, further down in the feet. Look at the skin. If the skin's getting enough blood, you will see nice color, like, normal color. If you're not getting enough blood, you will see shiny, little bit more pale color. Sometimes you will lose the hair in the lower extremities. That's always indication of less blood flow. This is all. We do not do any fancy test. Just by talking to the patient, basic physical exam, and just inspection and observation.

Further down in testing, the most simple screening test, as you mentioned, ankle brachial index. As it says, it's basically putting the ratio between the blood pressure in the lower extremities and the upper extremities. So, we take a blood pressure machine that we have in every exam room, every physician office. We check the blood pressure in the upper extremities, in the arms and in the legs. And then, we see the ratio between those two readings. And the idea of this is if the heart pumping the blood and getting you certain amount of pressure reach to the upper extremities, it should be the same pressure to able to deliver it all the way down to your lower extremities. So, the normal number should be exactly the same. If my blood pressure is 120 in my upper arm, should be sometimes little bit higher in the lower extremities, but in the same range, around 120, 130. So, we get a ratio around one. When we get much lower number and these ratios start to go down below 0.9, that's indicative of significant plaque into the arteries. So, that's a very simple test.

And interestingly, about the test, it will determine where is the level of the plaque or the blockage. Is it all the way up by the thigh? Is it lower down by the knee? Is it further down by the ankle? It's not a perfect test. It gets affected, especially in diabetic people, in patients who had kidney problems. They have a lot of calcium in the arteries. You cannot collapse those arteries. So, there is a little bit more complicated testing we can do.

We proceed after that to what's called an ultrasound. You mentioned a simple technique where we can see how the arteries look like exactly like a pipe, supposed to be clean and nice inside. If it filled up with the plaque, we can see it during this ultrasound. This is X-ray free.

Further up, if we decide that the patient has significant plaque and the blockages, we can proceed with a little bit more complicated—do something called CT angiography. That's an angiogram. Just taking actual picture by injecting the dye and look further down by a CAT scan machine.

And then, if we decide that the patient needs some further intervention or workup because there is severe blockage that needs to be fixed, we do what's called conventional angiogram. This done in the cath lab, which we're able to do it in our hospital locally here; put a catheter in the groin area. The patient will be on a table. A camera on top will be able to take a picture by injecting the dye directly into the lower extremities and identify the blockage.

If it's significant enough in the range of 60%, 70%, and we feel it's significant to be treated, we proceed with what's called the balloon angioplasty with a balloon and open that artery. Sometimes we place a stent to keep the artery open. This is some of the diagnostic testing. Some other testing requires a special situation where we can do an MRI to see also the arteries and more specific information about those blockages.

Host: Now, obviously you mentioned some surgical things that we can do, but what about drugs? What about drug treatments that we have right now that are treating this disease? When are they the right thing to use?

Ahmad B. Hadid, MD: So, we went further down talking about the intervention. But as you say, the prevention is really the best thing we have to start with. As you said from the beginning, the patient at risk of having those problems are diabetic and smokers. So, that's number one risk factor, diabetes and smoking. Number two, hypertension. Number three, high cholesterol. Number four, sedentary lifestyle. And number six is getting older. Older age, we develop more plaque.

So, the treatment starts by advising the patient to correct these risk factor and improve lifestyle. No smoking. By stopping smoking, it will decrease the risk of having peripheral vascular disease sixfold, just if you stop smoking, without using any other intervention. So, that's how important controlling the diabetes, the blood sugar. If it's high, it has to be controlled. Why is that? Because when the sugar is high, it affects the lining of the arteries. And when the lining of the arteries get affected, it start to have inflammation there. It will lead to build up of plaque and blockages.

Controlling the blood pressure, being on a cholesterol medication for a patient who has high cholesterol. The very common medication that we know, and a lot of my patients, they know about it, statin. It's to reduce the cholesterol. Healthy lifestyle, exercise, walking every single day. Fifteen, twenty minutes of walk, five days a week. That will improve the exercise tolerance, make patients walk more. Even if they have a blockages, because it's a proven, it's something what's called a supervised exercise program. I mean, you can walk obviously around your neighborhood by yourself, but there is a program where we can refer a patient to walk under supervision and increase that intensity of walking to create smaller branches and new vessels that can supply the area that they have a blockage.

Other medications that we can use other than statin, something we call it antiplatelet, simply like aspirin, a small aspirin to prevent a clot from forming. There is a specific medication. It can make people walk more. It does cause little dilatation of the arteries and give more blood. Also, it's available to us to use.

We always try initially by lifestyle modification, exercise program, simple medication, as we talked about. Then, we proceed, if these fail or if the patient has severe symptoms where they have symptoms of significant pain and lack of blood coming to the foot or the leg, or they have an ulcer that's not healing, that requires a little bit further than just medication. That's where we proceed with the further testing, may require an angiogram, may require what's called a balloon or stent. And if the blockages are extensive, we proceed by consulting one of our colleagues from vascular surgery, and some of the patients require like a bypass surgery for the lower extremities, bypass surgery, to improve the healing and improve the circulation and get back on track again.

Host: So, this is obviously a cardiovascular system issue that's happening here. So, what should patients and general practitioners know about managing the overall risk for the cardiovascular system once the peripheral artery disease is diagnosed?

Ahmad B. Hadid, MD: It's a very good point because all starts from primary care, and we always encourage and we always deal with our colleague in the primary care and internal medicine. We talk to them about any patient comes in just to screen for the symptoms. And if they suspect it, they will start the treatment, get referred to us or the vascular surgeon.

And the key here is if a patient has peripheral vascular disease, as you say, it's a very common problem, it's not only involving the lower extremities. That will give us some concern about his cardiovascular health. Does he have a plaque somewhere? Does he have a blockage in the arteries? Does he have a blockage in what's called the arteries of the heart or in the carotid arteries?

So, if you have peripheral vascular disease, 50% chance you will have some type of a heart disease. So, those require to have good history, exam, their symptoms. I'm concerned about those patients because they're not able to walk a lot because of the symptoms of the lower extremities, they get tired. They may not have any cardiac symptoms. Do you get any shortness of breath? No. Do you get any chest pain? No. Why? Because not doing enough activities to show any symptom. So, that requires us to screen them also whenever they have peripheral vascular disease for significant coronary disease, which is a blockage in the arteries of the heart or in the carotid arteries, those are the main pipes, they come up to the brain.

Host: Anything you'd like to add about peripheral vascular disease?

Ahmad B. Hadid, MD: I'd just like to summarize that it's a common problem, easy to detect. I always talk to my colleagues in internal medicine, with the nurse practitioners who sees patient in our office and in the hospital to have just a quick talk to the patient, even if the patient did not offer these symptoms, to ask him about specific information. As I say with the exam, inspect his lower extremities, witness how he walks. And from there, further testing, screening testing if needed. And if we document that somebody had peripheral vascular disease, definitely has to be screened for coronary disease or carotid disease.

Good news is if we find the problem early, we can correct it. We can prevent the progression of the disease. We can prevent major complication. So, it's treatable and patient will do very well, and they will live a normal lifestyle.

Host: And that is wonderful news. Dr. Hadid, thank you very much for all the information today.

Ahmad B. Hadid, MD: I appreciate it. Thank you.

Host: Once again, that was Dr. Ahmad B. Hadid, an interventional cardiologist at Montefiore St. Luke's Cornwall. To learn more about cardiac services, please visit montefioreslc.org. Again, that's montefioreslc.org. And if you enjoyed this episode, please share it on your social channels and check out the entire podcast library for topics of interest to you. I'm Evo Terra, and this has been DocTalk, presented by Montefiore St. Luke's Cornwall. Thanks for listening.