4) DIABETES AND HEART DISEASE

f) Peripheral Arterial Disease (PAD)

Peripheral arterial disease or PAD (a type of a broader condition known as Peripheral Vascular Disease or PVD) is a subject all persons with type 2 diabetes should become very well versed in. The large blood vessels in the legs have the lowest blood velocities of any vessels in the body. As such, the large vessels in the legs are very prone to the build up of plaque (fatty deposits of cholesterol, triglycerides, calcium and body cells). This build up of plaque in the extremities is called peripheral arterial disease or PAD. The most prevalent underlying cause of death in type 2 diabetes is when plaque from PAD breaks off and migrates to the heart, lung or brain and causes a heart attack, stroke or lung embolism. PAD also causes infections of the foot and lower legs which require amputation of the leg, and studies have shown that individuals with type 2 diabetes who have progressed to the point of amputation of the legs have a short life expectancy. It thus becomes extremely important to understand PAD and to work diligently to prevent it or ameliorate PAD if it has started.

How does a person with diabetes know if they have PAD? "Lesser" symptoms include:

1, Aching, pain or cramps in the calves, thighs or buttocks upon walking or climbing stairs ("claudication", the most common symptom)
2, Cold feet (both cold to the person with diabetes and cold to the feel)
3, Feet which are red, said redness disappearing as a white circular area when pressed with the tip of a finger
4, Feet which become pale when elevated
5, Disappearance of hair from the calves
6, Distorted toenails
7, Cool, dry, fissured and/or scaly skin on the feet
8, Numbness or tingling in the toes, feet or calves

Note that most people with PAD simply assume the symptoms are just the result of "getting old" and ignore the symptoms. The American Heart Association says that 75% of the cases of PAD go undiagnosed, especially in women. If you have type 2 diabetes it is very dangerous to ignore the symptoms. Pain and cramps in the legs after walking a distance or climbing stairs is not arthritis. Nor are any of the other symptoms "signs of old age".

From the American Heart Association Website:

How is peripheral artery disease diagnosed and treated?

Techniques used to diagnose PAD include a medical history, physical exam, ankle-brachial index test (ABI), Pulse Volume Recording Test, ultrasound, X-ray angiography and magnetic resonance imaging angiography (MRA).

Most people with PAD can be treated with lifestyle changes, medications or both. Lifestyle changes to lower your risk include:

Stop smoking (smokers have a particularly strong risk of PAD).
Control diabetes.
Control blood pressure.
Be physically active (including a supervised exercise program).
Eat a low-saturated-fat, low-cholesterol diet.

PAD may require drug treatment, too. Drugs include:

medicines to help improve walking distance (cilostazol and pentoxifylline).
antiplatelet agents.
cholesterol-lowering agents (statins).

In a minority of patients, lifestyle modifications alone aren't sufficient. In these cases, angioplasty or surgery may be necessary.

The common test for PAD is the ankle-brachial index test or ABI. The ankle-brachial index test is the measurement of the blood pressure in the arm versus the blood pressure in the leg. It is unfortunate that many persons with diabetes get only this test if they complain of PAD symptoms. The ankle-brachial index test is not always accurate for diabetics. Individuals with diabetes commonly have calcium deposits in their legs which can give good ankle-brachial index test readings even when they have advanced PAD. Unfortunately this fact is not well known among even some physicians.

If the person with diabetes has three or more of the symptoms of PAD, it is important that the person with type 2 diabetes be very firm in not accepting the results of a "good" ankle-brachial index test. They should demand a pulse volume recording test. Pulse volume recordings are a qualitative assessment of blood flow. The diabetic should receive a thorough "wave form analysis" of their pulse volume recordings by an expert in the field. Only then can the diagnosis be accurate. If PAD is caught early enough an exercise and weight loss program can reverse it and the risk of heart disease and death can be lessened considerably. If the PAD progresses to the point of foot ulcers, blocked arteries or amputation, it is much more difficult to prevent severe heart disease and accelerated death. This is why a person with type 2 diabetes must be so aware of PAD and its symptoms; it is a life threatening condition, not just an inconvenience.

At the earliest stages of PAD the toes begin to feel "funny", like they are "asleep" or like the nerves aren't quite all there. There is a way to "self diagnose" PAD. After some time in the vertical position or seated such that the feet are much lower than the head, a suspicious individual can look at the bottom of the big toe for "blood pooling", the bottom of the big toe will be reddish in color. When a finger is pressed against the red area then released, a white patch will remain for a few seconds, if the beginning stages of PAD are present. If that occurs, a doctor visit, a walking exercise program, and aspirin therapy are all in order to prevent further deterioration. Note that there is no drug which can remove existing plaque in blood vessels (this is the "holy grail" for the pharmaceutical companies and a huge amount of research is being pored into it but no firm results have yet come about). Rigorous exercise is the only way to stop and reverse PAD. Rigorous exercise will cause the body to create collateral blood vessels which can help reverse the disease. Unfortunately research has shown that reversal can only by accomplished by continuing to exercise even with some pain, to the point of where it is just impossible to continue.

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Current Chapter: 4) DIABETES AND HEART DISEASE

a) Introduction
b) Small Blood Vessel versus Large Blood Vessel Disease
c) Large Blood Vessel Mechanisms
d) Blood Lipid Chemistry
e) Diabetes and "Heart Failure"
f) Peripheral Arterial Disease (PAD)
g) Blood Proteins, Diabetes and Heart Disease
h) Genetic Risk Factors for Diabetes and Heart Disease

 

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