Presented by Matthew Mell, MD, Associate Professor of Surgery
Medical Director, Vascular Clinic and Lab
Division of Vascular Surgery
October 26, 2017
The first tip-off that something is wrong comes after walking 2 or 3 blocks. Cramps hit your lower legs. Once you stop walking, in a few minutes the cramps fade, then stop.
The cramp may mean nothing at all. But this scenario can also be a sign of peripheral arterial disease, or PAD. Many times, people are unaware they have this problem in the early stages because they have few symptoms other than the cramps. But it can be the harbinger of a higher risk for heart attack or stroke.
“Peripheral vascular disease is just part of the constellation of cardiovascular disease,” said Matthew Mell, MD, director of the vascular clinic and lab at Stanford University Medical Center, in a lecture at the Stanford Health Library.
“A lot of times, it’s sort of the first diagnosis that allows people to realize that there may be other things going on,” Dr. Mell said. “It actually provides opportunity for all the risk reduction that we now know is so successful.”
Hardening of the arteries. Atherosclerosis. Blocked arteries. Peripheral arterial disease. They sound different, but they’re all related to the same thing: a problem getting blood delivered to the body.
Getting leg cramps doesn’t necessarily mean someone has PAD. There are other causes. Night-time leg cramps are almost never PAD. But if the cramps start during exercise—and then go away within 2 or 3 minutes after exercise stops—that suggests the pattern of PAD, Dr. Mell said.
That’s because the muscles in your legs require more blood when you walk than when you’re resting. If your arteries are narrowed by PAD, when you walk the supply of blood can’t keep up with the oxygen demand of the muscles. So you get cramping. After resting, the cramps stop.
PAD can be an early sign of the risk that atherosclerotic disease is developing elsewhere in the body, narrowing blood vessels that deliver blood. Getting an early diagnosis can enable people to stop this development by using holistic methods (like exercise) rather than surgery or other procedures.
Atherosclerotic disease leads to almost one million American deaths yearly. “It’s actually responsible for more deaths than cancer, accidents, HIV combined,” Dr. Mell said.
PAD is just one small segment of atherosclerotic or cardiovascular disease. All of these conditions are problems of the body’s circulation system that carries blood. There are 3 major components of the circulation:
- The heart, which pumps blood
- The arteries, which carry blood from the heart to the rest of the body
- The veins, which return blood from the body back to the heart
PAD involves the arteries. Over time, the walls of the arteries can thicken and narrow from a buildup of fat, dead cells and other debris. That slows down the flow of blood to the body.
In the earliest stages, there may be no symptoms. Later on, people may get muscle cramps in the lower legs when they exercise. Among people with mild to moderate PAD, 80 percent don’t get any worse over the years.
About 10 or 20 percent gradually get worse. In a very few patients—perhaps 1 in a hundred—PAD gets so severe that someone may need amputation to avoid gangrene, Dr. Mell said.
Other causes of cramps
Some people get similar symptoms that aren’t caused by PAD.
“We see a lot of patients who get night cramps, where they get calf cramps at night—that’s almost never a vascular problem,” Dr. Mell said.
Other non-PAD causes of leg pain include sciatica or spinal stenosis—conditions that compress nerves and cause pain.
Who gets PAD
PAD becomes more common as people age. By age 70 or older, about 1 in 6 people (or 15 percent) have PAD, according to one large study. Another study found a higher rate of 29 percent in those age 70 or older.
Sometimes the disease can be very mild at the time it is diagnosed, so people don’t have any symptoms. About half to three-quarters of patients with mild to moderate PAD have some kind of leg pain, Dr. Mell said.
If people are diagnosed with PAD and they also have diabetes, high blood pressure, or other conditions, it is especially important for them to take steps to maintain their health, Dr. Mell said. Otherwise, they have a higher risk that the PAD will grow severe over time. They also have a higher risk a higher risk of heart attack or stroke from other cardiovascular disease.
Getting a diagnosis
PAD is usually diagnosed by a doctor from a physical exam, with a careful check of your pulse taken from various points up and down your arm and leg. Whether the pulse is present, absent, or diminished provides clues to the diagnosis.
Occasionally doctors do an additional check called the ankle-brachial index test. That compares your blood pressure measured at your ankle with your blood pressure measured at your arm. That can indicate narrowed or blocked arteries in your legs.
There are multiple steps people can take to treat PAD, including lifestyle changes and medicines.
By far, the most important change to make–for anybody who smokes cigarettes–is to stop. “That would be a No. 1 holistic treatment,” Dr. Mell said. “That’s not an easy thing to do.”
Other measures to reduce risks from PAD include:
- Regular exercise training, supervised
- Taking medicine that lessens leg pain by increasing blood flow to the legs
- Taking medicine that prevents blood clots, and medicine that lowers cholesterol
If these steps don’t help enough, there are still more options: surgery or a procedure called angioplasty to clear clogged arteries.
Reducing leg pain
The best way for people with PAD to decide what treatment they want is to talk it over with their doctors. Each option has different benefits and risks, and the best choice may depend on each individual person’s priorities for their health and life.
“Shared decision-making is really important,” Dr. Mell said.
For mild to moderate PAD, there is strong medical evidence for the following 2 options to improve leg pain:
- A regular exercise program can improve walking capacity by 100 percent to 200 percent. That means someone who was limited (by leg pain) to walking 2 blocks can extend their capacity to 4-6 blocks—or a quarter- to half-mile—with regular exercise.
“It takes a lot of motivation,” Dr. Mell said. The best results come from supervised exercise, which helps people stay on track and guides them to increase distance safely. Unsupervised exercise doesn’t show the same benefits.
Although health insurance typically hasn’t covered the cost of this therapy, Medicare recently decided to pay for 12 months of this treatment, Dr. Mell said.
- Medicine called cilostazol that reduces leg pain from PAD. Cilostazol increases blood flow and the amount of oxygen that gets to leg muscles. One study found cilostazol improved walking distance by 60 percent by the 5th year of taking the medicine.
Lowering cardiovascular risks
Even if people start exercising, take cilostazol, and are free of pain, other issues remain. They still have a higher risk for heart attack or stroke.
About 40 percent of patients with peripheral arterial disease will have a heart attack, a stroke or cardiovascular death within 5 years.
“This to me is the really important point,” Dr. Mell said. “There are things we can do to really decrease those risks.”
Treatment options to reduce the risk for these additional cardiovascular problems include:
- Taking clopidogrel (such as Plavix), a blood-thinner that reduces risk of blood clots.
- Taking a statin drug (such as Lipitor or Crestor) that lowers cholesterol. Statins lower the risk of death from heart attack and stroke by 25 percent.
Sometimes statins can have side effects, including muscle cramps. For most people, the benefit of statins outweighs the risks, Dr. Mell said.
If people with PAD have symptoms that are severe, or their medicines don’t meet their expectations, there are other options to reduce the risk of cardiovascular disease. A procedure called angioplasty, which clears arteries and props them open with a device called a stent, can reduce risk. So can bypass surgery.
The risks for these bigger steps can be weighed against their benefits in the context of each person’s priorities for their health and life.
Dr. Mell said the risk that a person’s PAD will grow severe over time is less than the higher risk they face of getting a heart attack, stroke, or other cardiovascular problem.
So they may want to choose a combination of treatments that not only reduce the symptoms of PAD, but also the risks of cardiovascular disease.
“That’s the super-important take-home message,” he said.
For more information: