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Peripheral arterial disease (PAD) is the narrowing or blockage of the lower limb

arteries as a result of atherosclerosis, resulting in reduced blood flow to the muscles and tissues (Golledge, 1997). Atherosclerosis is a progressive systemic condition affecting the arteries throughout the body, and patients with PAD not only have the risk of lower limb loss, but also an increased risk of heart attack and stroke (Gresele et al, 2011). The build-up of plaque within the lumen of the artery occurs in a sequential fashion (Figure 1).

Detecting and treating peripheral arterial disease in primary care

Jane Todhunter, vascular nurse practitioner, North Cumbria University Hospitals

Peripheral arterial disease is caused by atherosclerosis and reduces blood flow to the legs. The most common symptom is pain when walking, known as intermittent claudication which carries the risk of lower limb loss but is also a marker for the increased risk of death from heart attack and stroke. It affects a significant number of people in the UK over 60, with a higher incidence in patients with diabetes and coronary artery disease. Early diagnosis and management of risk factors is important to improve outcomes for patients. Mild symptoms can be managed in primary care and community nurses have a role to play in the early detection of PAD, as well as assisting the patient to manage risk factors and optimise best medical therapy. This article provides an overview of the assessment and management of PAD, the importance of appropriate referral and the role of the community nurse.

KEYWORDS: Peripheral arterial disease Risk factors Assessment Management Quality of life

Jane Todhunter

Figure 1.Build up of plaque in the artery (adapted from Delewi et al, 2016).

Decreased blood flow

Artery wall

Plaque formation

1. Cholesterol-rich lipids (fat) infiltrate the epithelium and are deposited within the wall of a blood vessel

2. Smooth muscle cells migrate to the site of the developing plaque, causing a bulge that narrows the lumen of the artery

3. Formation of a connective tissue cap (scar tissue) over the developing plaque

4. Plaque rupture

Artery cross-section Narrowed artery

Normal blood flow

A Normal artery B Atherosclerotic artery

Plaque

PAD is common in the UK and is associated with ageing. Population studies have found that about 20% of people aged over 60 years have some degree of PAD (National Institute for Health and

Care Excellence [NICE], 2018). These high rates of prevalence, combined with the high risk of cardiovascular events, mean that PAD has significant consequences for both patients and healthcare professionals.

SYMPTOMS OF PAD

The symptoms of PAD are as a result of reduced blood flow to the muscles and tissues of the lower limbs. Intermittent claudication is the most common symptom and is experienced as cramping, aching pain in the muscles of the leg brought on by mobilisation and relieved by rest (Scott and Stansby, 2009). The location of the intermittent claudication will be distal to the artery stenosis (Norgren et al, 2007). For example, if the aorta or iliac artery is occluded, pain will be felt in the buttock or thigh, whereas femoral or popliteal artery occlusion will cause calf pain. As the artery narrows and becomes

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occluded, the body will try and compensate for the reduced blood flow to the tissues and muscles by developing a collateral system, rather like small minor roads diverting traffic from a traffic jam on the motorway. However, this may not be sufficient and as the blood supply to the limb deteriorates, the patient may develop critical limb ischaemia with associated rest pain; pain that usually starts in the toes, is worse upon leg elevation and is relieved by hanging the affected foot down out of bed, or by getting up and walking around. Ulcers or gangrene may also develop to the toes and feet (NICE, 2018). Critical limb ischaemia warrants an urgent same day referral to vascular services in the secondary setting for investigation and revascularisation (NICE, 2019).

WHO IS MOST AT RISK OF PAD?

Risk factors for PAD are the same as those for any atherosclerotic disease process. Many are lifestyle related and can be modified by individuals with support from healthcare professionals. These include: Smoking Diabetes Hyperlipidemia Hypertension Obesity Age Genetic predisposition (NICE,

2018).

Smith (2012) suggests that

smoking is the most significant risk factor and is associated with disease progression, increased chance of amputation and early death. Diabetes is also of substantial consequence with every 1% rise in HbA1c associated with a 28% increased risk of PAD (Adler et al, 2002). It is recognised that patients with diabetes have impaired collateral vessel formation, making the feet and lower legs more susceptible to ischaemia and ulceration (Schaper et al, 2012). Indeed, the combined effect of PAD and diabetes is also known to increase the risk of lower limb amputation by up to 15 times (Diabetes UK, 2019a).

Figure 2.Buerger’s sign.

How to measure ABPI (NICE, 2019)

The person should be resting and supine if possible

Record systolic blood pressure with an appropriately sized cuff in both arms and in the posterior tibial, dorsalis pedis and, where possible, peroneal arteries

Take measurements manually using a doppler probe of suitable frequency in preference to an automated system

Document the nature of the doppler ultrasound signals in the foot arteries

Calculate the index in each leg by dividing the highest ankle pressure by the highest arm pressure.

Figure 3.Arterial ulcer.

history, clinical examination and an ankle brachial pressure index (ABPI) measurement. It should be undertaken by a healthcare professional who is familiar with the theoretical basis of ABPI and can interpret the results (Al-Qaisi et al, 2009).

Taking a clinical history will help to differentiate from other conditions with similar symptoms, such as spinal problems or osteoarthritis. The Edinburgh intermittent claudication questionnaire could be used to aid diagnosis (Leng and Fowkes, 1992). NICE (2019) recommends that clinical examination should include: Visual inspection of the legs and

feet for colour — may be pale, mottled or demonstrate Buerger’s sign of pale extremities on elevation changing to rubor on dependency (Figure 2)

Visual inspection of the legs and feet for ulceration or gangrene — ulcers tend to be deep, punched out with a sloughy or pale wound base and located on the feet (Figure 3). Gangrene may affect the toes and heels and may be dry or moist

Feeling the limbs for temperature and palpating femoral, popliteal and ankle pulses

Performing an ABPI.

ABPIAn ABPI is the ratio of the highest ankle systolic pressure out of the dorsalis pedis and posterior tibial artery for each leg, with the highest

‘Assessment of a patient for PAD should include a detailed clinical history, clinical examination and an ankle brachial pressure index (ABPI) measurement.’

ASSESSING PATIENTS FOR PAD

PAD may be asymptomatic and of those who do have symptoms only a third report these symptoms to their doctor, resulting in underdiagnosis and suboptimal treatment (Hirsh et al, 2001). The under-treatment of atherosclerotic disease would be expected to adversely affect clinical outcome, increasing the risk of myocardial infarction (MI) and stroke (Hirsh et al, 2001). Community and general practice nurses are well placed to carry out clinical assessment for PAD and support risk factor modification. NICE (2019) recommends assessing people for PAD if they: Have symptoms suggestive

of PAD Have diabetes, non-healing

wounds on the legs or feet, or unexplained leg pain

Are being considered for interventions to the leg or foot

Need to use compression hosiery.

Assessment of a patient for PAD should include a detailed clinical

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range up to 1.4 and the parameters of arterial disease as per Figure 4.

The quality of the ABPI signal should be commented on, noting if the signals are triphasic, biphasic or monophasic. Healthy triphasic signals indicate the absence of arterial disease, while monophasic signals are abnormal and indicate calcified arteries, which are common in patients with diabetes and may be incompressible (Sibley et al, 2016). Patients who provide a clinical history suggestive of PAD, but have a normal ABPI, should be referred to vascular services for further investigations (Scott and Stansby, 2009).

Baseline blood tests If PAD is diagnosed, it is helpful to have some baseline blood results that will help inform the management plan. Begg et al (2018) suggest that blood should be taken to identify: Diabetes — will increase the risk

of complications of PAD, HbA1c should be optimised

Chronic kidney disease — risk factor for calcified arteries and may impact the choice and dose of drugs prescribed

Biochemistry — liver function tests as a baseline before starting statin therapy

Haematology — anaemia may worsen symptoms of PAD.

MANAGEMENT OF PAD

Aims of management are to improve symptoms, reduce the risk of cardiovascular events and improve quality of life (Thomas, 2017). People with PAD should be given information about their condition so that they can share decision-making, understand the course of the disease and what they can do to help prevent disease progression (NICE, 2019). Patient information can be accessed from websites such as the Circulation Foundation and Legs Matter. Reducing cardiovascular risk will require lifestyle modification with the addition of suitable pharmacology.

ExercisePatients should be offered the

opportunity to take part in a supervised exercise programme, as it is considered a first-line treatment option with the potential to increase maximum walking distance and quality of life (NICE, 2019). This should involve two hours of supervised exercise a week for a three-month period, and encouraging people to exercise to the point of maximal pain. However, the availability of exercise programmes that patients can access can be limited. If supervised exercise is not available, consider suggesting unsupervised exercise using clinical judgement and taking into account the person’s motivation and comorbidities (NICE, 2019). Patients should thus be advised to exercise for approximately 30 minutes three to five times per week, walking until the onset of symptoms, then resting to recover. Patients may find it helpful to maintain an exercise diary, use a step counter, or there may be local walking groups that patients could be signposted towards. Small changes can make a difference, such as parking the car at the furthest away space from the shop entrance, or getting off the bus one stop sooner. It is estimated that even small increases in physical activity for people with PAD can significantly reduce all-cause mortality (Gardner et al, 2008).

However, the difficulty lies in persuading people with PAD to increase walking, as they often have condition-specific barriers as a result of intermittent claudication (Burton et al, 2016). Some patients believe the intense cramp-like pain to be harmful, have low confidence in their walking ability and may feel they have little personal control over health outcomes (Cunningham et al, 2010). Illness and treatment beliefs predict adherence to recommended levels of walking in people with PAD, with adaptive self-management belief being a key target to enable walking among this group (Cunningham et al, 2010). Further research is needed to see if brief behavioural counselling can be effectively delivered by healthcare professionals who are not qualified psychologists (Burton et al, 2016). There may be potential

Calcified vessel

Normal

Mid PAD

Moderate PAD

Severe PAD

0.51–0.69

0.7–0.89

0.9–1.4

> 1.4

≤ 0.5

Vessel disease ABPI

overall brachial pressure, measured on a supine patient resting for at least 10 minutes. It can be measured using a handheld doppler and manual sphygmonanometer, as currently recommended by NICE (2018). However, lack of time and confidence to undertake ABPI assessments has been identified as a key challenge in the care of housebound patients with a leg ulcer (Dowsett and Taylor, 2018). Using an automated machine such as MESI (medi UK), simplifies the process of ABPI measuring and may address some of these issues (Freeman, 2017), facilitating early detection of PAD and appropriate referral to vascular services. As with any diagnostic technology an automated machine can be fallible and should be used in conjunction with full assessment and clinical judgement (Wounds UK 2019).

The normal range of 0.9–1.3 is 95% sensitive and specific for detecting PAD (Al-Qaisi et al, 2009). Sibley et al (2016) classify the normal

Figure 4.Parameters of arterial disease (adapted from Sibley et al, 2016).

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‘Smoking cessation is one of the key lifestyle changes that should be encouraged, as those with PAD who continue to smoke increase their chance of limb amputation.’for community nurses to be able to

support and motivate their patients to maximise exercise intervention for PAD using such an approach.

Smoking cessation Smoking cessation is one of the key lifestyle changes that should be encouraged, as those with PAD who continue to smoke increase their chance of limb amputation (NICE, 2018). Patients should be signposted to local smoking cessation services with the knowledge that stopping smoking can increase walking distances by 2–3-fold in 85% of people (Scott and Stansby, 2009).

Weight loss and healthy eatingBody mass index (BMI) should be recorded, and patients signposted to weight management if obese or overweight (Begg et al, 2018). NHS (2019) defines the following parameters as a risk factor for cardiovascular disease: BMI of 25 or above Man with a waist measurement

of 94cm (about 37 inches) or more

Woman with a waist measurement of 80cm (about 31.5 inches) or more.

NHS (2019) dietary advice for reducing cardiovascular risk factors includes: Low levels of saturated fat

(found in foods such as fatty

cuts of meat, lard, cream, cakes and biscuits) — try to include healthier sources of fat, such as oily fish, nuts and seeds, and olive oil

Low levels of salt — aim for less than 6g (0.2oz or 1 teaspoon) a day

Low levels of sugar Plenty of fibre and

wholegrain foods Plenty of fruit and vegetables —

eat at least five portions of fruit and vegetables a day

Avoid excess alcohol.

various antihypertensive drugs in people with PAD, so it is unknown whether significant benefits or risks accrue from their use (Lane and Lip, 2013). However, this lack of data specifically examining outcomes in patients with PAD should not detract from the compelling evidence of the benefit of treating hypertension and lowering blood pressure as part of a secondary cardiovascular risk reduction plan (Lane and Lip, 2013).

Diabetes UK (2019b) report the risk of cardiovascular disease to be more than four times higher for people with type 1 diabetes and 2.5 times higher for people with type 2 diabetes than for non-diabetics. Any reduction in HbA1c is likely to reduce the risk of cardiovascular disease and complications with the lowest risk being in those with HbA1c values in the normal range (Stratton, 2000).

Weight reduction can reduce HbA1c which, in turn, reduces the risk of PAD (Adler et al, 2002). Thus, lifestyle modification advice should also include weight management and healthy eating choices.

Patients should receive antiplatelet agents to prevent the progression of PAD and reduce cardiovascular risk (CAPRIE Steering Committee, 1996). The CAPRIE study (1996) recommended clopidogrel 75mg in favour over aspirin 325mg, due to increased gastrointestinal bleeds in the aspirin group. However, the usual dose of aspirin is 75mg, which somewhat reduces the applicability of results. Nevertheless, the recommendation by NICE (2018) is clopidogrel 75mg as first-line therapy, with aspirin 75mg as second-line.

Referral First-line management of PAD should always be maximising best medical therapy and a supervised exercise programme. However, if this approach fails to improve symptoms and the patient’s quality of life is adversely affected, NICE (2018) recommends referral to vascular services for endovascular intervention as the first choice

Red Flag Critical limb ischaemia

If the patient has: Rest pain Ulceration of toes and/or feetDry gangrene of toes and/

or feet.Warrants urgent referral to vascular team for urgent outpatient appointment.

If patient has:Uncontrolled rest painDeep infectionWet spreading gangrene Rapid progression of symptoms.Warrants an urgent admission to hospital under the vascular team.

Pharmacological modifiable cardiovascular risk factorsOther risk factors that should be addressed are control of lipids, hypertension, diabetes and antiplatelet therapy (NICE, 2019). Statin therapy is recommended for all patients with PAD, even if they have a normal cholesterol level based on the outcome from the Heart Protection Collaborative Study Group (2002). However, this is less frequently prescribed to patients with PAD than those with cardiac disease (Smith, 2012). The recommendation from NICE (2019) is to start statin treatment in people with cardiovascular disease with atorvastatin 80mg, but use a lower dose of atorvastatin if there are potential drug interactions, a high risk of adverse effects, or patient preference. Some patients may query the need for statins especially if they have a ‘normal’ lipid profile, so it is important that healthcare professionals have the knowledge and expertise to explain the risks and benefits related to PAD disease and statin use.

Around 35–55% of patients who present with PAD also show hypertension (Clement et al, 2004). There is a lack of evidence on

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opportunity to diagnose PAD through routine assessment of leg ulcers, compression hosiery assessments and when patients complain of intermittent leg pain. A patient history incorporating the Edinburgh Intermittent Claudication Questionnaire combined with a physical examination, including ABPI measurement, will provide a reliable diagnosis. Risk factors for PAD need to be as aggressively managed as they are for other cardiovascular conditions, such as MI and stroke. Patients who fail to respond to best medical therapy should be referred to the vascular team, and those who develop critical limb ischaemia warrant urgent referral.

causal indicators of quality of life (Burckhardt and Anderson, 2003). An alternative would be the EQ-5D which is a standardised instrument developed by the EuroQol Group as a measure of health-related quality of life that can be used in a wide range of health conditions and treatments (EQ-5D, 2019). Euroqol questionnaire is an abbreviated instrument that can be answered quickly. It consists of a questionnaire that classifies the patient into five health domains with three levels, plus a visual analogue scale (VAS) on which patients can rate their own health between 0 and 100. It could be used to measure initial quality of life at presentation/diagnosis of PAD, and at subsequent visits to quantify the impact of best medical therapy and exercise.

ROLE OF THE COMMUNITY AND GENERAL PRACTICE NURSE

PAD can be asymptomatic and is underdiagnosed (Thomas, 2017). Community nurses are well placed to diagnose PAD when carrying out leg ulcer assessments that include ABPI, or when assessing non-symptomatic patients for compression therapy. Individuals with PAD face a considerable challenge with behaviour change regarding exercise, weight loss, smoking cessation and healthy eating, and may benefit from ongoing support and behavioural counselling from healthcare professionals. Community and general practice nurses could provide education, health promotion and monitor symptoms with annual surveillance.

CONCLUSION

PAD is a common chronic atherosclerotic syndrome that is associated with reduced quality of life and a high risk of MI, stroke and death. It is both undertreated and underdiagnosed, adversely affecting clinical outcomes (Hirsch et al, 2001).

Community nursing staff and general practice nurses have an

of treatment. If the patient does not wish to be considered for intervention, the vasodilator naftidrofuryl oxalate could be considered for 3–6 months, but stopped if no symptomatic benefit is seen in that time (NICE, 2018).

IMPACT ON QUALITY OF LIFE

PAD is a chronic disease that can have a significant impact on patient quality of life (Burton et al, 2016). Maximal walking capacity in people with PAD is less than 50% of that in age match controls, and the functional limitations are similar to those seen in people with severe heart failure (Askew et al, 2013). The tendency is to avoid walking and related activities, which affects daily activities of living and constrains social and role functioning resulting in a reduced quality of life (Oka et al, 2004).

A quality of life measuring tool could be used to monitor the impact of PAD. The Quality of Life Scale (QOLS) is a valid instrument for measuring quality of life across patient groups with chronic illness and is conceptually distinct from health status or other

KEY POINTS Peripheral arterial disease (PAD)

is the narrowing or blockage of the lower limb arteries as a result of atherosclerosis, resulting in reduced blood flow to the muscles and tissues.

Risk factors for PAD are the same as those for any atherosclerotic disease process. Many are lifestyle related and can be modified by individuals with support from healthcare professionals.

Assessment of a patient for PAD should include a detailed clinical history, clinical examination and an ankle brachial pressure index (ABPI) measurement.

Aims of management are to improve symptoms, reduce the risk of cardiovascular events and improve quality of life.

People with PAD should be given information about their condition so that they can share decision-making, understand the course of the disease and what they can do to help prevent disease progression.

Patients who fail to respond to best medical therapy should be referred to the vascular team, and those who develop critical limb ischaemia warrant urgent referral.Having read this article,

reflect on:

Your knowledge of peripheral arterial disease

How to interpret ankle-brachial pressure index (ABPI) measurements

Health promotion advice you can offer your patients with PAD

The impact PAD can have on patient quality of life.

Then, upload the article to the free JCN revalidation e-portfolio as evidence of your continued learning: www.jcn.co.uk/revalidation

RevalidationAlert

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