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{{Peripheral arterial disease}} | {{Peripheral arterial disease}} | ||
''' | {{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}, [[User:Rim Halaby|Rim Halaby]] | ||
==Overview== | |||
The risk factors associated with [[peripheral artery disease]] are similar to those associated with [[coronary artery disease]]. They can be classified as traditional and non traditional. Another way to classify the risk factors is depending on their level of risk: high risk factors (tobacco and [[diabetes]]), moderate risk factors ([[hypertension]] and hyperhomocysteinemia) and low risk factors ([[hypercholesterolemia]]). Some risk factors are modifiable, like [[hypertension]], whereas others are not. | |||
==Risk Factors== | |||
===Traditional Risk Factors=== | |||
====Advanced Age==== | |||
*The [[prevalence]] of PAD increases with age. | |||
*The risk for lower-extremity [[peripheral arterial disease]] varies with age depending on other co-existing risk factors: | |||
**Age less than 50 years: | |||
***Risk factors: diabetes and one other atherosclerosis risk factor ([[smoking]], [[dyslipidemia]], [[hypertension]], or [[hyperhomocysteinemia]]). | |||
**Age 50 to 69 years: | |||
***Risk factors: smoking or [[diabetes]]. | |||
**Age 70 years and older: | |||
***Risk factors: similar to other atherosclerotic diseases. | |||
*Younger patients with PAD tend to have poorer overall long-term outcomes, as well as a higher number of failed bypass surgeries leading to amputation, compared with their older counterparts.<ref name="Spittel">Spittel P. Chapter 44. Peripheral vascular Disease. In Murphy J, Lloyd M. Mayo Clinic Cardiology Concise Textbook. Fourth edition.Mayo clinic scientific press.2013</ref> | |||
====Cigarette Smoking==== | |||
*[[Cigarette smoking]] is the single most modifiable risk factor for the development of PAD; in fact, smoking increases the risk of PAD 4-fold and accelerates the onset of PAD symptoms by nearly a decade. | |||
**The association between smoking and PAD is about twice as strong as that between smoking and [[coronary artery disease]]. | |||
**An apparent dose-response relationship exists between the pack-year history and PAD risk. | |||
*Compared with their nonsmoking counterparts, smokers with PAD have poorer survival rates and are more likely to progress to critical limb ischemia, and twice as likely to progress to amputation, and also have reduced arterial bypass graft patency rates. | |||
*Individuals who are able to stop smoking are less likely to develop rest pain and have improved survival.<ref name="Spittel">Spittel P. Chapter 44. Peripheral vascular Disease. In Murphy J, Lloyd M. Mayo Clinic Cardiology Concise Textbook. Fourth edition.Mayo clinic scientific press.2013</ref> | |||
====Diabetes Mellitus==== | |||
*[[Diabetes mellitus]] confers a 1.5-fold to 4-fold increase in the risk of developing symptomatic or asymptomatic PAD and is associated with an increased risk of cardiovascular events and early mortality among individuals with PAD. | |||
**[[Diabetes]] is a stronger risk factor for PAD in women than in men. | |||
**The prevalence of PAD is higher in African Americans and Hispanics with diabetes than in non-Hispanic whites with diabetes. | |||
*In patients with [[diabetes]], the prevalence and extent of PAD also appears to correlate with the age of the individual and the duration and severity of his or her diabetes. | |||
**There is a 28% increase of PAD for every percentage-point increase in [[hemoglobin A1c]]. | |||
*PAD prevalence is also increased in individuals with impaired glucose tolerance. | |||
=====The Presentation of PAD in Patients with Diabetes Mellitus===== | |||
*Late, progressive and more severe presentation as a result initial asymptomatic nature of PAD in diabetics | |||
*Occlusive disease in the tibial arteries | |||
*Impaired wound healing due to microangiopathy and neuropathy | |||
*Higher risk for ischemic ulceration and gangrene.<ref name="Spittel">Spittel P. Chapter 44. Peripheral vascular Disease. In Murphy J, Lloyd M. Mayo Clinic Cardiology Concise Textbook. Fourth edition.Mayo clinic scientific press.2013</ref> | |||
=====Additional Risk Factors Usually Present in Patients with Diabetes Mellitus===== | |||
*Abnormalities in vascular smooth muscle cells | |||
*Endothelial cell dysfunction | |||
*[[Elevated blood pressure]] | |||
*Impaired fibrinolytic function | |||
*Increased levels of [[triglycerides]], [[cholesterol]], and other blood lipids | |||
*Increased vascular inflammation | |||
*Increased in platelet aggregation | |||
*Tobacco use | |||
====Dyslipidemia==== | |||
*Elevations in total cholesterol, LDL cholesterol, very low-density lipoprotein (VLDL) cholesterol, and triglycerides are all independent risk factors for PAD. | |||
**There is 10% increased risk of developing PAD for every 10-mg/dL rise in total cholesterol. | |||
*Elevations in [[high-density lipoprotein]] (HDL) cholesterol and [[apolipoprotein A-I]] appear to be protective | |||
*The form of dyslipidemia seen most frequently in patients with PAD is the combination of a reduced HDL cholesterol level and an elevated triglyceride level (commonly present in patients with the [[metabolic syndrome]] and [[diabetes]]).<ref name="Spittel">Spittel P. Chapter 44. Peripheral vascular Disease. In Murphy J, Lloyd M. Mayo Clinic Cardiology Concise Textbook. Fourth edition.Mayo clinic scientific press.2013</ref> | |||
====Hypertension==== | |||
*[[Hypertension]] has been reported in as 50-92% of patients with PAD. | |||
*Patients with PAD and hypertension are at greatly increased risk of [[stroke]] and [[myocardial infarction]] independently of other risk factors. | |||
===Nontraditional Risk Factors=== | |||
====Race/Ethnicity==== | |||
*PAD has been shown to be disproportionately prevalent in black and Hispanic populations | |||
====Chronic Kidney Disease==== | |||
*There is an association between PAD and chronic kidney disease independently from diabetes, [[hypertension]], ethnicity and age. This association might be related to the increased vascular inflammation and markedly elevated plasma [[homocysteine]] levels seen in chronic kidney disease. | |||
*The prevalence of an abnormal ABI (< 0.90) is much higher in patients with end-stage renal disease than in those with chronic kidney disease, ranging between 30% and 38%. | |||
====Genetics==== | |||
*Genetic predisposition to PAD is supported by observations of increased rates of cardiovascular disease (including PAD) in "healthy" relatives of patients with intermittent claudication. | |||
*To date, no major gene for PAD has been detected. | |||
== | ====Hypercoagulable States==== | ||
*Hypercoagulable state, caused by altered levels of [[D-dimer]], [[homocysteine]] or [[lipoprotein a]], is an uncommon risk factor for PAD. | |||
*Hepercoagulable state is suspected in younger persons who lack traditional risk factors, patients with a strong family history of premature atherosclerosis, and individuals in whom arterial revascularization fails for no apparent technical reason. | |||
**[[Hyperhomocysteinemia]] is associated with premature atherosclerosis and appears to be a stronger risk factor for PAD than for CAD.<ref name="Spittel">Spittel P. Chapter 44. Peripheral vascular Disease. In Murphy J, Lloyd M. Mayo Clinic Cardiology Concise Textbook. Fourth edition.Mayo clinic scientific press.2013</ref> | |||
== | ====Abnormal Waist-to-Hip Ratio==== | ||
*An association between abdominal [[obesity]] and PAD has been reported, although it is unclear whether any association exists between PAD and [[body mass index]] ([[BMI]]) | |||
*The lack of association between PAD and BMI can be explained by the tendency of smokers (those at an increased risk for PAD) have lower BMIs than nonsmokers. Also, many of the individuals at risk for PAD are elderly males, who generally have lower BMIs as well. | |||
==References== | ==References== | ||
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[[Category:Peripheral Arterial Disease]] | [[Category:Peripheral Arterial Disease]] | ||
Latest revision as of 18:36, 6 October 2020
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Peripheral arterial disease Microchapters |
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Differentiating Peripheral arterial disease from other Diseases |
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Diagnosis |
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Treatment |
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Case Studies |
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AHA/ACC Guidelines on Management of Lower Extremity PAD |
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Guidelines for Structured Exercise Therapy for Lower Extremity PAD |
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Guidelines for Minimizing Tissue Loss in Lower Extremity PAD |
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Guidelines for Revascularization of Claudication in Lower Extremity PAD |
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Guidelines for Management of Acute Limb Ischemial in Lower Extremity PAD |
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Guidelines for Longitudinal Follow-up for Lower Extremity PAD |
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Peripheral arterial disease risk factors On the Web |
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American Roentgen Ray Society Images of Peripheral arterial disease risk factors |
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Directions to Hospitals Treating Peripheral arterial disease |
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Risk calculators and risk factors for Peripheral arterial disease risk factors |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2], Rim Halaby
Overview
The risk factors associated with peripheral artery disease are similar to those associated with coronary artery disease. They can be classified as traditional and non traditional. Another way to classify the risk factors is depending on their level of risk: high risk factors (tobacco and diabetes), moderate risk factors (hypertension and hyperhomocysteinemia) and low risk factors (hypercholesterolemia). Some risk factors are modifiable, like hypertension, whereas others are not.
Risk Factors
Traditional Risk Factors
Advanced Age
- The prevalence of PAD increases with age.
- The risk for lower-extremity peripheral arterial disease varies with age depending on other co-existing risk factors:
- Age less than 50 years:
- Risk factors: diabetes and one other atherosclerosis risk factor (smoking, dyslipidemia, hypertension, or hyperhomocysteinemia).
- Age 50 to 69 years:
- Risk factors: smoking or diabetes.
- Age 70 years and older:
- Risk factors: similar to other atherosclerotic diseases.
- Age less than 50 years:
- Younger patients with PAD tend to have poorer overall long-term outcomes, as well as a higher number of failed bypass surgeries leading to amputation, compared with their older counterparts.[1]
Cigarette Smoking
- Cigarette smoking is the single most modifiable risk factor for the development of PAD; in fact, smoking increases the risk of PAD 4-fold and accelerates the onset of PAD symptoms by nearly a decade.
- The association between smoking and PAD is about twice as strong as that between smoking and coronary artery disease.
- An apparent dose-response relationship exists between the pack-year history and PAD risk.
- Compared with their nonsmoking counterparts, smokers with PAD have poorer survival rates and are more likely to progress to critical limb ischemia, and twice as likely to progress to amputation, and also have reduced arterial bypass graft patency rates.
- Individuals who are able to stop smoking are less likely to develop rest pain and have improved survival.[1]
Diabetes Mellitus
- Diabetes mellitus confers a 1.5-fold to 4-fold increase in the risk of developing symptomatic or asymptomatic PAD and is associated with an increased risk of cardiovascular events and early mortality among individuals with PAD.
- Diabetes is a stronger risk factor for PAD in women than in men.
- The prevalence of PAD is higher in African Americans and Hispanics with diabetes than in non-Hispanic whites with diabetes.
- In patients with diabetes, the prevalence and extent of PAD also appears to correlate with the age of the individual and the duration and severity of his or her diabetes.
- There is a 28% increase of PAD for every percentage-point increase in hemoglobin A1c.
- PAD prevalence is also increased in individuals with impaired glucose tolerance.
The Presentation of PAD in Patients with Diabetes Mellitus
- Late, progressive and more severe presentation as a result initial asymptomatic nature of PAD in diabetics
- Occlusive disease in the tibial arteries
- Impaired wound healing due to microangiopathy and neuropathy
- Higher risk for ischemic ulceration and gangrene.[1]
Additional Risk Factors Usually Present in Patients with Diabetes Mellitus
- Abnormalities in vascular smooth muscle cells
- Endothelial cell dysfunction
- Elevated blood pressure
- Impaired fibrinolytic function
- Increased levels of triglycerides, cholesterol, and other blood lipids
- Increased vascular inflammation
- Increased in platelet aggregation
- Tobacco use
Dyslipidemia
- Elevations in total cholesterol, LDL cholesterol, very low-density lipoprotein (VLDL) cholesterol, and triglycerides are all independent risk factors for PAD.
- There is 10% increased risk of developing PAD for every 10-mg/dL rise in total cholesterol.
- Elevations in high-density lipoprotein (HDL) cholesterol and apolipoprotein A-I appear to be protective
- The form of dyslipidemia seen most frequently in patients with PAD is the combination of a reduced HDL cholesterol level and an elevated triglyceride level (commonly present in patients with the metabolic syndrome and diabetes).[1]
Hypertension
- Hypertension has been reported in as 50-92% of patients with PAD.
- Patients with PAD and hypertension are at greatly increased risk of stroke and myocardial infarction independently of other risk factors.
Nontraditional Risk Factors
Race/Ethnicity
- PAD has been shown to be disproportionately prevalent in black and Hispanic populations
Chronic Kidney Disease
- There is an association between PAD and chronic kidney disease independently from diabetes, hypertension, ethnicity and age. This association might be related to the increased vascular inflammation and markedly elevated plasma homocysteine levels seen in chronic kidney disease.
- The prevalence of an abnormal ABI (< 0.90) is much higher in patients with end-stage renal disease than in those with chronic kidney disease, ranging between 30% and 38%.
Genetics
- Genetic predisposition to PAD is supported by observations of increased rates of cardiovascular disease (including PAD) in "healthy" relatives of patients with intermittent claudication.
- To date, no major gene for PAD has been detected.
Hypercoagulable States
- Hypercoagulable state, caused by altered levels of D-dimer, homocysteine or lipoprotein a, is an uncommon risk factor for PAD.
- Hepercoagulable state is suspected in younger persons who lack traditional risk factors, patients with a strong family history of premature atherosclerosis, and individuals in whom arterial revascularization fails for no apparent technical reason.
- Hyperhomocysteinemia is associated with premature atherosclerosis and appears to be a stronger risk factor for PAD than for CAD.[1]
Abnormal Waist-to-Hip Ratio
- An association between abdominal obesity and PAD has been reported, although it is unclear whether any association exists between PAD and body mass index (BMI)
- The lack of association between PAD and BMI can be explained by the tendency of smokers (those at an increased risk for PAD) have lower BMIs than nonsmokers. Also, many of the individuals at risk for PAD are elderly males, who generally have lower BMIs as well.