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Atherosclerosis & Intermittent Claudication
by Dr Panayiotopoulos, Consultant Vascular and General Surgeon Essex.

Atherosclerosis

1. What is atherosclerosis?

It is a progressive disease of the arteries [vessels that carry blood] which starts the day we are born and stops the day we die. However, it may vary from an extremely slow to an aggressive disease. It is not a degenerative disease as most people feel. The arteries become hardened [sclerosis] and narrow, so the blood that flows through them decreases. It is similar to the lime scale that forms in water pipes.

Atherosclerosis

·  Is more or less a generalized disease - albeit patchy in condition.

·   It may affect any vessel in the body, like the heart vessels, the arteries that supply the brain and the leg arteries.

·    The leg arteries are the ones more frequently affected, followed by the arteries that supply the brain

2. What does atherosclerosis cause?

In many patients this decrease in blood flow causes little trouble, as the narrowing is not significant. As the course of atherosclerosis is extremely slow, the serious event is usually preceded -years in advance- by small signs and symptoms of ischaemia [inadequate blood supply], like angina, mini strokes or intermittent claudication [pain on walking]. Only rarely the first event is dramatic - a stroke or sudden death. However, very few people reach “old age” without a potentially dangerous degree of atherosclerosis. Half of all deaths are caused by circulatory problems, the basis of which is atherosclerosis.

3. Who is affected by atherosclerosis?

Men are much more likely to be affected by atherosclerosis than women. Women’s protection weans off with age, the disease increasing rapidly after menopause, and by “old age” the risks are similar in both sexes. At any age the protection is wiped out by diabetes.

Atherosclerosis

The symptoms depend on the extent and the level of blockage

·    Narrowings may cause mild or no symptoms

·    Short blockages may cause mild symptoms

·    Blockages at two levels will cause moderate symptoms

·     Long blockages at two levels usually cause severe symptoms

·    With blockages at 3 levels and especially when the calf vessels are affected, the leg may be threatened.

The simple answer is that all people are affected by the disease and everyone is at risk of developing symptoms, however, some are much more than others. Even those with the lowest risk are more likely to die from cardiovascular causes, but they will get the disease later in life.

4. What is the cause of atherosclerosis?

There isn’t any single cause for arterial disease. It is more likely to be caused by a combination of factors, amongst which the wear and tear effect, the genetic [inherited, familial] predisposition and the high concentration of low density lipoproteins in the blood, reflecting the high intake of saturated fat in the diet are the most prominent.

Although we do not know what actually initiates atherosclerosis, we know a lot of factors which accelerate it [risk factors]:

.  High blood cholesterol [a specific fat substance] concentration. The normal levels should be less than 5mmol/lt. Unfortunately, in most middle aged people is above 6.3mmol/l. Reducing the cholesterol levels in the blood reduces significantly the risk of cardiovascular death.

.   High blood pressure. People with diastolic [the low reading] blood pressure more than 85mmHg are at risk of developing symptoms attributable to atherosclerosis at an earlier age and also show a higher risk of cardiovascular death.

.   Diabetes. People with diabetes develop atherosclerosis at an earlier stage and is quite often dramatic. Diabetes affects the small vessels in the legs and the kidney in particular and quite often the damage is not only irreversible but often not even reconstructable.

.   Diet containing high quantities of fat [especially saturated, animal fat].

.  Smoking. It causes spasm of the arteries, makes the blood sticky [thrombotic effect] and accelerates the effect of all other risk factors [apart from causing lung cancer as well]. The number of cigarettes smoked seems less important than the mere fact of smoking.

SMOKING

·    The incidence of arterial disease with blockages increases by :

·    50% in people who smoke 15 cigarettes daily

·    100% when the number of cigarettes is more than 35

About 5-14% of patients will develop severe symptoms within 5 years of diagnosis.

.  Combination of risk factors. These combinations cause the most problems. Most vascular diseases are caused by such combinations, because the arteries stand reasonably well to one risk factor in isolation. The risk of heart attack is trebled if the patient smokes, has a serum cholesterol of 6mmol/l and has a diastolic blood pressure greater than 85mmHg.

5. What can I do against atherosclerosis?

There isn’t much you can do to avoid the disease; however, there is much you can do to slow it down.

.   Stop smoking

.   Have regular exercise

.   Change your diet. Eat whatever flies [poultry, etc.], swims [fish], drops [fruit] or grows [wheat, vegetables]. Avoid animal fat. Red wine is also helpful. It is better to have more frequent and small rather than a single large meal.

.   Lower your cholesterol. Walking and regular exercise is the best means to reduce the cholesterol and increase the beneficial cholesterol called HDL. If your blood cholesterol level is high and cannot be brought to normal by strict diet, your doctor may prescribe some specific drugs [simvastatin, pravastatin, etc.].

.   Look after your blood pressure.

.   Take a small dose of aspirin [75-150mg] daily. Affects the platelets, an essential factor in atherosclerosis, reducing the overall risk by 25%.

.   Take good care of your feet; avoid injuries and infection.

.   Consult your doctor early if you develop symptoms.

Intermittent Claudication

1. What is intermittent claudication?

As atherosclerosis has progressed, it causes either a narrowing or a blockage in the arteries taking blood to your leg. Over the years, cholesterol and calcium build up inside the arteries like lime scale. The muscles get oxygen and food from the blood, therefore, when walking, the demands for blood are higher. Because of the blockage, the muscles are deprived from blood and send a signal [pain] to make it understood. This pain you feel on your legs making you limp is called claudication. It appears on exercise and eases off if you stop for some minutes. You are then able to continue walking, but the cramping pain will come back after a while.

Doppler measurement of ankle pressures

·    In normal cases the pressure measured at the ankle by ultrasound  is the same as the arm blood pressure [ratio AP/BP = 1.0]

·    In patients with blockages is less than 1, <0.8 in mild claudication, <0.6 in severe, < 0.4 in critical

The functional effect of the blockages can be easily checked by measuring the blood pressure at your ankle [a quick and painless test done by your specialist].

Occasionally more sophisticated tests may be needed to establish the position of the blockages, like a Quick-Scan, Duplex Ultrasound or even arteriography.

2. Does the blockage ever clear itself?

No, unfortunately not, but the situation can improve due to opening up of smaller arteries [collateral circulation] which carry blood around the block. Many people notice some improvement, as the collateral circulation opens up, within six to eight weeks of the onset of claudication.

3. What is the prognosis and how is it going to be in a year’s time?

The prevalence of intermittent claudication depends on age. Is very low for people under the age of 60, but increases with age [2.4% for people 60-70 years]. Less than 10 % of patients with lower limb atherosclerosis have intermittent claudication and only 10 % of patients with intermittent claudication are under the care of a doctor. The future [prognosis] is generally good for the limb but poor for the patient as a whole. As atherosclerosis affects not only the leg but also the heart and the brain vessels, there is a higher risk of cardiovascular death [myocardial infarction or stroke]. The average annual risk of death is 5%.

Less than 10% of patients referred to a vascular surgeon will progress to critical limb ischaemia, a condition in which the limb is threatened. However, in up to 60% of patients deterioration will occur in 2-3 years. Within a year, 2% of patients with claudication will require a major amputation and 6% will require surgical or radiological intervention for deteriorating ischaemia.

4. How can I help myself?

There are several things you can do which may help. The most important is to stop smoking, take regular exercise and lose weight.

.  Smoking. If you are a smoker you must make a sincere and determined effort to give up completely. Firstly, it speeds up hardening of the arteries [atherosclerosis] which is the basic cause of trouble and secondly, cigarette smoke causes spasm of the small collateral vessels, reducing thus further the amount of blood and oxygen delivered to the muscles.

The best way to give up is to choose a day when you are going to stop completely  rather than trying to cut down gradually. If you do have trouble giving up please ask your doctor who can give you advice on nicotine gum and patches or put you in touch with a support group. Unfortunately, although many patients cut smoking down, only 30% give it up completely.

.   Diet. It is very important not to put on weight, because the more weight the legs have to carry around  the more blood they will need. Your doctor or dietitian will give you advice with regard to weight reducing diet. If your blood cholesterol is high you will need a low fat diet and may also require cholesterol lowering drugs.

.  Exercise. There is good evidence that people who take regular exercise [walking at a regular pace until pain comes on, then stopping and continue again when the pain disappears] develop a better collateral circulation. Try to make it a little further each day and you will almost certainly find that the distance you can manage without pain slowly but steadily increases. Regular exercise for at least 6 months has been shown to improve the claudication distance [distance you are able to walk without pain] by 180% and the maximum walking distance by 120%.

.   Blood pressure. If you have a high blood pressure it is important that this is well controlled by tablets. You should have regular checks by your GP.

Treating Claudication in 50 words.

·         Stop smoking and keep walking

·         Take an anti-platellet agent [Aspirin, ticlopidine or clopidogrel]

·         Lower blood pressure over 140/90mmHg

·         Lower cholesterol over 5.5 mmol/l

·         Diet [low fat, calories, salt]

·         Loose weight [especially if obese and hypertensive]

·         Exercise

·         Drugs

·         Fibrate which lowers fibrinogen

[e.g. bezafibrate, ciprofibrate, fenofibrate]

·         Statins

[e.g. simvastatin, pravastatin, etc.]

5. What about treatment?

·         Most people with intermittent claudication do not require surgery.

The conservative treatment [summarised in the previous table] suffices in the majority of the cases.

·         However if your symptoms are severe [claudication distance less than 100m] and make your life difficult, or if they do not improve with the conservative treatment, further treatment may be necessary.

·         An x-ray of the arteries [arteriogram] is usually performed first to see what can be done. Short blockages can be stretched open with a balloon [angioplasty] in the x-ray department. This is usually done under local anaesthesia and often involves an overnight stay in the hospital.

·         Longer blockages can be bypassed using either a plastic tube or a vein from your leg [bypass graft]. This is a major operation under general anaesthesia and involves being in the hospital for about a week to ten days.

The decision about surgery is usually one for you to make yourself after your specialist Vascular Surgeon has explained the likelihood of success and the risks involved. There is an overall risk of 1% of surgery threatening your limb after failure, plus the risk of surgery and anaesthesia. However, on average, these grafts remain open in 70% of patients for 5-10 years. Angioplasty has a lower overall risk, however the long term result is not as good as surgery. Only 50% of balloon stretched arteries are open after 12 months and the blockage rate is 10-15% per year afterwards. More detailed information about these procedures is also available - please ask your specialist.

·         The exact place of surgery and angioplasty in people with less severe claudication is unclear at present. The risk of surgery and / or angioplasty should be balanced against your overall benefit. However, there is evidence that early intervention is beneficial as the policy to intervene only on patients with severe short distance claudication has a number of potential drawbacks:

1) It may be too late

2) It may prejudice the outcome

3)  The patients quality of life is reduced

We are conducting a trial to assess this and also the effect of fat in claudication. You may be asked to participate in this trial.

6. Do drugs help?

Although there are quite a number of proprietary tablets and drugs on the market [vasodilators, haemorrheological agents etc.] there is very little evidence that they will actually help - drugs will not unblock the artery. Perhaps your doctor has already tried one of these drugs in your case, so that you can judge for yourself.

·    Aspirin is the only drug that has a beneficial effect and is usually prescribed in small doses [75-150mg per day]. It makes the blood less sticky and lowers the risk of heart attack and strokes.

·    A variety of similar drugs can be used, especially if aspirin causes side-effects.

·    Drugs to reduce your cholesterol may be necessary if all the other measures to control it fail.

7. What is the risk of losing my leg?

Very few patients with intermittent claudication end up with an amputation and your specialist will make every effort to avoid it. Within a year the risk of amputation is 2% and the risk of developing a complication that will necessitate urgent intervention is 5-10%.

The majority of people with claudication develop no problems and the condition may stay the same for years if you look after yourself and follow medical advice.

The most important thing is that you improve your lifestyle - keep walking, lose weight and stop smoking!

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Please note:
A written referral from a general practitioner is helpful but is not essentially required in order to make an appointment to see a consultant specialist.

 

This page was last updated on 01/10/2006

Vascualr surgeon for varicose veins, renal and general surgical conditions and procedures