You are in: eMedicine Specialties > Physical Medicine and Rehabilitation > MEDICAL DISEASES Vascular Diseases and RehabilitationArticle Last Updated: Nov 21, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Gianna M Rodriguez, MD, Instructor, Department of Physical Medicine and Rehabilitation, University of Michigan Health System Gianna M Rodriguez is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Paraplegia Society, American Spinal Injury Association, International Spinal Cord Society, and Philippine Medical Association Coauthor(s): Brian M Kelly, DO, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Michigan Medical School; Assistant Program Director, Residency Training Program, Consulting Staff, Service Chief 6A, Inpatient Rehabilitation Services, University of Michigan Health System; M Catherine Spires, MD, Associate Professor, Associate Chair, Program Director of Residency Training Program, Department of Physical Medicine and Rehabilitation, University of Michigan Health System; Charlie C Huynh, MD, Rehabilitation Associates of Nevada, Summerlin Hospital; Percival H Pangilinan Jr, MD, Clinical Instructor and Consulting Staff, Department of Physical Medicine and Rehabilitation, University of Michigan Health System Editors: Robert J Kaplan, MD, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Kansas School of Medicine and Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Richard Salcido, MD, Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine; Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center; Denise I Campagnolo, MD, MS, Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St. Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers, Phoenix Author and Editor Disclosure Synonyms and related keywords: peripheral vascular disease, PVD, peripheral artery disease, claudication, coronary artery disease, CAD, cardiovascular rehabilitation, peripheral arterial occlusive disease, PAOD BACKGROUNDSection 2 of 10
  Cardiovascular disease is, without question, the current leading cause of morbidity and premature deaths of modern era medicine. Approximately 14 million people in the United States have a history of myocardial infarction (MI), angina pectoris, or both, while the annual incidence is reported at 1.5 million cases. Many of the risk factors for coronary artery disease are applicable to patients with peripheral vascular disease (PVD), as both are manifestations of atherosclerotic disease. As many as two thirds of patients with a clinically significant cardiovascular event have an incomplete recovery, and it is in this patient population that physical, psychosocial, and vocational rehabilitation can have a positive bearing on morbidity and mortality. Patients with PVD can be assured that less than one third of patients require any surgical or radiologic intervention. Approximately 4-8% of PVD patient result in amputation. However, this fact should not minimize the statistical data showing that patients with symptomatic PVD have at least a 30% risk of death from MI or cerebrovascular disease within 5 years and a risk of approximately 50% in 10 years. PVD is an independent risk factor for cardiovascular death. Approximately 50% of patients presenting with PVD have additional symptoms related to coronary artery disease (CAD), with 90% likely to have abnormalities on coronary angiography and 40% with carotid artery disease on Duplex sonography. Progressive symptomatic PVD requiring surgical intervention more than doubles a patient's risk for cardiovascular events. For excellent patient education resources, visit eMedicine's Circulatory Problems Center. Also, see eMedicine's patient education article Peripheral Vascular Disease. ETIOLOGYSection 3 of 10
Systemic manifestation of arteriosclerosis commonly manifests as peripheral arterial occlusive disease (PAOD), and it is most common in older individuals and disproportionately affects African Americans. PAOD develops earlier in men than in women. Rates of PAOD increase with age, with estimates of 1-2.5% in individuals aged 50-60 years and 5-9% in those older than 65 years. Causes of arterial occlusive disease include thrombosis, embolism, dissection, atherosclerosis obliterans, vasculitis, vasospastic disorders, fibromuscular dysplasia, and thromboangiitis obliterans. Peripheral arterial occlusion of the extremities often results from atherosclerotic plaques (atheromas), thrombi, or emboli. Such occlusions manifest as acute or chronic ischemia. Intermittent claudication is the most common initial symptom. Most patients present with occlusive disease in the femoropopliteal vessels, and 40% have stenosis in the distribution of the tibioperoneal artery. Nearly one third have disease in the aorta or iliac arteries. Further division occurs in patients with diabetes melitis (DM). The vessels most commonly affected in patients with DM are the femoral and tibial arteries; in contrast, the abdominal aorta and the iliac and femoral arteries are most often affected in patients without DM. Acute ischemia is often a consequence of a ruptured proximal atherosclerotic plaque; an embolism from the heart, aorta, or other large vessels; or a dissecting aneurysm. In contrast, chronic ischemia is typically due to gradual circumferential enlargement of an atheromatous plaque. Life-threatening ischemia occurs in 2-5% of patients with intermittent claudication. The mortality rate in this patient population is 20-30% at 5 years after diagnosis, 40-70% after 10 years, and 74% after 15 years. Cardiovascular events cause 75% of deaths in these patients. RISK FACTORSSection 4 of 10
Major risk factors for the development of PVD include the following:
PAOD develops earlier in men than in women, with peak incidence during the sixth and sevenths decades of life. Rates of PAOD increase with age, with estimates of 1-2.5% in individuals aged 50-60 years and 5-9% in those older than 65 years. Cigarette smoking is a more potent risk factor for PAOD than for CAD and increases the risk of developing peripheral atherosclerosis 3- to 4-fold. Nicotine use affects patient outcomes and is associated with an increased risk of progressing from claudication to ischemic rest pain and an increased risk of amputation. Patients with arteriosclerosis in its advanced stage are also likely to have systemic disorders involving the coronary, cerebral, pulmonary, renal, and peripheral vessels. DM is also a risk factor for PAOD. An individual with diabetes is 2 times more likely to develop claudication than a nondiabetic counterpart. Hypertension is also a risk factor for PAOD. Of individuals with hypertension, 2-5% have intermittent claudication, while 35-55% of patients with PAOD have hypertension. The combination of hypertension and PAOD markedly increases the risk for MI, stroke, and death. CLINICAL PRESENTATION AND SYMPTOMSSection 5 of 10
Patients may present with various symptoms depending on the vessels involved, the degree of compromise to the vascular lumen, the rate of progression, and the presence of collateral flow. In general, a history of sudden onset of severe pain, numbness, coldness, and pallor in an extremity at presentation is consistent with acute occlusion. Physical examination may reveal absent distal pulses, sensory or motor loss, or muscular tenderness on palpation. In contrast, patients with chronic occlusion initially present with intermittent claudication. This most commonly affects the gastrocnemius muscle, but it can also involve the foot, thigh, hip, or buttocks. The usual relationships between the site of pain and the presence of arterial occlusive disease are summarized as follows:
Claudication is consistently reproducible and worsens with exertion, though it usually resolves within minutes after the person stops exercising. It is important to differentiate this from neurogenic claudication due to spinal arthropathy. When relatively old individuals with PAOD were compared with healthy counterparts, individuals with claudication had 50% less peak exercise capacity. Symptomatic claudication affected patients' quality of life (QOL) scores compared with those of asymptomatic individuals. The reduction was related to concomitant disease rather than domains of social functioning or mental health. The site of claudication can help provide a gross estimate of the level of occlusion. Progression of PVD is evident with a reduction in the distance that a patient can walk without symptoms. Ischemic pain eventually occurs at rest, often in the most distal extremity, particularly with the limb elevated, and it often disrupts sleep. Patients with such pain are forced to sleep with their feet over the side of their bed or in a chair with their legs in a dependent position. Decreased arterial flow and perfusion, edema, and further ischemia are likely consequences of persistent dependency of the involved extremity. Signs on physical examination that can help the physician confirm arterial insufficiency include diminished or absent pulses, delayed venous filling time on dependency after elevation (>20 s), and marked pallor of the involved extremity after elevation within 60 seconds or less. With gradual progression of ischemia, patients may develop trophic changes in the skin, which can appear dry and scaly with poor hair and nail growth. As ischemia worsens, ulcerations may develop, especially after local trauma. Severe ischemia leads to atrophy, necrosis, or gangrene with rubor, pain, and edema that can mimic cellulitis or venous insufficiency. An important concept to keep in mind is that many patients who have PVD may also have concomitant cardiovascular, pulmonary, or renal problems. For these patients, in-depth history taking and clinical evaluation are warranted, especially if surgery is considered. As mentioned earlier, risk factors for PVD overlap with those for CAD. The prevalence of serious CAD in patients undergoing peripheral vascular surgery is 37-78%. In these patients the risk of perioperative mortality is 4 times the risk of those without CAD. DIAGNOSTIC MODALITIESSection 6 of 10
Although arterial disease can be diagnosed clinically, noninvasive and invasive tests can help the physician confirm and delineate the extent of disease. Noninvasive tests frequently used to diagnose arterial insufficiency include calculation of the ankle-brachial index (ABI), ultrasonography, and magnetic resonance angiography (MRA). The systolic blood pressure in the ankle at rest normally is >90% of the brachial pressure, with mild arterial insufficiency at 70-90%, moderate insufficiency at 50-70%, and severe insufficiency <50%. Of note from a rehabilitation perspective, when systolic blood pressure in the ankle is <55 mm Hg in a nondiabetic patient or <70 mm Hg in a diabetic patient, ischemic lesions tend not to heal spontaneously. An ankle systolic blood pressure >70 mm Hg is more affirmative for healing after below-knee amputation. An ankle–brachial systolic pressure ratio of 0.9 or less supports the diagnosis of arterial occlusive disease. The segmental-pressure technique is used to obtain systolic pressures in the upper and lower thigh and calf in addition to ankle measurements. An abnormal pressure gradient between measurement sites indicates the presence and location of disease. This technique is problematic in persons with diabetes, who can present with falsely elevated pressure due to incompressible calcified arteries. Moderate areas of stenosis can also be missed because little or no pressure gradient may be created at rest. With continuous-wave Doppler sonography, normal peripheral arteries have flow waveforms that are typically triphasic, a feature that reflects forward flow during systole, reversed flow in early diastole, and forward flow again before a subsequent heartbeat. Waveforms recorded just distal to the stenosis are monophasic in the absence of reversed component. Directly over the stenotic segment, a high-frequency signal is revealed during both systole and diastole because the narrowed segment increases the velocity of flow. By comparison, Duplex sonography combines pulsed Doppler with real-time B-mode scanning that allows for exact localization of stenosis and that helps in defining the hemodynamic significance of the lesion. Although safer than arteriography, Doppler sonography and duplex imaging is operator dependent in terms of accuracy. MRA can further assist in visualizing the quality of PVD. MRA is often used when ultrasonography is not feasible, such as when the pelvic or intra-abdominal vasculature must be visualized. This is a new approach to the diagnosis of peripheral arterial disease. MRA is safer than angiography. In studies, MRA was sensitive and specific compared with the criterion standard of angiography (Auerbach, 2004). However, MRA might not aid in distinguishing complete tight or complete stenotic lesions, and it is institution dependent with regard to accuracy. As MRA is further developed, the need for angiography might be reduced in many instances. The benefit of invasive tests, such as contrast angiography or percutaneous catheterization, is that they can be used to accurately document the location and extent of disease should angioplasty, fibrinolytic therapy, or surgical bypass be pursued. In patients with renal insufficiency, cautious use of contrast material should be emphasized because these patients are at high risk for renal failure. Arteriography should be obtained only if intervention is planned. It enables visualization of the extent and type of peripheral arterial occlusion, and defines the rest of the arterial circulation. Iodinated contrast agent is injected. Arteriography is not without risk in patients with renal disease or other comorbidities. The mortality risk is approximately 0.15% with a morbidity risk slightly higher than this. The recent development of nonionic contrast material, digital subtraction angiography, and sophisticated imaging technology mitigates some of the risks of arteriography. Partial angiography involving the acquisition of selected views of the arterial tree also reduces the risk. The risks can also be reduced by using CO2 and gadolinium-based contrast agents in patients with renal insufficiency. Arteriography is considered the criterion standard for defining the anatomy of the arterial tree. RISK-FACTOR MODIFICATIONSection 7 of 10
Risk modification is fundamental to the treatment of PAOD. Management should aggressively address the control of modifiable risk factors, including tobacco use, hypertension, and hyperlipidemia. In addition, patients with PAOD should be screened for diabetes. In the ideal situation, glycohemoglobin levels should be maintained at <7.0%. However, glycemic control is not enough to mitigate disease progression. Intense glycemic control lowers the risk of other complications of diabetes that positively affect PAOD and its treatment options. An additional concern is the development of diabetic sensory–motor peripheral neuropathy. With reduced sensation and motor control of the lower limbs, affected individuals are at increased risk for ulceration. Neuropathy, coupled with underlying arterial disease, increases the risk of foot infection and sepsis, as well as limb amputation. Smoking increases the risk of arterial disease and worsens disease progression. Smoking is correlated with an increased risk of amputation, stroke, MI, and death. Smoking cessation is critical to successful management. Patients should be informed that continued tobacco use accelerates disease progression and increases their mortality risk. Evidence suggests that disease progression slows and that symptom severity improves in those who stop smoking (Jonason, 1987). Hyperlipidemia is a well-recognized risk factor for atherosclerotic disease. Fasting lipid profiles should be evaluated in individuals with PAOD. Elevated LDL-C and triglyceride levels, and depressed HDL-C levels, are associated with atherosclerosis. The target lipid profile also includes reduction of the serum LDL-C concentration to <100 mg/dL and perhaps <70 mg/dL. Pharmacologic intervention is often required. Hypertension should be treated similarly to how it is treated in patients with cardiovascular disease. Reduction of blood pressure is required to lower the risk of the morbidity and mortality associated with MI, stroke, and cardiovascular disease. Neuropathy and skin care Foot problems are an important cause of morbidity in patients with diabetes. Both vascular and neurologic factors contribute to this problem. Neuropathy is present in >80% of patients with foot ulcers. It promotes ulcer formation by decreasing pain sensation and pressure perception, by causing muscular imbalance that can lead to anatomic deformities, and by impairing microcirculation and skin integrity. After ulcers form, healing may be delayed or difficult to achieve, particularly if infection penetrates to deep tissues and bone and/or if local blood flow is diminished. Foot amputations, many of which are preventable with early recognition and therapy, are too often the outcome. The mean cost of foot ulcers in diabetic patients is almost $28,000 for the 2 years after the ulcer is diagnosed. The best predictors of future lower-limb amputation are a history of foot ulcers, the presence of neuropathy and peripheral arterial disease, and poor glycemic control. Screening for peripheral neuropathy is recommended. For such screening, a Semmes-Weinstein 5.07 (10-g) monofilament is applied at specific sites to detect a loss of sensation in the foot and to identify patients at risk. Routine skin and foot care is extremely important for preventing skin compromise, especially in diabetic patients. Patients should inspect their feet daily for cracks, fissures, calluses, corns, and ulcers, and they should seek early intervention from podiatrists. Their feet should be washed daily in lukewarm water with mild soap and dried thoroughly. Heating pads and hot water should be avoided to prevent thermal injuries. A lubricant, such as lanolin, should be applied to dry scaly skin, whereas moist feet can be remedied with a bland, nonmedicated foot powder. Toenails should not be cut too close to the skin, and patients should change their socks or stockings daily. Constricting garters should be avoided, as should adhesive plasters or tape. Patients should also refrain from using harsh chemicals and corn cures to prevent chemical trauma. To prevent mechanical injuries, shoes should fit properly with a wide toe space, and they should be changed often. Walking barefoot should be avoided at all times. Customized footwear or selected foot or lower-extremity orthoses should be prescribed for stabilization and protection. The goal is to enhance function of the lower extremity and to reduce pressures. Rocker-sole shoes can diminish the work of the gastrocnemius muscle during ambulation, and ankle-foot orthoses (AFOs) can minimize ankle motion. Improved walking tolerance, distance, and comfort are reported in patients who use orthoses. For patients with pain at rest, particularly at night, the head of the bed should be elevated 4-6 inches, which should improve lower-extremity perfusion due to the effects of gravity on blood flow. In diabetic patients with neuropathic ulcers, weight bearing should be avoided in the acute healing process. Then, when appropriate, orthotics should be used to redistribute pressure points and ensure proper fit of shoes. Aggressive wound care and tight management of capillary blood glucose levels in patients with DM further augments wound healing. Debridement and antibiotics specifically selected on the basis of wound-culture results greatly contribute to healing, and early drainage of infection may prevent major surgical wound revision. Enzymatic debridement may be irritating and can increase pain. PHARMACEUTICAL INTERVENTION AND ALTERNATIVE OPTIONSSection 8 of 10
Medication Drugs, such as vasodilators, are prescribed to manage intermittent claudication with the general aim to increase peripheral delivery of oxygen. However, their efficacy remains questionable. Beta-blockers can result in peripheral vasoconstriction and, though evidence is inconclusive that use increases claudication, these drugs are avoided in patients with arterial occlusive disease. Because platelet aggregation can exacerbate disease by causing mechanical obstruction or stimulating local vasospasm, drugs that reduce platelet activity are considered beneficial. Pentoxifylline (Trental) may be variably effective in patients with intermittent claudication because they increase RBC deformability, decrease plasma viscosity, and diminish fibrinogen concentrations. One trial comparing pentoxifylline with exercise showed that patients receiving drug therapy achieved significantly greater walking distances after 3 months than those receiving exercise therapy (Ciuffetti, 1994). No evidence supports the idea that fibrinolytic agents, anticoagulants, or antiplatelet agents are effective for treating intermittent claudication. However, strong evidence supports the use of aspirin to prevent coronary and vascular graft thrombosis. Low-dose aspirin reduced the risk of peripheral arterial surgery by 54% compared with placebo (Hiatt, 2006). Ticlopidine (Ticlid) is a thienopyridine that selectively inhibits adenosine diphosphate (ADP). It is used less now than before to manage PAOD. Ticlopidine therapy requires monitoring because of serious adverse effects such as neutropenia and thrombotic thrombocytopenia purpura. Clopidogrel (Plavix) is also a platelet aggregation inhibitor. Clopidogrel therapy is associated with decreased progression of atherosclerotic disease. However, it has the adverse effects of minor bleeding, gastrointestinal complaints, and edema. This drug is more beneficial than aspirin for patients at high risk of cardiovascular events. Cilostazol (Pletal) is reported to have fewer adverse effects than pentoxifylline (Trental). This drug induces vasodilatation and inhibits platelet aggregation and proliferation of the smooth muscle. However, its mechanism of its effect is not fully understood. Cilostazol is contraindicated in patients with congestive heart failure. The most common adverse effect in other populations is headache. Transient diarrhea, dizziness, and palpitations are also reported. Preliminary evidence led to postulations of the efficacy of antioxidants like vitamins C and E and beta-carotene to retard arteriosclerosis (Kleijen, 2000). However, as additional evidence emerges, the validity of this claim is questioned. In theory, chelating agents may potentiate the regression of arteriosclerosis because they extract calcium from the plaques. However, they have not been proven to be clinically effective, and they are not recommended at the present time. Fibroblast growth factors to stimulate the growth of new blood vessels are currently being studied in clinical trials. Alternate treatments Hyperbaric oxygen treatment and the application of negative pressure to the lower limb have gained popularity. However, the present authors know of no data from randomized controlled studies to support claims of efficacy. Chelation therapy with EDTA has undergone randomized trials. No reduction in claudication or improvement in perfusion was documented in the treatment of peripheral disease (Ernst, 1997). Sympathectomy to manage pain, to increase perfusion, to reduce tissue loss, or to serve as an adjuvant to revascularization surgery has had disappointing results. Sympathectomy is typically reserved for individuals who have inoperable disease. At present, this procedure is most commonly done with injected chemicals. Exercise In general, conservative management is advocated as the treatment of choice for patients with intermittent claudication. With respect to physical rehabilitation and exercise programs, a substantial reduction of 20-25% in cardiovascular death has been observed. A consistent trend toward survival benefit is demonstrated, and the risk of mortality decreases as the level of physical activity increases. Exercise training programs result in physiologic changes, such as improved peripheral utilization of oxygen and glycolytic-oxidative metabolic capacity, which improve functional capacity to decrease cardiac effort. Blood flow increases during and after active exercise. Physical training elevates muscular metabolic demand, and increased collateral circulation is the presumed mechanism of symptomatic improvement. Extended walking distance with exercise was demonstrated in many controlled trials (Leng, 2000). Recent investigators compared the long-term results of angioplasty and exercise training, reporting minimal differences in walking distance and QOL score at 5 years. Patients with intermittent claudication are encouraged to walk 30-60 minutes per day, 3-5 days per week, at a pace of 2 miles per hour; if discomfort occurs, the patient should stop and resume when the pain abates. Coexisting cardiac limitations should be considered when an exercise program is planned. Gradual improvement should be seen within 3-6 months. Physical rehabilitation involving dynamic aerobic exercise and resistance training improves cardiovascular endurance and positively affects patient survival. Exercise is a noninvasive and inexpensive activity with minimal complications and is an invaluable first-line treatment for patients with PVD. INVASIVE TREATMENTS AND PREVENTIONSection 9 of 10
Percutaneous endovascular therapy In the setting of acute thrombosis, early intervention is crucial in preventing neuromuscular damage and optimizing limb salvage. Anticoagulation with intravenous (IV) heparin therapy helps to maintain residual luminal patency and to prevent propagation of thrombus, which promotes adequate blood flow to the microvasculature. Further intervention depends on the extent of disease delineated with arteriography. Percutaneous endovascular therapy includes percutaneous transluminal angioplasty (PTA), stenting, and thrombolytic therapy. Diffuse disease or lack of restorable patent adjacent collateral circulation is not successfully treated with this procedure. The outcome of PTA in isolated iliac occlusive disease is improving, such that it may be preferred over surgery. However, infrainguinal disease is most likely to be diffuse, and surgical bypass is likely to be preferred. Indications for PTA include rest pain; gangrene; and progressive, limiting intermittent claudication that prevents the patient from functioning. PTA is associated with a high recurrence rate of obstruction, but it is a useful treatment for localized short ( <10 cm), segmental, and occlusive arterial lesions. Successful PTA obviates or delays surgery and requires a short hospital stay. PTA is an optimal choice for high-risk cardiac patients who are poor surgical candidates. Five-year patency rates are 60-90%, depending on the vessel involved. Stents are inserted into the vessel at the site of the obstruction, and the recurrence rate reportedly is less than that of PTA. However, stents work best in large arteries with high flow and do not work as well in small vessels and long occlusions. Synthetic grafts are inserted through small catheters into the site of aneurysm and expand to protect and provide structural support of the weakened vessel wall. Patients with stents return home with additional antiplatelet therapy. Thrombolytic therapy is most effective for acute arterial occlusions of less than 2 weeks, and its use is indicated in severely ischemic limbs. Therapeutic exercise versus PTA Therapeutic exercise and angioplasty were compared by Creasy in 1990. At 6 months, walking time increased in patients given PTA compared with those participating in walking exercise. However, after 6 months, results in the angioplasty group declined, whereas results in the exercise group improved. At 12 months, the exercise group improved further. In a prospective randomized trial of 56 patients, investigators compared participants who underwent PTA versus those in a walking exercise program. No difference was seen between the groups at 15-month follow-up (Perkins, 1996). In general, PTA should not be used for mild claudication, for which an exercise program is best. Surgery Surgical intervention is indicated in patients with incapacitating claudication, resting pain, gangrene, and tissue loss. Surgery is an option most likely to be pursued in patients with diffuse disease, extended occlusions, and severe arterial calcifications. Surgical procedures include bypass grafting and resection with graft placement and thromboendarterectomy. Autogenous veins are used most often to bypass occlusive lesions of the superficial femoropopliteal or tibial arteries. Revascularization is associated with a mortality rate of 50-70% due to the effects of metabolic products on the pulmonary and renal systems (reperfusion syndrome). Early amputation may be a preferred option in patients with extensive vascular disease. In refractory cases or cases of osteomyelitis, surgical amputation is necessary, particularly if revascularization, endarterial therapy, or thrombolytic therapy fails. In this patient population, amputations often result because of thermal, chemical, or mechanical trauma incurred on a limb with preexisting chronic occlusive disease. Amputation to manage uncontrolled infection, unrelenting resting pain, and progressive gangrene should be done as distally as possible because the level of amputation greatly influences the optimal use of a prosthesis. Of interest, the overall rate of amputation (30 cases per 100,000 population) does not decline despite medical intervention. Hence, conservative management of intermittent claudication is further reemphasized as a mainstay of treatment. Prevention with cardiovascular rehabilitation The goal of therapy should be reducing risk factors and restoring the ischemic limb to a functionally pain-free state. The extent of vascular disease and the patient's underlying medical problems often dictate the course of treatment. One of the primary aims of cardiovascular rehabilitation is secondary prevention of risk factors. Modified diets and routine exercise programs effectively lower levels of LCL-C and elevate levels of HDL-C. Exercise substantially reduces systolic and diastolic blood pressures during and after the exercise period. Exercise also contributes to weight loss and improves regulation of capillary blood glucose concentrations in patients with DM. Modified diet and cyanocobalamin-folate supplementation can reduce levels of homocysteine, preventing damage to endothelial cells, which predisposes arterial vessels to premature arteriosclerosis. Salt restriction should be recommended for patients with hypertension or heart failure. Smoking is associated with silent ischemia and reinfarction, arrhythmias, elevated plasma fibrinogen levels, sudden death after MI, and coronary spasms. Smoking cessation is undoubtedly beneficial in improving cardiovascular disease and its associated morbidity and mortality (Jonansen, 1987). Secondary prevention improves both symptoms and perceived QOL, and it stabilizes angiographic progression in approximately 50% of patients and induces regression in approximately 25%, leading to strong endorsements from the American Heart Association and the American College of Cardiology. Although underutilized, comprehensive cardiovascular rehabilitation has a positive bearing on morbidity and mortality in this patient population. Cardiovascular rehabilitation is more cost-effective for secondary prevention and arresting progression of disease process than thrombolytic therapy, coronary artery bypass surgery, or cholesterol-lowering medication. Cardiovascular rehabilitation involves a multidisciplinary approach to support the patient's functional capacity and symptoms, QOL, early vocational reentry, and psychological recovery. Early intervention reduces loss of function and productivity from the patient's temporary or permanent disability. The multidisciplinary team typically includes, but is certainly not limited to, a physician, a psychiatrist or psychologist, a nurse, a health educator or counselor, a dietitian or nutritionist, an exercise physiologist, an occupational therapist, a physical therapist, a vocational therapist, a social worker, and a pharmacist. Multifaceted programs include physical, pharmacologic, psychosocial, and occupational and vocational rehabilitation, as well as education, counseling, and behavioral intervention. Cardiovascular events not only result in physical hindrances but also alter psychosocial adaptation. Patients often do not return to their previous work, leisure, and intimate activities, an outcome that eventually leads to social isolation, negative perceptions about their health, depression, and poor medical compliance. Both anxiety and depression are common in patients with cardiovascular problems enrolled in outpatient cardiac rehabilitation programs. The goals of physical, psychosocial, and vocational rehabilitation are maximizing functional capacity and adaptation consistent with the patient's impairments and environmental limitations to enable the patient to return to a useful and personally satisfying role in society. Conclusion The benefits of cardiovascular rehabilitation involve the physical, emotional, and psychosocial aspects of a patient's life. The American Heart Association established a specific risk-stratification scheme to define the level of intensity and mode of exercise that is safe and effective for the individual patient. With persistence, patients achieve improvements in exercise tolerance and functional capacity. A reduction in cardiac symptoms, as well as perceived stress and anxiety, occurs and lead to improved productivity and psychological well-being. Patients learn to adapt and become self-reliant as they realize that they can influence their hypertension, DM, weight, and smoking activity by means of behavioral and lifestyle modifications. With comprehensive rehabilitation, the patient's QOL improves, they return to work faster than they otherwise might, and their rates of hospital readmission are reduced. Cardiovascular rehabilitation promotes the reversal of arteriosclerosis and reduces subsequent mortality. Such rehabilitation should be established as the standard of care in addition to the use of antiplatelet, cholesterol-lowering, and thrombolytic agents, along with possible revascularization. REFERENCESSection 10 of 10
Vascular Diseases and Rehabilitation excerpt Article Last Updated: Nov 21, 2006 |
