Monday, July 20, 2009

HEART TO HEART: Understanding PVD

HEART TO HEART: Understanding PVD
Monday, July 20th, 2009 02:52:00

STAND up. Feel the ground beneath you. Is it firm? Walk around and jump up and down. Go kick a ball. Now look at your feet. Look at them hard.
Why have I asked you to do this? What is my point?

For most people, this is not something that we think of consciously. The ability to stand and walk is what all of us learned to do months after birth. It is a natural part of our everyday life.
Unfortunately, the same cannot be said of Ibrahim (not his real name). He had his left leg amputated above the knee in March this year. His right leg followed two weeks ago. His life will never be the same again.

Ibrahim is a 60-year-old man with peripheral vascular disease (PVD). It is an occlusive arteriosclerotic disease affecting the arteries to his legs.

He also has diabetes, hypertension and high cholesterol.

Although he does not smoke, he has the other risk factors for severe PVD.

His problem started in the middle of last year. He complained of cramp-like feeling at the back of both calves when walking. The medical term for this symptom is intermittent claudication.

After a few weeks, he began to notice the walking distance it took for the claudication pain to come on was becoming less.

In late November, he noticed a small wound on the sole of his left foot. He had no recollection of how he sustained it. He had been having numbness in his feet for some time before that and he attributed it to his longstanding diabetes. When he sustained the wound to his foot, he had no knowledge of it till later.

Ibrahim has had diabetes, hypertension and high cholesterol for more than 10 years. He was not diligent in taking his medications or clinic follow-up appointments.

Instead, he resorted to traditional treatment to help heal the wound. By the middle of February, the wound had become worse. It was bigger and the whole foot was in pain even at rest.

When he eventually came to the hospital two weeks later, all his left toes were black and gangrenous. Infection had already spread to the bones of his foot. He had osteomyelitis.

He initially refused medical advice to have a below-knee amputation. He insisted on the medical team to perform a miracle to save his leg. Unfortunately, despite aggressive treatment with intravenous antibiotics and regular wound care, his leg could not be saved. As I am writing this, Ibrahim is recovering in the hospital from his second amputation. Sadly, his case is not isolated.

He is just 1 of about 10,000 diabetics whose legs are amputated in Malaysia every year, where 40 to 50 per cent of these cases are preventable.

Did you know that patients with PVD have a four-fold risk of death from heart attack and heart-related diseases, and a two to three times greater risk of stroke?

Diabetics are two to four times more likely to get PVD and for those who also smoke, the risk of having an amputation is 30 per cent in the next five years. With the rising number of diabetic patients, which currently stands at 14.9 per cent in Malaysia for those above 30 years of age, PVD is fast becoming an epidemic.

As a clinical condition, PVD is grossly neglected, vastly underdiagnosed and badly managed. As with Ibrahim
and thousands others, severe PVD leading to critical limb ischaemia (painful leg at rest, non-healing wounds and gangrene) is the first presentation to the doctor. Chances of a good recovery will be smaller at this stage.

For some, it may even be too late.

Ignorance is the main cause of the rising number of PVD cases worldwide. Perhaps we place too much concentration on the symptoms and signs of heart attack and stroke that we tend to neglect PVD, the third commonest manifestation of cardiovascular disease.

To halt the growth of this serious disease, drastic measures need to be instituted before the situation gets out of hand.

Early identification of patients at risk of PVD, aggressive risk factor modification and timely referral to the vascular surgeon in severe cases is vital.

If you are diabetic or at high risk of getting PVD, please consider the following:
● Watch your diet. It has to be low in sugar and fat.
● Take your medicines as prescribed. Follow the advice of your doctor.
● Stop smoking.
● Exercise regularly.
● Take care of your feet. Make sure they are clean and dry at all times, especially in the spaces between
the toes.
● If numbness develops on the soles of your feet, take appropriate measures to protect your feet from accidentally having a cut.
● If you have any of the PVD symptoms and signs (claudication or critical limb ischaemia), see a doctor straight away.

Once you see a doctor, he may order an ankle-brachial pressure index (ABPI) test. It is a measure of the fall in blood pressure in the arteries supplying the legs compared to the pressure in the arms. A reduced ABPI (less than 0.9) is consistent with PVD. Values of ABPI below 0.8 indicate moderate disease and below 0.5 severe disease.

These days, CT angiogram which is a non-invasive imaging test, is being used on a wider basis to visualise the extent of the disease. Based on this and the clinical picture, the vascular surgeon will advise on the best treatment from the available options which are:

● Conservative measures with medicines and life style modification only.
● Angioplasty, which is the opening up of narrowed arteries using special balloons inserted through the groin. This is the preferred option in certain cases especially in those at high risk of surgery.
● Bypass surgery using either the saphenous vein from the leg or an artificial graft to circumvent the blockage in the artery.

If you have any questions or comments, feel free to write to me at See you next Monday.

No comments:

Post a Comment