How does peripheral artery disease affect people with diabetes?

WWhen we think about clogged arteries, most of us think about the heart. “But the accumulation of fatty deposits can occur in any artery, including those in the blood vessels,” says Dr. Samuel Kim, a preventive cardiologist and blood lipid specialist at Weill Cornell Medicine in New York. vessels that carry blood away from the heart.

The arteries that branch and enter our arms and legs make up the majority of what we call peripheral arteries. And the narrowing in these vessels is called peripheral artery disease (PAD), a common condition in which the legs or arms don’t get enough blood flow. “Interestingly, the arteries in our legs and feet are much more susceptible to blockages than the arteries in our arms and hands,” Kim said. But exactly why that happens remains unclear.

It is possible to have PAD without plaque buildup in the heart and brain vessels, signs of heart attack and stroke. “Although these diseases may occur separately, it is not uncommon for these disease entities to occur separately,” said Dr Philip Goodney, a vascular surgeon at Dartmouth Hitchcock Medical Center in Lebanon, NH. go together. Therefore, patients with symptoms of coronary or cerebrovascular disease will often be evaluated for PAD and vice versa.

The link between diabetes

In the United States, nearly 12 million people have PAD, one-third of whom also have Type 1 or Type 2 diabetes, according to World Journal of Diabetes. While the data are insufficient to indicate whether either type is more specifically associated with PAD, “Type 2 diabetes is more common, simply because there are more people with type 2 diabetes,” Kim said.

There are risk factors for peripheral artery disease Diabetes: older and have high cholesterol, High Blood Pressure, and chronic kidney disease both increase the chances of someone being diagnosed with PAD. “But smoking and diabetes are the top two problems,” says Dr. Aaron Aday, a cardiologist and specialist in vascular medicine at Vanderbilt University Medical Center in Nashville.

So how exactly does diabetes lead to blood vessel blockages?

“Inflammation is key,” says Aday. Diabetes causes persistent inflammation, which can be measured with blood tests such as the C-reactive protein test. Some studies show that high levels of this protein enhance blood clotting in arteries, making them more susceptible to narrowing and blockage.

In addition, high blood sugar – such as when diabetes is not adequately controlled – produces a lot of reactive oxygen species, which are rather unstable molecules that constrict in cells and damage cells. important components such as DNA and RNA. In addition, protein kinase C (PKC), a key arbiter of these reactive oxygen species, has been shown to be harmful to blood vessel structure and function.

Kim highlights the negative impact diabetes has on endothelial cells, the inner lining of blood vessels. When healthy, they produce a gas molecule called nitric oxide, which not only helps blood vessels to dilate and repair when needed, but also emits chemical signals that tell our bodies to clot properly. inappropriate. However, when exposed to high amounts of sugar, these cells lose their ability to regulate nitric oxide levels – and the complex structure of blood vessels, along with their amazing flexibility, is severely damaged.

Although having diabetes can increase someone’s risk of developing PAD, the relationship is not unidirectional. Many people already have arterial disease before receiving a diagnosis of diabetes, which is then aggravated by poor blood sugar control. Lifestyle factors including smoking, unhealthy diet, and inactivity — along with genetic factors such as high levels of lipoprotein(a) and familial hypercholesterolemia — can fray the lining of blood vessels long before diabetes is officially diagnosed. But studies have consistently found that the duration of diabetes corresponds to the extent of damage to the arteries. Plus, each 1% increase in HbA1c — a test that measures how much sugar is chemically bound to blood cells (versus just floating around in the blood as measured by a conventional blood sugar test) — associated with a nearly 30% increased risk of being diagnosed with PAD.

Race and ethnicity also play a role in developing this duodenal disease. “If you have diabetes and you are black,” says Dr. J. Antonio Gutierrez, an interventional cardiologist at Duke Health who is also involved in outreach activities among minority communities. , your risk of PAD is almost twice that of Caucasians. In addition to Durham, NC Spaniards, Puerto Ricans and Mexicans are also at increased risk, he said.

Read more: People with diabetes are more prone to heart disease. How to reduce the risk

Warning signs and symptoms

About five years ago, Steve Shipley, then in his 60s, noticed some blisters under his toe after practicing softball. Diagnosed with type 1 diabetes in 1977, he tries to stay active, coaching basketball and softball at a Tennessee high school, and playing and refereeing those sports for fun. .

“I noticed the blisters and thought, ‘Well, maybe it’s the shoes rubbing on that area,’ so I don’t pay too much attention to it,” he says. have had anything like this before, or experienced any unusual pain or cramps in the legs.

But after a few days, the blisters look worse. “I made an appointment with my pediatrician and we decided to try these flats with Velcro straps designed to prevent any rubbing of the toes,” he says. However, Shipley soon realized that the blisters did not heal.

For a few more days, he remained cautiously optimistic that the wound would eventually heal, and kept an eye on his feet. Then one evening, when he noticed his toe was turning dark, he went right back to the pediatrician, who had to perform an emergency surgery. “I’m glad I went when I arrived, because if I had waited any longer, I could have lost my entire leg instead of just one toe,” he said.

Shipley is one of many patients who experience virtually no symptoms while their peripheral arteries insidiously build up plaque. By the time more obvious symptoms appear, blood vessels can become severely blocked and the condition becomes life-threatening.

“Only a third of patients have classic textbook symptoms, but for others the symptoms can be a lot more subtle,” says Gutierrez. Most commonly, these people feel a sharp pain, cramping, or burning sensation in their legs – especially in the calves – when walking or exercising and find that the condition improves within minutes of rest. . These painful sensations may be localized to specific areas depending on what type of pulse is involved. “You could have buttock pain, which means you could be facing a blood vessel near the side, or pain in the thigh or somewhere further down the leg,” says Kim.

There are other signs to watch for. “Patients may experience some degree of hair loss in the lower legs, skin and toenail changes, and/or temperature differences between the feet,” says Aday. And in cases of poor diabetes management, PAD can progress to blistering, non-healing leg ulcers, infection, and tissue death, eventually requiring amputation.

However, as Goodney points out, not everyone with PAD will experience pain or other obvious symptoms. Many people with diabetes also have problems with their nerves, he said, “which limits their ability to spot some of those symptoms or warning signs.” That means it’s not uncommon for people with peripheral artery disease to not know they have it.


Given that symptoms are unreliable, Goodney emphasizes the importance of periodic evaluation. “One of the most important things diabetics can do is make sure they get their diabetic foot exam every year,” he says.

During these visits, health care providers also ask detailed questions about diabetes management, lifestyle factors such as smoking and diet, and mobility difficulties. Your doctor may order a noninvasive test called the ankle-brachial index, which can help determine the severity of your artery disease. This test is usually done at rest, but patients are sometimes asked to run on a treadmill to better identify symptoms.

In addition to the ankle-brachial index, anatomical evaluation may be needed to visualize the location and extent of the obstruction more accurately. “That can be done through ultrasound, contrast-enhanced CT or magnetic resonance angiography,” says Kim. Together with the patient’s medical history and physical examination, these scans can better inform the nuances of a treatment plan.

Read more: The link between type 2 diabetes and mental disorders

The treatment

There are several treatment options for peripheral artery disease. Many people with PAD are instructed to start supervised exercise therapy. “You push people to exercise beyond the boundaries of what they can tolerate,” says Kim. “The idea here is that over time, your body builds extra blood vessels that go around the clogged vessel.” Such a program can be done at home — by walking short to moderate distances — or at rehabilitation centers. “At the same time, it’s important to make sure that people’s diabetes is managed properly, their blood pressure is under control, they’ve stopped smoking, and they’re eating healthily to lower their cholesterol,” says Aday. .

Combined with exercise and lifestyle adjustmentsThe American Heart Association/American College of Cardiology Guidelines recommends that patients with PAD be started on medication. “We started the patient on antiplatelet therapy with aspirin or clopidogrel, a high-intensity statin for lipid-lowering, and high blood pressure medication,” says Kim. Studies have shown that following a strict dosing regimen can not only improve some plaques, but also reduce the overall risk of heart attacks, strokes, limb loss, and death.

However, depending on the extent of the blockage, medication alone may not be enough and surgical intervention may be necessary. “We can help reopen the arteries with things like balloons, stents or catheters that patients can have pretty big effects on,” says Goodney. “But for people with more severe disease, those with damaged balloons and stents, we can help rebuild the arteries, similar to bypass surgery.”

In some time-sensitive cases, amputation may be necessary. “When a patient is critically ill and all options for rebuilding their artery have been exhausted without success, amputation may be the only path left to cure,” says Goodney. get rid of severe pain or a life-threatening infection,” says Goodney. Diabetes-related amputations can cause intense guilt, low body image and self-esteem, and depression. These patients should generally seek behavioral health services.

Shipley felt self-conscious for months after her toe amputation. “It made you feel different,” he recalls. “For example, if I’m at the pool or if I’m not wearing my shoes and someone comes to the door, I have to make sure I put them on before I see them.”

The emotional burden is even heavier around those at home. “Ironically, when I first got it, our niece was only a few years old, and I was really afraid that the missing toe would scare her,” he said. But by chance, one day, she recognized it and said, “’Papaw, I’ll give you my toes if I can.’ And since that time, my mental outlook has completely changed.”

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