Peripheral arterial disease:
Little respect for a serious disease
Their lives couldn’t be more different.
One is a vascular surgeon and works at Massachusetts General Hospital as director of the vascular surgery research laboratory.
The other is a retired Chelsea police officer and former truck driver.
They met about six years ago.
For Dr. Michael T. Watkins, his relationship with Leroy Tyler personified his goal back in medical school to go beyond simply providing a treatment to actually establishing a bond with a patient.
For Leroy Tyler, the relationship was about pain.
Walking had become a problem for Tyler. The pain was more than an occasional ache or cramp. And for Tyler it was particularly debilitating, largely because he was very active, walking just about everywhere, so much so that his friends and neighbors nicknamed him “the runner.”
The pain became worse after he retired at age 62. He used to play basketball and softball, and run around with his grandson but the pain got so bad, he realized he needed to see a doctor. “It felt like my whole calf was in a knot,” he said. “It was very painful.”
What was more painful was that no one knew exactly what was wrong at first. He had gone to his primary care physician who in turn referred him to a foot doctor. The podiatrist then referred Tyler to Dr. Watkins.
The doctor’s diagnosis was something unfamiliar to Tyler — peripheral arterial disease.
Though relatively unknown, PAD is a common and serious cardiovascular condition that affects almost 12 million people across the country. The disease is the product of clogged arteries resulting from atherosclerosis — excess deposits of cholesterol and fat, or plaque.
Too much plaque in the arteries of the heart can result in a heart attack; in the brain, it can lead to a stroke. In the arteries outside of the heart — the peripheral arteries — excessive plaque causes PAD. Though most common in the legs, PAD can occur in the arms, kidney, and aorta, the main artery of the body.
If the buildup of plaque is excessive, circulation can decrease or stop altogether.
One of the problems with PAD is that it gets little respect.
In fact, Dr. Alan T. Hirsch, Chair of the Peripheral Arterial Disease Coalition, says PAD is “the most dangerous disease that most Americans have never heard of.”
Dr. Watkins has a theory. “Compared to other things like HIV/AIDS or heart attacks, PAD doesn’t command our attention as much,” Dr. Watkins said. “While the loss of a limb can certainly alter a lifestyle, PAD is not in general life threatening. Most people don’t see the loss of a toe as a big deal when compared to, say, a heart attack.”
But Dr. Watkins cautions against taking PAD lightly. “People who have lost a limb or have other symptoms of PAD are more than likely to have other undiagnosed cardiovascular problems,” he explained.
Those undiagnosed problems could lead to well-known complications — stroke, heart attack, amputation, and in some extreme cases, death. Accumulation of plaque in the arteries of the legs is often a warning sign of widespread atherosclerosis throughout the body, and the heart and brain are likely targets. A person with PAD has a six times greater chance of heart disease, heart attack, or stroke.
People over the age of 50 are at higher risk, but smoking and diabetes are the leading risk factors. Smokers and diabetics carry a risk up to four times greater than that of non-smokers and those without diabetes.
The disease is common in blacks due in part to higher incidences of other chronic conditions, such as high blood pressure, diabetes and high cholesterol.
Recent studies have shown that the incidence of PAD among African Americans is due in some measure to the lack of detection, lack of access to quality health care and inability to afford expensive medicines and healthier foods.
Dr. Watkins said part of the problem is that African Americans come to the attention of medical providers when the disease is in a more advanced stage. As a result, Dr. Watkins said, “a doctor’s ability to salvage the problem is greatly reduced.”
The lack of detection is critical. “One of the first signs of PAD is change in the color of skin,” Dr. Watkins said. “But in African Americans, that is not always an obvious physical finding.”
The symptoms of PAD, when present, are unique. Most common is “intermittent claudication,” a cramping or ache in the calf, thigh or buttocks th at occurs after walking a certain distance or climbing steps. The pain is the result of an inadequate flow of blood to the muscles of the leg, and while a short rest can temporarily cause the pain to subside, the pain usually returns when walking is resumed, and can range from mild to severe.
The pain can be deceiving. Some think they have pulled a muscle, or are suffering the effects of old age or simply having a “Charlie horse.”
Those who have symptoms are the lucky ones. Twenty to 50 percent of people over the age of 50 with PAD are unaware that they have the disease or experience no symptoms, while only 10 to 35 percent experience claudication, according to the American Heart Association and the American College of Cardiology.
A small percentage experience such severe symptoms, that within a year, one-fourth of them have undergone an amputation and another fourth have died from a cardiovascular event.
Like most people with PAD, Tyler said he had no idea that he had it. But he knew he had a problem. “The cramps got so bad that I could barely walk to the bathroom,” he said.
And that’s when Dr. Watkins entered the picture. Throughout his medical career, Dr. Watkins had prided himself on his decision in medical school to work with patients before they needed surgery. Though he has a lot of respect for the technical expertise of surgery, he has equal respect for doctors who can develop a diagnosis and recommend what often become lifestyle changes to their patients. Such was the case with Tyler.
“In some surgical specialities, a surgeon is referred a patient, does the surgery, and that is pretty much the end of his contact with a patient,” Dr. Watkins said. “In vascular work, the relationship with the patient is much different. We must determine the tests to be performed, then determine a diagnosis and then follow a patient for years prior to any surgical or catheter based intervention.”
Dr. Watkins first assessed Tyler’s risk factors. The answers weren’t good. Tyler didn’t have diabetes, but he did have high cholesterol and high blood pressure. Two of his brothers died relatively early from heart attacks, one at age 55, the other at 45.
And worse, Tyler admitted that he smoked, not much, just three or four cigarettes a day since the age of 15.
Dr. Watkins was not pleased. “That’s three or four too many,” Dr. Watkins said.
Tyler was also not amused. He was tired of being in pain and decided to fight back. He said he would get so angry that he would start kicking things as he walked down the street.
Dr. Watkins liked his feistiness. And Tyler backed the talk with the walk.
He quit smoking after about a year, and faithfully took medicine prescribed by Dr. Watkins to improve his blood flow. He kept his blood pressure and cholesterol under control. And Tyler continued to walk.
Tyler is 70 years old and is doing pretty well these days. As long as the surface is flat, he walks with little discomfort. But walking on any inclined surface is still a problem.
Dr. Watkins has been pleased with Tyler’s progress and doesn’t believe surgery is necessary.
But making people aware that PAD deserves respect is another story.
“The emphasis is always on the heart,” Dr. Watkins said. “And that’s understandable. You can’t live without the heart. But the presence of PAD is usually the tip of the iceberg.” |
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With the help of medication and lifestyle changes, Leroy Tyler can continue walking without pain.
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Michael T. Watkins, M.D.
Director, Vascular Surgery
Research Laboratory
Massachusetts General Hospital
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