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Peripheral Vascular Disease

  • SARA LOMAX-REESE: We are joined in studio like I said with Dr. Donee Patterson, welcome.

    DONEE PATTERSON, MD: Thank you, good afternoon.

    LOMAX-REESE: Good afternoon.  And Dr. Rashad Choudry of Einstein Health Care Network.  Good afternoon Dr. Choudry.

    RASHAD CHOUDRY, MD: Thanks for having us, good afternoon.

    LOMAX-REESE: So in recognition of American Heart Month, which is February, we are going to talk about peripheral vascular disease, which is a disease of the arteries and veins located outside of the heart and the brain.  I just want to say if you are 50 or over and you are African American, you should really get a paper and something to write with because we are going to be talking about something that is more prevalent in that category of folks than in others, so you want to know what this is all about.  So first up, let's start with you Dr. Donee, a lot of us are familiar with the general category of heart disease, but we are now realizing that there are a lot of subcategories of related illnesses that are  connected to heart disease.  Why do we need to know about PVD or peripheral vascular disease?  What is it and why is it relevant to us?

    PATTERSON: OK, I just want to step back and add to something you said.  If you have high blood pressure, high cholesterol, have had a heart attack, whether you are over 50 or not, or have diabetes or someone you know has one of those things, then you need to listen in today.  Don't tune out; this is definitely going to affect you and may change your life.  It may save a limb; it may save your life.  Peripheral vascular disease is talking about the arteries and the veins in our bodies.  We know that heart disease is the number one thing that is a killer for African Americans but just Americans in general, men and women.  The arteries that lead to and from the heart can be affected as well.  Today, we are going to talk about this disease because it is often some silent symptoms that are going on and we want people to know; to be advocates for themselves and to know what to look for and to know what tests to ask for and to know that this can definitely affect your life.  If you are having some damage to these vessels, you could be at risk for having a heart attack or stroke; you can be at risk for losing a limb; so we want to teach you about this; we want to teach you who you need to talk to; the questions you need to ask and the tests you need to get.

    LOMAX-REESE: So let's turn to you, Dr. Choudry.  You are a vascular surgeon.  Tell us, first of all, what exactly a vascular surgeon does.

    CHOUDRY: Again, thanks for having me here; it is a privilege to speak to your audience members.  A vascular surgeon is a surgeon who, after they complete the general requirements of becoming a general surgeon or surgeon who specializes in various aspects of the human body, goes on to do additional training in both open as well as what we call endovascular procedures that assist in repairing diseases of the arteries.  A good segment of our training is spent on the conservative management, diagnosis and proper treatment of these diseases, not just doing procedures in and of themselves.  In addition to peripheral vascular disease, vascular surgeons also fix blockages of the arteries that go to the brain and also the main artery in the body, known as the aorta often is diseased with things such as aneurysms or when an artery starts to become ballooned out and these are very easily fatal problems that we often have to intervene to do surgery on.

    LOMAX-REESE: We are going to get to prevention and treatment and all of those things in just a minute, but I am curious, as a surgeon, this seems like, as a vascular surgeon, very precise, very careful, very delicate surgery.  How do yo prepare yourself psychologically to do this kind of work?  That is one question, and what kind of technology has evolved to make it more efficient and effective to do this kind of surgery?

    CHOUDRY: I think it is a certain type of personality that enjoys working on patients with vascular disease because of the technical aspects.  A lot of the things we do often take hours to complete and I think you have to be ready to stand in one position to do that and there are the physical challenges involved as well as the mental challenges of having someone start bleeding on the operating room table.  All those things I think become a part of your personality and your core structure as a surgeon as time goes on and you develop a practice.  Your comment about the technology changing, since even when I trained in general surgery many years ago, the technology has come once over.  In the old days when we thought about becoming a vascular surgeon, everything was suppose to be about big incisions and taking our veins and doing bypasses with the microscope loops and things and since then it is overwhelming that the majority of things we can do for patients with vascular disease is what we would call through the skin or percutaneous.  My practice, about 80% of the people go home the same day, only a few hours after the procedure, whether we are fixing veins or arteries.  With aortic aneurysms and bigger operations, they typically will go home the next day.  So a lot has changed and the technology that now we are using a lot more ultrasound and x-ray guidance, CAT scanning, all those things you read about in the papers to fix the problems that we where initially just using them to diagnose the problem.

    LOMAX-REESE: That is Dr. Rashad Choudry and he is a surgeon at the Einstein Department of Vascular Surgery.  Dr. Donee, let's talk about…the  reason I said if you are African American and over 50 you should listen up is because I was looking at some information from the National Heart, Lung and Blood Institute and it said your risk increases if you are, and the number one thing says is if you are African American.  I was like wow.  So talk about why African Americans are more than twice as likely to have peripheral vascular disease than their white counterparts.

    PATTERSON: Well we talked many times a bout diabetes and hypertension and high cholesterol.  Actually we have cholesterol coming up in a couple weeks, but all those diseases are higher in African Americans because of sometimes our lifestyles, sometimes our access to health care, our genetics, and so all oft those risk factors lead to higher risk of peripheral vascular disease.  So if you have hypertension and you are African American, if you have diabetes and high cholesterol, all those things are additive and they increase your risk of peripheral vascular disease.  

    LOMAX-REESE: Smoking is a major risk factor.  I wanted to see, Dr. Choudry, if you could talk about, because one of the things that I saw was that it is pretty difficult to diagnose.  A lot of times you don't know that you have this until there is a significant event.  So what should people be looking out for from a diagnosis or prevention standpoint?

    CHOUDRY: I think true to the statement, about 20, maybe 25% of people who have peripheral disease, and I will generalize the term to say not just peripheral artery disease but peripheral vascular disease are what we would call asymptomatic.  They walk around, they go to their jobs, they take care of their children and for the most part they don't have any specific problems.  As Dr. Patterson was just mentioning, the major risk factors for developing peripheral artery disease are specifically the use of cigarettes, and in my research and in looking as to why African Americans and minorities in general would have higher incidents or prevalence of peripheral vascular disease, in my research it has come to the fact that there is a higher rate of diabetes.  The majority of research that has been done to elucidate peripheral vascular disease and it's outcomes in African American people has been in the diabetes medicine journals.  This is where the rates of amputation and needing surgical operations for vascular problems have really come out from.

    LOMAX-REESE: So let's talk about diabetes and I know that usually falls under the prevue of an endocrinologist I believe but what is it about diabetes that damages your arteries or your veins?

    CHOUDRY: Diabetes affect on the heart tends to reek it's havoc on the smaller vessels and in vascular surgery and as vascular specialists, what we see is  it is usually the arteries below the knee joint that are most affected in patients with diabetes.  For the reasons of hyperglycemia or high sugar in the blood, the body has a tendency to place calcium as well as cholesterol in those vessels.  Another unique place where diabetes tends to do a lot of damage is in the foot itself.  The higher your sugar the more chances you are going to have problems with feet as well as problems in the leg arteries.  I don't think the exact nature of the mechanism is revealed yet but certainly we know that the higher the sugar in the blood the more global changes there are in the vessel wall itself.

    LOMAX-REESE: Dr. Donee?

    PATTERSON: We do know that inside the blood vessel wall, sugar is toxic to the inside of the lining and it actually destroys the inside of the lining.  A lot of times people say to me if I have high blood pressure or if I have diabetes, if I get on the medicine that means I am going to be on it for life, and often that is because the inside of your lining is actually damaged and a lot of people don't realize that high blood pressure actually has an inflammatory component that damages the inside of the blood vessel and it builds up plaque.  It's this cholesterol, fatty substance that builds up inside the lining.  People that have high cholesterol diets it also adds to that and then you have diabetes that adds to the damage of it and then you smoke and that adds to the damage of the inside of the vessel.  So the inside of the vessel is actually being damaged.  Eventually some people will get to the point where their arteries get clogged and they have a higher risk of having a heart attack or stroke because if the arteries are clogged to the heart, a person will have a heart attack and if the arteries are clogged to the brain, a person can have a stroke.  All these inflammatory process that damage the inside of the vessel are what's leading up to it.  We are talking today because there are ways to prevent it and we really hope that people listen and again, are self advocates for themselves and ask for the risk testing and make some lifestyle changes.  Number one thing you can do is have lifestyle change to prevent these things from happening and hopefully prevent having a heart attack or stroke or loss of a limb which totally changes a life; totally changes your quality of life; changes how you can work; often leads to depression and has so many repercussions.  

    LOMAX-REESE: So let's step back.  I do want to get a little bit deeper into prevention and some of the things you were just referencing.  You talked about high cholesterol and the clogging of the arteries and I believe the technical name is arthrosclerosis.  One of the things I was reading in some of the research is that the clogging of the arteries process can actually being very early in life, actually in childhood for some people.  Dr. Choudry, can you talk a little bit about that because I think we often feel like children are immune to just about everything and they can eat what they want, they can kind of do what they want and they will have this resilience and they will be OK as long as they can get to a certain age.

    CHOUDRY: Things have definitely changed.  In medical school you see the pathology books and they will show you an artery in a child at age 13 or 14, the plaque that starts generally is called a fatty streak and as you progress through life, the fatty streak kind of minds it's own business and as you develop medical problems and you adapt certain social and lifestyle changes, such as smoking, the fatty streak then has a mind of it's own and it gets blocked and blocked and blocked.  I think what is changing significantly is childhood obesity and the fact that we are seeing diabetes at much earlier ages in people in their 20s, so that whole timeline has shifted I guess to the unfavorable mention of children.  As the decades progress, we are going to be seeing peripheral disease in a much younger patient than we have seen historically.

    LOMAX-REESE: I read an article recently in the Inquirer that said that hypertension and high blood pressure is becoming more prevalent in younger and younger children.

    CHOUDRY: Very much so.  I will be honest, I have spent most of my  years since medical school on Board Street in one hospital or another for training, as well as for practice and without a doubt we have seen younger and younger people come in with high blood pressures well over 200, sugars in the 300s and it's just something we have been forced to get used to but if I were to look back, I think when we were first training and learning how to do vascular surgery, in my career, it was a much older patient that came to our attention.

    PATTERSON: We want to encourage people to…we are going to talk about cholesterol coming up in further shows but cholesterol levels, there is an LDL, which is your bad and there is a HDL which is good.  HDL actually acts like a vacuum cleaning and it goes around inside the blood vessels and it helps clean up those plaques and the LDL is the deposit that kind of clogs the arteries.  Different fruits and vegetables have antiinflammatory components, have antioxidant components, so increasing a diet high in fruits and vegetables usually comes with higher HDL, the good cholesterol and really does help decrease some of these fatty plaques that we are talking about.

    LOMAX-REESE: We are going to get a little bit deeper into that in just a minute.  We are talking with Dr. Donee Patterson, and that was her speaking just then.  She is a family medicine physician with Einstein and Dr. Rashad Choudry, a vascular surgeon also at Einstein.  We are talking today bout heart health but most specifically, peripheral vascular disease.  Stay tuned we will continue our conversation in just a minute.

    LOMAX-REESE: We are back.  We are talking today about heart health. It is American Heart Month, February, and it is also Valentine's month.  Valentine's Day is just in a few days, so it is a celebration, it is an acknowledgement.  It is an understanding of the heart and today to give us greater clarity on heart health is Dr. Rashad Choudry.  He is a vascular surgeon at Einstein and Dr. Donee Patterson, a family medicine physician with Einstein Internal Medicine.  Let's talk about symptoms and what people should look for to be able to raise awareness about maybe I should get checked for this specific illness.  I will go with you Dr. Donee?

    PATTERSON: So as we spoke about, a lot of people don't have symptoms.  About 20% of people just have the classic symptoms but if….

    LOMAX-REESE: Which are what; the classic symptoms?

    PATTERSON: Most of the time the main symptoms is if someone is walking their calves are cramping and when they rest the symptoms actually go away.  So if you have cramping when you walk we call that claudication.  It is a symptom that your arteries may be clamping down.  You can also have achiness in your buttocks area or toe pain or you can have ulcers or sores that just don't heal very well.  All those could be symptoms of other things, herniated disks, or just diabetes with poor wound healing itself, but often that can be a sign of peripheral vascular disease and you should make sure you mention it to your doctor.  Sometimes older people think oh this is just arthritis, this is just pain; I'm just achy because of arthritis and they never think to tell their doctor and just try to take Tylenol until it is very, very late and they may lose a limb.  If your foot or your leg is  cool all the time, especially if one leg is warm and the other is cool or it's dark; it's starting to turn dark or the pulses are going down, those are also symptoms of peripheral vascular disease.

    LOMAX-REESE: So Dr. Choudry, tell us a little bit about…obviously you are a surgeon so you are seeing people who are at the stage that surgical intervention is essential.  What are the treatment options in addition to surgery?

    CHOUDRY: I think it is very interesting, yesterday I saw about 40 or 50 people in the office and it was a long day and I think of those 50 we only booked about 4 or 5 for a surgical procedure or an endovascular procedure such as a stent or an angioplasty.  All things are within the realm of treatment now.  The majority of folks that we saw yesterday were for what we would consider to be an initial evaluation and conservative approach towards their disease.  As Dr. Patterson was stating, the major symptoms, if you have symptoms of peripheral arterial disease, the first is claudication pain.  That comes in three different varieties, mild, moderate, severe and that is pretty much historically accepted way of looking at it.  Claudication in Latin means to limp and that's exactly what people do, literally, they will be walking down the street and the pain will start in the calf or in the  toe and they basically have to stop because if they don't stop they are going  to have the sensation that almost a tourniquet is going on around their calf.  That is the first major category.  The second major category is if this shortness of blood is much more apparent and it's much more severe, you are in the range of what we call pain at rest.  If you are having pain when you first get up in the morning or when you lay flat or all times during the day without even walking a distance to go to the store that is that category of difficulty.  The last and what we consider by the vascular specialist to be the absolutely worse case scenario is when you start actually losing tissue.  Whether that tissue is skin or fat tissue and the worse case is muscles or bones.  These things can develop into ulcers; essentially the body has given up on a territory of tissue where enough blood just couldn't get there.  It's basically a draught.  We see all those in the office but I would say for the patient with claudication our first approach is to control their risks factors, to make sure they are taking their diabetes medications, to make sure they are on a cholesterol agent and doing dietary modification and most importantly that they quit smoking.  I tell patients that if you have claudication pain and you smoke, you basically have developed an allergy to cigarettes' and I think patients sometimes see things a lot differently when they realize they have an allergy.  If they had an allergy to seafood or an allergy to penicillin, they are never going to let someone give that to them.  I tell them the same thing, why are you going to let the clerk at the local store let him sell something to you if you are allergic to it?  If you tell patients in a format that they will understand, I think you will see pretty decent results, especially if they are hurting and they stoop hurting when they do quit smoking.  The most important thing that patients with claudication type of pain and that we counsel them to do is to ambulate.  If you can encourage the body to build better circuits of blood and actually grow blood vessels internally rather than me having to open up a blocked artery through an angioplasty or a stent or even a bypass procedure, number one you saved them from a procedure and surgery that could have side effects and complications but at the same time you overall globally helped their health.

    LOMAX-REESE: So when you say ambulate, do you mean walk?

    CHOUDRY: We want them to walk as far as possible.  Walk up to the pain and then I tell them another 100 feet and then if you have to stop, stop, but stop less each time and sure enough, within the order of about 6-12 weeks, we oftentimes will see an improvement in their overall walking distance.

    LOMAX-REESE: Dr. Donee?

    PATTERSON: I was just going to add to that just that it seems backwards, that exercise would actually help something of this nature, but when you walk you make collaterals, your body almost heals itself and it makes collateral blood flows, meaning arteries branch off and even though they may be smaller arteries, they are still giving oxygen and nutrients to your muscle, bone and tissues.  That walking that Dr. Choudry was talking about actually makes those collateral blood flows and it helps to actually treat yourself.

    LOMAX-REESE: So it all goes back to diet and exercise.  It seems like those are the pillars of good health on every level.

    PATTERSON: And stop smoking.

    LOMAX-REESE: And stop smoking and I would throw in stress reduction as probably a wellness strategy across the board.  I wanted to, as we get ready to finish up, one thing that I have been told helps with inflammation and heart health is omega 3 fatty acids, whether that is in fish oil pills or flaxseed or eating more fish.  I just wanted to get your thoughts on that from a supplement or dietary standpoint in terms of heart health.  Dr. Choudry?

    CHOUDRY: Absolutely.  I would suggest if you have documented peripheral arterial disease is to probably adopt a vegan or a mostly seafood based lifestyle for eating.  In our own house, and we don't have documented peripheral arterial disease, given our lifestyles currently, we have done that and we encourage strongly for people to strongly do that.  The reason I think the omega 3s are very valuable in peripheral arterial disease is truly what you just said, the antiinflammatory affect. As Dr. Patterson was mentioning earlier,  arthrosclerosis is a degenerative process is based on inflammation and if there is anything you can take to quench that thirst of inflammation you are going to hopefully stop arthrosclerosis from getting any worse if it has developed.  We are yet to see the results that omega3s and things that carry omega3s can actually reverse those effects but the family of drugs known as statins which I know there is another segment in the near future on cholesterol, we think the reason it works and the reason it helps peripheral arterial disease by controlling cholesterol is it's affects on inflammation.  You can actually measure the levels of inflammation in a patient with peripheral arterial disease.  There are simple blood tests you can do in addition to omega 3 fatty acids, one of the things we often tell patients to do is increase their folate and vitamin B12 intakes and that is the treatment of choice for elevated homocystine levels which are a direction indicator of the amount of inflammation in your blood stream.

    LOMAX-REESE: Excellent.  Dr. Donee, final thoughts?

    PATTERSON: My final thoughts are, like in every talk, what are people willing to do to improve your life?  There are things that are so delicious and so tasty but we have to push away from them.  We really need to think about our future and how it affects our hearts; how it affects our children; how it affects our blood vessels; how it increases our risk for heart attack and stroke.  What are we going to do different?  I think we should even have an e-mail back and forth or Facebook of people giving us what they are going to do in 2013 to make their lives different and improve their quality of life for years to come.

    LOMAX-REESE: Absolutely.  I want to thank both of you for sharing this very valuable information; it's critical, especially in February, it's Black History  Month, it's American Heart Month, it is Valentine's Day, all important reasons to embrace and celebrate our heart health and our health in general.  Dr. Donee you have a gift to give away?

    PATTERSON: If you need a physician or you want to see Dr. Choudry you can call is at 1-800-EINSTEIN and as usual we have a $25 ShopRite gift card to give away.  If you answer some simple questions on our Facebook page, that's Einstein Health on our Facebook page, you can be eligible to win that gift card.  You can also follow me on twitter for daily health tweets, that is Dr. Donee and follow us on Einstein's Facebook page as well.

    LOMAX-REESE: Excellent. We thank you both.  I appreciate your time and your information; it is fantastic.  I have all kinds of fish oil in my cabinet so I'm going to start taking my fish oil again starting tomorrow. Thank you both for being here.

    CHOUDRY Thanks for having us.

    PATTERSON: Thanks for having us.

    LOMAX-REESE: That is Dr. Donee Patterson and Dr. Rashad Choudry from Einstein.