Vascular Disease Awareness Month

In 2016, cardiovascular disease (CVD) was the leading cause of death in the United States, claiming over 900,000 lives. All too often we hear these startling statistics and fail to understand their impact on our daily lives. Most CVDs can be prevented by addressing behavioral risk factors like smoking, unhealthy diet, and obesity. Early detection of CVDs is a crucial factor in obtaining appropriate disease management; therefore, it is imperative we educate ourselves and patients to intervene at earlier stages.^1-2

The cardiovascular system consists of the heart and a closed system of vessels called arteries, veins and capillaries that play a vital role in maintaining balance within the body via controlled movement of blood through thousands of miles of vasculature.³ Diseases affecting the cardiovascular system are a group of disorders that affect the heart and/or the blood vessels. The most common CVDs in all states across the U.S., being atherosclerotic vascular diseases, are colloquially known as “clogged arteries”. Atherosclerosis is the buildup of fats, cholesterol, and other substances in and on the arterial walls causing arteries to narrow and block blood flow.⁴ Common types of atherosclerotic vascular disease include ischemic heart disease, stroke, aortic aneurysm, and peripheral artery disease.¹ Of the atherosclerotic vascular diseases mentioned, peripheral artery disease or PAD, is the third leading cause of cardiovascular morbidity worldwide and affects over 20 million people in the United States.^5,6 PAD can also contribute to the development of chronic wounds and ulcers in the lower extremities due to decreased blood supply and prolonged vascular pressure. Factors related to the development of chronic wounds in patients with PAD include infection, smoking, diabetes, and other metabolic and nutritional disorders, immunosuppression, immobilization, and age.^5,6

Critical limb ischemia (CLI) is the most severe form of PAD and is associated with a high rate of lower extremity amputations typically exceeding 15-20% of patients with CLI within 1 year of symptom presentation. These amputations are oftentimes due to insufficient wound management.^5,7 More than 80% of patients with CLI who undergo major amputations will not survive more than 5 years post-amputation.⁵ Because of the health-associated risks and economic burdens accompanying amputations in patients with CLI, more effort has been made in recent years to improve amputation prevention, particularly through improved access to appropriate diagnosis, revascularization of the lower extremities, and wound care. Management of wounds in patients with CLI is challenging and requires treating healthcare providers (HCPs) to be well-educated in wound care. Evidence in the literature suggests that lower extremity wound outcomes regarding morbidity and mortality may improve when multidisciplinary care teams are engaged to evaluate, treat, and manage patients with lower extremity wounds.^8,9 Skillsets that may be included in the multidisciplinary care team are endovascular revascularization, surgical revascularization, wound healing therapies and foot surgeries, and medical evaluation and care.⁸

While CLI may cause significant health complications, public knowledge is lacking with frequent underdiagnosis and undertreatment until lower limb symptoms become severe.¹⁰ Today HCPs are confronted by an aging population with increased incidence of vascular disease-associated risk factors such as smoking, diabetes, hypertension, and hyperlipidemia. These factors are directly related to the increasing prevalence of lower extremity wounds associated with morbidity and mortality. It is crucial that physical examination, noninvasive imaging evaluations, diagnosis, and intervention are implemented earlier in the continuum of care to mitigate the risks associated with lower extremity wounds in patients with CLI.⁹

The need to limit major amputation, secondary to PAD, is a priority recognized by several societies and leaders in vascular care due to the costly and morbid challenges associated with the disease and its consequences.¹¹ Prevention of wounds and the minimization of tissue loss in patients with PAD can be achieved in part with foot examination, prompt recognition of foot infections, and patient education.⁸ It is particularly important to educate patients with PAD who also have diabetes with peripheral neuropathy. Any untreated foot infections can lead to tissue loss or gangrene in patients with PAD; therefore, it is important that HCPs diligently examine patients for signs of infection and provide prompt referrals to appropriate members of a multidisciplinary care team. Local pain or tenderness, periwound erythema or edema, induration or fluctuance, pretibial edema, discharge, a foul odor, visible bone or a wound close to the bone are all signs of a foot infection in patients with PAD. Systemic inflammation may also be a symptom.¹²

Education for patients on how to reduce wounding and/or tissue loss should include healthy foot behaviors, such as daily inspection of feet, wearing shoes and socks while avoiding barefoot walking, proper footwear, and the importance of communicating to their HCP when new foot problems arise.^8,12 Furthermore, empowering patients by educating them on their condition and actions they can take that will enable them to play a role in their treatment journey may motivate them to learn more about their health and illness and develop an increased desire to self-monitor for symptoms and care for themselves accordingly.⁵

For the latest updates on StimLabs, information on disease states that may create risk factors for chronic wounds, and non-medicinal educational patient tips, please follow StimLabs Unprocessed.

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1. Roth GA, et al. The Burden of Cardiovascular Disease Among US States, 1990-2016. JAMA Cardiol. 2018 May 1;3(5):375-389. Doi: 10.1001/jamacardio.2018.0385. 2. Cardiovascular diseases (CVDs) Fact Sheet. World Health Organization. Last updated 11 June 2021. https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds). Accessed 26 August 2021. 3. SEER Training Modules, Cardiovascular System. U.S. National Institutes of Health, National Cancer Institute. Accessed 26 August 2021. https://training.seer.cancer.gov/. 4. Mayo Clinic, Arteriosclerosis/atherosclerosis. Accessed 26 August 2021. https://www.mayoclinic.org/diseases-conditions/arteriosclerosis-atherosclerosis/symptoms-causes/syc-20350569. 5. Olivieri B, et al. On the Cutting Edge: Wound Care for the Endovascular Specialist. Semin Intervent Radiol. 2018 Dec;35(5):406-426. doi:10.1055/s-0038-1676342. 6. Hess CT. Checklist for Factors Affecting Wound Healing. Adv Skin Wound Care. 2011 Apr;24(4):192. doi:10.1097/01.ASW.0000396300.04173. 7. Duff S, et al. The burden of critical limb ischemia: a review of recent literature. Vasc Health Risk Manag. 2019;15:187-208. 8. 2016 AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease: Executive Summary. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017;135:e686-e725. 9. Star, A. Differentiating Lower Extremity Wounds: Arterial, Venous, Neurotrophic. Semin Intervent Radiol 2018;35:399-405. 10. Swaminathan A, et al. Lower extremity amputation in peripheral artery disease: improving patient outcomes. Vascular Health and Risk Management 2014:10 417-424. 11. Goodney PP, et al. Variation in the use of lower extremity vascular procedures for critical limb ischemia. Circ Cardiovasc Qual Outcomes 2012;5(01):94-102. doi:10.1161/CIRCOUTCOMES.111.962233. 12. Peripheral Artery Disease Go-To Guide. American Heart Association. https://www.heart.org/-/media/files/health-topics/peripheral-artery-disease/pad-toolkit.pdf?la=en. Accessed 22 August, 2021.