Endocrinologists and Peripheral Vascular Specialists: An Opportunity for Better Care

Researchers and medical professionals have discovered a strong link between diabetes and peripheral arterial disease on a global scale. Patients with diabetes are incredibly prone to developing atherosclerosis — the build-up of plaque in the arteries. Commonly referred to as hardening of the arteries, atherosclerosis “limits the flow of oxygen-rich blood to your organs and other parts of your body.” Consequently, many patients with diabetes develop peripheral arterial disease, as atherosclerosis is the disease’s most common cause.  Thus, a peripheral vascular specialist and endocrinologist partnering with one another can have a powerful positive impact on the health and longevity of their patient by addressing underlying causes which may inhibit their ability to get treatment.

Peripheral arterial disease most typically “occurs if plaque builds up in the major arteries that supply oxygen-rich blood to your legs, arms, and pelvis.” And “numbness, pain, and, sometimes, dangerous infections” can result from the reduction or blockage of blood flow to those body parts.  Peripheral arterial disease is also “a major risk factor for lower-extremity amputation.”

In short, “people who have diabetes do not make enough insulin in their pancreas to metabolize food for energy,” which in turn “causes sugars to build up in their blood and leads to complications.” There are two types of diabetes: Type 1, insulin-dependent diabetes — which comprises 10% of all diabetics,  and Type 2, non insulin-dependent diabetes. Patients with diabetes or those who smoke are at the highest risk of developing peripheral arterial disease. Diabetic individuals often experience sped up atherosclerosis, “accounting for as much as 44% of all-cause mortality.”  And to make matters worse, peripheral arterial disease is accelerated by diabetes, “making these patients more susceptible to ischemic events and impaired functional status compared to patients without diabetes.”

As of 2015, “over 170 million people worldwide [had] diabetes… and the worldwide burden is projected to increase to 366 million people by 2030.”  And although individuals living with diabetes are already considered high-risk for the development of peripheral arterial disease, there are additional risk factors. Obesity, physical inactivity, smoking, hypertension, and bad cholesterol put these patients at “an even greater chance of developing the condition.” Moreover, a family history of cardiovascular disease, stroke, or peripheral arterial disease, as well as the individual’s previous history of coronary artery disease, immensely increases the risk of developing peripheral arterial disease.

In order to ensure that patients are receiving thorough and adequate care, it is imperative to be mindful of the fact that more peripheral arterial disease patients “are asymptomatic rather than symptomatic.” Specifically, of all patients living with peripheral arterial disease, “over one-half are asymptomatic or have atypical symptoms.” Due to a lack of reporting of symptoms from this vast population of asymptomatic patients, the true link between diabetes and peripheral arterial diabetes has been historically difficult to assess. Peripheral arterial disease in patients with diabetes is more commonly asymptomatic due to “the distal territory of vessel involvement and its association with peripheral neuropathy.”  So, patients living with both conditions “may present later with more severe disease and have a greater risk of amputation.”

Treatment Methods for Diabetics

Unfortunately, treatment for peripheral arterial disease patients is often “expensive, owing to [the] need for a variety of diagnostic tests, therapeutic procedures, and hospitalizations.” As a result, routine screenings have been recommended by the American Diabetes Association “for all patients over 50 years of age”. And it should be noted that ABI (Ankle-Brachial Index) screenings are enormously productive for peripheral arterial disease patients who also have diabetes, with “routine screening[s] of individuals over 50 years of age… expected to identify PAD in nearly one-third of individuals.”

In order to minimize the adverse effects of both diabetes and peripheral arterial disease, specialists are advised to initiate and maintain “aggressive treatment of underlying risk factors including optimizing glycemic control, using HMG CoA reductase inhibitors to reduce LDL cholesterol, tobacco cessation, and blood pressure control.” Furthermore, antiplatelet therapy has often been suggested for peripheral arterial disease patients, both with and without diabetes. And therapies geared towards improving limb perfusion — like exercise and weight loss — are encouraged.

Revascularization methods, like traditional bypass surgery and endovascular approaches, are also an often prescribed treatment. However, “the available data suggest that, as in the coronary arteries, patients with diabetes have higher rates of restenosis following angioplasty or stenting.” Although, “history, clinical exam, and the ABI (Ankle-Brachial Index) are simple and effective methods of detecting major restenosis,” they are not foolproof and “may miss silent lesions that may progress to sudden thromboses if uncorrected.” Today’s resources, data, and technology sometimes necessitate major amputations, most typically of a foot or lower extremity, as a result. In an attempt to decrease the number of amputation procedures that take place, specialists have tightened their criteria — operating “only when there is [an] overwhelming infection that threatens the patient’s life, when rest pain cannot be controlled, or when extensive necrosis secondary to a major arterial occlusion has destroyed the foot.”

Overall, it is absolutely crucial for the longevity and health of their patients that peripheral vascular specialists “diagnose [peripheral arterial disease] in patients with diabetes to elicit symptoms, prevent disability and limb loss, and identify a patient at high risk of [heart attack], stroke, and death.” The American Diabetes Association suggests a two-fold care approach for patients with both diabetes and peripheral arterial disease. Endocrinologists and peripheral vascular specialists alike should work with their patients to modify primary and secondary cardiovascular disease risk factors, like hyperglycemia and cigarette smoking. In addition, via a combined effort on the part of both a patient’s endocrinologist and peripheral vascular specialist, peripheral arterial disease symptoms like critical limb ischemia and claudication can be treated to limit the progression of the disease. Understanding the pathophysiology of atherosclerosis in diabetic patients is the key to mitigating and minimizing the cardiovascular risks that are emphasized by peripheral arterial disease. And when specialists “function cooperatively and effectively… in the management of this complex patient population, with the common goal of reducing vascular events that too often result in disability, social decline, and death,” better care can be achieved for patients around the world.

At Avicenna Cardiology, we understand the complexities of diagnosing Diabetes related cardiovascular disease, as well as finding both lifestyle modification and clinical approaches to optimal treatment. Come see us for a screening and consultation today by making an appointment or calling our offices at (347) 558-4094.

About the Author

Azadeh Beheshtian

Azadeh Beheshtian is board certified in cardiovascular disease and internal medicine by the American Board of Internal Medicine. She specializes in interventional cardiology and peripheral artery disease, with a focus on women’s heart health.