alexa Management of Patients with Diabetes Mellitus and Peripheral Artery Disease in the General Practice | Open Access Journals
ISSN: 2329-9126
Journal of General Practice
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Management of Patients with Diabetes Mellitus and Peripheral Artery Disease in the General Practice

George Galyfos*, Georgios Karaolanis, Fragiska Sigala and Konstantinos Filis
Vascular Division, First Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
Corresponding Author : George Galyfos MD, Ph.D
Nikis Street, Kifisia, 14561
Athens, Greece
Tel: +30-213-2086243
Fax: +30-210-7707574
E-mail: [email protected]
Received: July 13, 2015 Accepted: July 15, 2015 Published: July 15, 2015
Citation:Galyfos G, Karaolanis G, Sigala F, Filis K (2015) Management of Patients with Diabetes Mellitus and Peripheral Artery Disease in the General Practice. J Gen Practice 3:e107. doi:10.4172/2329-9126.1000e107
Copyright: ©2015 Galyfos G, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Related article at Pubmed, Scholar Google

Visit for more related articles at Journal of General Practice

Abstract

Peripheral artery disease (PAD) has been associated with specific risk factors such as smoking, diabetes mellitus (DM) as well as previous coronary and cerebrovascular disease [1]. The prevalence of DM for all age groups worldwide was estimated to be 2.8% (171 million) in 2000, a figure that was predicted to double over the subsequent two decades [2]. Moreover, approximately 20% to 30% of patients with diabetes also have PAD. Diabetic patients are at high risk for PAD characterized by symptoms of intermittent claudication (IC) or critical limb ischaemia. Furthermore, the presence of PAD identifies those at increased risk of ulceration, failure to heal an ulcer, and amputation [3]. Finally, patients with IC and DM have more risk cardiovascular factors, cardiovascular conditions, disability and worse haemodynamic status and quality of life than claudicant patients without diabetes [4]. Therefore, proper diagnostic and therapeutic management of such patients in the general practice is a crucial matter in order to decrease morbidity and improve quality of life.

Editorial

Peripheral artery disease (PAD) has been associated with specific risk factors such as smoking, diabetes mellitus (DM) as well as previous coronary and cerebrovascular disease [1]. The prevalence of DM for all age groups worldwide was estimated to be 2.8% (171 million) in 2000, a figure that was predicted to double over the subsequent two decades [2]. Moreover, approximately 20% to 30% of patients with diabetes also have PAD. Diabetic patients are at high risk for PAD characterized by symptoms of intermittent claudication (IC) or critical limb ischaemia. Furthermore, the presence of PAD identifies those at increased risk of ulceration, failure to heal an ulcer, and amputation [3]. Finally, patients with IC and DM have more risk cardiovascular factors, cardiovascular conditions, disability and worse haemodynamic status and quality of life than claudicant patients without diabetes [4]. Therefore, proper diagnostic and therapeutic management of such patients in the general practice is a crucial matter in order to decrease morbidity and improve quality of life.

Regarding diagnosis, inconsistencies of clinical findings in the diagnosis of PAD in diabetic patients are frequent [5]. However, detailed medical history including a systematic review of symptoms (walking impairment, claudication, ischemic rest pain, and/or nonhealing wounds) as well as careful clinical examination should be included in the initial management of such patients, especially over 50 years old with atherosclerosis risk factors [6]. According to recent Guidelines, patients at risk for PAD such as the diabetic patients should undergo comprehensive pulse examination and inspection of the feet (Class I; Level of Evidence C) [6].

The measurement of ankle-brachial index (ABI) in both extremities has also been recommended in order to verify the presence of PAD and assess additional cardiovascular risk in patients with DM (Class I; Level of Evidence B) [6]. A recent meta-analysis has shown that ABI in combination with Framingham risk score may improve the accuracy of cardiovascular risk prediction [7]. Specifically in patients with known DM, those with low (< 0.9) and high (>1.4) ABIs are both at higher risk for cardiovascular complications [8,9]. Additionally, very high (>1.4) as well as very low (< 0.4) ABI has been associated with increased mortality in diabetics [10]. However, increased arterial calcification and stiffness may limit the predictive value of ABI in diabetic patients leading to a large number of falsely high measurements. However, data indicate that other tools such as the toe-brachial index could overcome such limitations in patients with increased ABI (>1.4) [6,11]. Finally, in patients with normal resting index and symptoms of IC, ABI should be measured after exercise as well [6].

As aforementioned, patients with DM show an increased cardiovascular risk [1]. Prediabetes and DM have been independently associated with the development of subclinical myocardial damage and furthermore, with the occurrence of clinical coronary events [12]. Coronary artery disease remains the single most common cause of death in diabetics who frequently fail to perceive the classical symptoms of coronary disease [13]. Therefore, an initial evaluation including clinical examination, electrocardiogram and cardiac risk stratification is recommended even in asymptomatic patients with more than one risk factor. However, data so far does not indicate that screening with cardiac imaging reduces total cardiovascular events in asymptomatic patients. Regarding carotid artery disease, patients with DM show a very high prevalence of subclinical carotid atherosclerosis [14]. At present, carotid ultrasound is recommended in diabetic patients with cerebrovascular symptoms. However, the probability of finding a carotid stenosis >60% is highest in diabetics with known coronary artery disease or a decreased ABI [15]. Therefore, the screening criteria could be extended in such patients. Finally, there is strong epidemiological evidence that patients with diabetes have a lower incidence as well as expansion rate of abdominal aortic aneurysm (AAA) [16], although the link between diabetes and AAA development and expansion is still unclear. A number of studies have supported the hypothesis that protection is the result of diabetes-mediated changes in the vascular extracellular matrix biology, although there is the theory that treatment regimens used in diabetes may afford protection against AAA due to their pleotropic effects [17]. However, clinical suspicion – when present - should always be verified with duplex ultrasonography.

Regarding early therapeutic measures, modification of major risk factors is imperative in general practice to improve symptoms and quality of life. First of all, cessation of smoking has been associated with increase in the walking distance and reduction of overall caridovascular risk [1], and therefore, it is strongly recommended [6]. Furthermore, regulation of antidiabetic treatment and proper diet are necessary in order to reduce hemoglobin A1C to less than 7% and thus, reduce microvascular complications and potentially improve cardiovascular outcomes [1]. Finally, proper foot care, including use of appropriate footwear, daily foot inspection, skin cleansing, or use of topical moisturizing creams, should be encouraged and skin lesions/ulcerations should be addressed urgently [1].

One of the milestones of proper management in patients with DM and PAD is regular exercise. Supervised exercise training should be performed for a minimum of 30-45 minutes, in sessions performed at least 3 times per week for a minimum of 12 weeks [1]. A recent meta-analysis showed that regardless of exercise length and modality, regularly intensive walking exercise improves walking ability in PAD patients more than usual care control, although the presence of diabetes may attenuate the improvement of walking performance in patients with PAD following exercise [18]. This could be justified as peripheral neuropathy, decreased muscle strength as well as obesity have been associated with walking in diabetics [19]. Regarding prediabetes stages, the American Diabetes Association (ADA) recommends that adults with prediabetes engage in ≥ 150 minutes per week of moderate activity and target a 7% weight loss [20]. Finally, recent studies conclude that everyday exercise programs do not only improve cardiovascular function but also improve overall mental health in diabetics [21].

Concerning proper medical therapy, a strategy of combined antihypertensive, antiplatelet and antihyperlipidemic therapy is optimal. Traditionally, the prescription of aspirin (75-325mg daily) or clopidogrel (75mg daily) has been associated with reduction of MI/stroke/vascular death risk and therefore, their daily use has been recommended [1]. However, recent data have shown that a newer antiplatelet drug, namely cilostazol (100mg twice daily), improves symptoms and increases walking distance due to its pleotropic effects (in patients without heart failure) [22]. Additionally, in patients with diabetes, a goal of less than 130mmHg systolic and 80mmHg diastolic arterial pressure should be achieved [1]. Angiotensin-converting enzyme (ACE) inhibitors as well as beta-blockers are reasonable choices to reduce the risk for adverse cardiovascular events [1]. Furthermore, statins have shown beneficial effects on several diabetic complications and predisposing risk factors such as endothelial dysfunction, oxidative stress and inflammation, metabolic syndrome, renal disease and others [23]. Low-density cholesterol levels should be lower than 100mg/dl in patients with PAD, and high-density cholesterol levels should remain high. When triclycerides levels are high as well, fibric acid regimens could be added [1].

In conclusion, the general practicioner plays a very important role in early diagnosis and management of a patient with DM and symptoms of PAD. Early measures could improve all-day quality of life as well as reduce overall cardiovascular risk in such patients. When there is a failure of conservative management or there is an indication for further invasive investigation or treatment, the patient should be referred to a specialist vascular surgeon immediately.
 
References
























Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Relevant Topics

Article Usage

  • Total views: 11974
  • [From(publication date):
    September-2015 - Oct 20, 2017]
  • Breakdown by view type
  • HTML page views : 8135
  • PDF downloads :3839
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri, Food, Aqua and Veterinary Science Journals

Dr. Krish

[email protected]

1-702-714-7001 Extn: 9040

Clinical and Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemical Engineering and Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001 Extn: 9040

Earth & Environmental Sciences

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

General Science and Health care Journals

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics and Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001 Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Informatics Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Material Sciences Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Mathematics and Physics Journals

Jim Willison

[email protected]

1-702-714-7001 Extn: 9042

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001 Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

John Behannon

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001 Extn: 9042

 
© 2008-2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version
adwords