Group 7

LARISCA, Mary Grace L.

LENON, Erik Y.
LINGAT, Danna
MABBORANG, Chanelle Louize I.
MARBIBI, Ian Brenard D.
OLIZA, Jireh Angelo B.
OXIMAS, Kalea S.

Group Preceptor: Dr. Paul Michael R. Hernandez

OUTLINE - Cardiovascular: Peripheral Arterial Occlusive Disease

I. Case Study
In a case report, authored by Janefa et al. (2016), there was a certain Mr. S, a
55-year-old male, who arrived at the outpatient department complaining of non-healing
ulcer on his left big toe that had developed following an injury three months prior, as well
as periodic claudication pain. His condition has made it challenging for him to perform
his everyday tasks. He does not have a notable family history of Peripheral Arterial
Occlusive Disease (PAOD) or any further comorbidities. He has, however, a lengthy
history of alcohol consumption (about 300 milliliters per day for 35 years) and has been a
chain smoker for 38 years, averaging 20 cigarettes each day.

Janefa et al. (2016) added that the distal section of the right Superficial Femoral Artery
(SFA) and both of the bilateral internal iliac arteries had atherosclerotic alterations, as
shown by a CT angiography of the aorta. Furthermore, thrombi were seen in the distal
section of the common peroneal trunk and the posterior tibial artery, which resulted in
partial blockage on the left side and partial luminal occlusion on the right side and the
SFA.

With a normal range of 0.9 to 1.2, the Ankle-Brachial Pressure Index (ABPI) was 1.36 on
the right and 0.91 on the left. Upon physical examination, the patient had weak
peripheral pulses, poikilothermia in the left leg, a non-healing ulcer, and significant
claudication pain. After receiving a diagnosis of PAOD, he was admitted to the vascular
surgery unit and had a saphenous vein graft used during left femoro-popliteal bypass
surgery (Janefa et al., 2016).

II. Background
A. Definition of Peripheral Arterial Occlusive Disease (PAOD)
Peripheral Arterial Occlusive Disease (PAOD) is a chronic condition
characterized by the narrowing of arteries in the legs and arms due to the buildup
of plaque (atherosclerosis), which restricts blood flow to the limbs (Teo, 2023).
This reduced blood flow can lead to symptoms such as pain, numbness, and, in
severe cases, tissue damage.
 B. Prevalence and Risk factors of PAOD
According to the case study by Jenefa et al. (2016), PAOD is particularly
common in older adults and individuals with risk factors like diabetes,
hypertension, and smoking. The primary symptom of PAOD is intermittent
claudication, defined as pain or cramping in the legs during exercise that is
relieved by rest. Diagnosing PAOD typically involves imaging studies to detect
arterial narrowing or stenosis.

C. PAOD as a public health concern

PAOD is a significant public health concern, affecting over 200 million adults
worldwide, with a global prevalence of 1.52% among individuals aged 40 and
older. The incidence of PAOD rises significantly with age, reaching up to 20% in
those over 70 years old. Although traditionally perceived as a disease
predominantly affecting men, recent evidence suggests that the prevalence of
PAOD is equal among elderly men and women. However, males and individuals
in low-income countries, despite having lower overall prevalence, bear a
disproportionate burden of disability and mortality from PAOD. This disparity is
worsened by under-diagnosis in primary care, as many patients do not present
with the typical claudication symptoms described in textbooks. Modifiable risk
factors, particularly smoking, play a crucial role in the development and severity
of PAOD. Smoking, in particular, increases the risk of PAOD fourfold and
significantly worsens disease progression, leading to shorter life spans, higher
rates of critical limb ischemia, and a greater likelihood of amputation. Other
contributing factors include high blood pressure, high cholesterol, diabetes, and a
sedentary lifestyle, alongside non-modifiable risk factors such as age, gender,
and family history (Kim et al., 2023).

III. Pathophysiology
A. The process of atherosclerosis causes intimal thickening and plaque formation,
which decreases the effective radius of the afflicted arterial segment.
1. Atherosclerotic plaque builds up slowly on the inside of arteries.
2. In the early stages of PAOD, the arteries compensate for the plaque
buildup by dilating to preserve flow through the vessel.
3. Eventually, the artery cannot dilate any further, and the atherosclerotic
plaque starts to narrow the arterial flow lumen.
B. Although atherosclerosis is generally a diffuse process affecting all of the arteries
to some degree, some arterial segments in the limb often undergo greater
stenotic lesions (narrowing) than others.
1. It leads to decreased flow capacity during exercise resulting in
ischemic/claudication pain.
2. In some cases, the cause of sudden ischemia may be emboli (blockage in
a blood vessel) either of cardiac origin or from atherosclerotic disease of
the aorta.
3. Emboli tend to be most common at sites of arterial bifurcation or where
vessel branches have an abrupt takeoff.
4. The femoral artery is the most common site for emboli, followed by the
iliac arteries, aorta and the popliteal arteries.

C. The effects of atherosclerosis on blood flow depend on the degree of arterial

narrowing:
1. A decrease by half in its diameter corresponds to a significant loss in its
cross-sectional area, further limiting the blood flow.
2. As the narrowing worsens, the blood flow shifts to smaller arteries, in line
with diseased arteries.
3. The network of smaller vessels never carries as much blood flow as the
main artery.
4. This blood flow restriction represents the hallmark of PAOD and its typical
symptoms.
a) The muscles of the lower extremity require increased blood flow
during ambulation to meet the increased energy demand.
b) Patients with PAD reach a point during walking at which collateral
blood flow is maximized and cannot provide any more perfusion to
the lower extremity muscles.
c) This supply-demand mismatch causes temporary ischemia of the
muscles which manifests as pain, cramping, or fatigue and
ultimately makes the patient with PAD slow down or stop walking.
IV. Common Signs and Symptoms
A. Signs vs. Symptoms
Signs and symptoms differ in that signs are medical conditions found objectively
by a medical professional, while symptoms are subjective and are commonly
experienced by the patient.
1. Signs
Beginning with the signs, in the case study, Mr. S was the patient being
studied, and the following have been observed:
a) History in intermittent claudication pain
b) Ulcer on left toe that does not heal
c) Feeble Peripheral Pulses
This happens when the peripheral pulse rate becomes lower than
the normal range of 60-100bpm.
d) Pokilothermia on the Left Leg
e) Atherosclerotic and Thrombys
The patient's Computed Tomography (CT) angiogram revealed a
fat buildup in the distal part of the right superficial femoral artery
and bilateral internal iliac arteries. A thrombys or blood
coagulation was also noted in the distant portion of the posterior
tibial artery and common peroneal trunk.
f) Increased Ankle Brachial Pressure Index (ABPI)
If the tibial artery is being compressed, the ABPI increases, and in
the case of the patient, it is 1.36 in the right and 0.91 in the left
which is higher than the normal range of 1.2 and 0.9 respectively.

Moreover, further research revealed the following signs that can be

observed:
g) Dependent Rubor
Rochon & Patel (2018) explained that due to the unusual artery
and capillary regulation, the legs turn red when placed in a
drooping position or regarded as dependent rubor.
h) Brittle and Shiny Skin and Loss of Hair on Feet
Because of a lack of blood circulation and a supply of nutrients in
the lower extremities, skin changes occur (Boll, Dreyer & Zemaitis,
2023).
i) Thickened and Opaque Nails
This indicates a foot ulcer or foot sore. The patient is prone to
infection because a lack of blood supply causes wounds to take
time to heal, as explained by Teo (2023).
j) Gangrene
Death of body tissues can possibly arise in the arms or legs if
there is not enough blood flow or a bacterial infection occurs
(Cleveland Clinic, n.d.).

The study of Lilie & Smith (2023) also stated that PAOD is presented in
6P’s, which aside from pain includes:
k) Pallor
 l) Paresthesia
If ischemia is experienced for an extended time, paresthesia
replaces pain.
m) Paralysis
If the severity of extremity pain occurs, there is a possibility that
muscles will be unable to move.
n) Pulselessness
o) Poikilothermia
This pertains to an abnormal regulation of body temperature
contributed by the contraction of arteries (Goldberger et al., 1998).

2. Symptoms
Patients with PAOD commonly exhibit claudication, mostly experienced in
the thigh, calf, or buttocks or in the lower extremity muscles during an
exercise because the arterial blood flow narrows (Cleveland Clinic, n.d.).
To further explain, there are two types associated with this pain, namely
a) Ischemic Pain
This is perceived when a continuous burning pain, which is more
aggravating at night, is experienced.
b) Intermittent Claudication Pain
On the other hand, this type of pain is manifested mostly during
activity because cramps are being experienced in
exercise-induced pain due to limited blood flow or oxygen in
certain limbs.

Aside from the different types of pain experienced, the following can also
be present:
c) Cool/Cold Feet and Loss of Pulse
Icahn School of Medicine at Mount Sinai (2024) explained that
since arteries become narrow, blood flow decreases; thus, these
signs may be experienced.
d) Difficulty in performing daily activities
Claudication pain in the lower extremities causes restricted
mobility and makes daily activities such as walking or climbing the
stairs challenging (National Heart, Lung, and Blood Institute, n.d.).
e) Erectile Dysfunction
ED is commonly associated with PAOD, but the cause of which
remains unknown.

V. Overview of Commonly Used Diagnostics

Diagnosis of PAD is primarily based on information related to family and personal
medical history, conduction of physical examination, and results from laboratory tests
and procedures.
A. Personal health background
To have a complete picture of the patient’s health, the healthcare provider initially
asks for the following information:
 1. Risk factors
Personal lifestyle/diet and potential existing physiological risk factors such
as high blood pressure or high blood sugar
2. Clinical history
a) Personal
Been previously diagnosed with/ has existing medical conditions
like diabetes, chronic kidney disease
b) Family-related
Have had relatives diagnosed with PAD, blood-vessels related
health issues or heart disease

B. Physical examination
1. Checking of weak pulses in legs/arms
2. Use of stethoscope to detect bruit (abnormal vascular sound) which may
signify poor blood flow
Sound of Bruit: https://youtu.be/ToL3vuvdZA0?si=QTN1IuTWaTQjhtJH
3. Look for physical signs of PAD: swelling, pores, and pale skin. (National
Heart, Lung, and Blood Institute, n.d.) and other physical manifestations
of PAD (e.g. hair loss or decreased hair growth on the legs, decreased
toenail growth, etc.)

C. Laboratory tests/procedures
1. Blood tests are conducted to check for possible sources of increased
vulnerability to PAD or complications (example: high cholesterol or high
blood sugar)
a) High cholesterol leads to formation of deposits called plaque
which impede arterial blood flow. Blood clots are triggered when a
plaque ruptures and this can lead to serious blood flow blockages
in the legs. (Mayo Clinic, n.d.).
b) High blood sugar levels indicate hyperglycemia which usually
signifies that the patient is diabetic. The blood vessels may
decrease in elasticity or be clogged by plaque buildup due to
diabetes. Thus, the blood vessels become more susceptible to
blood flow obstruction which also increases the risk for contracting
PAD.
2. A common test conducted to diagnose PAD is called ankle-brachial
index (ABI). In ABI, the blood pressure readings in the arm and in the
ankle are compared before and after subjecting the patient to mild
exercise such as walking or light running. More specifically, the systolic
pressure (maximum arterial pressure during ventricular contraction) in the
upper limbs (each elbow) and in the lower limbs (posterior tibial and
dorsalis pedis arteries at each ankle). The recorded systolic pressure in
the ankle serves as the numerator which is then divided by the value of
the upper limb systolic pressure.
a) Example: In Right ABI = Highest pressure in right foot / highest
pressure in both arms
b) The lower ABI value upon comparing obtained values from each
leg (right/left) is taken as a result for the patient.
(1) ABI values interpretation:

(Stanford Medicine, n.d.).

(2) ABI values ranging from 1.00 to 1.4 are considered normal.
Mild to moderate PAD is indicated by an ABI of 0.5 to 0.9
while severe PAD is indicated by ABI values less than 0.5.
Abnormal ABI results may require further testing for PAD
diagnosis:
(a) Duplex ultrasound
Visualization of the arteries and veins with the use
of sound waves that bounce off blood vessels.
Abnormal results could indicate blockage of arterial
blood flow due to blood clot formation or narrowing
of arteries. (MedLine Plus, 2024).
(b) Doppler ultrasound
A special type of ultrasound that helps detection of
blocked or narrowed arteries.
(c) Computed tomographic (CT) angiography
A non-invasive test that uses x-ray and contrast
agent to visualize blood vessels in the arteries in
extremities.
(d) Angiography
 Involves the injection of a contrast dye into the
artery during an angiogram/arteriogram for it to
appear more clearly in the x-ray. It is taken
afterwards to visualize the blood flow in the arteries
and spot any blockages.

VI. Management with emphasis on public health management/interventions

A. Public Health Perspectives
Despite its critical nature, little priority is given to PAD compared to other
atherosclerotic diseases such as coronary artery disease here in the Philippines.
Other patients would have to undergo amputation despite revascularization
attempts. Currently, treatment of PAD is done too late because prevention is not
prioritized leading to more problems for patients in the country in which
healthcare expenditures are largely out-of-pocket. Leg bypass surgeries range
from 350,000 to 500,000 pesos and leg amputations amount to 50,000 to
100,000 pesos. From here alone, we can see the disparities arising in the
treatment of PAOD (Bernardo, 2022).
1. Disparities in PAOD Care
Grant et al. (2023) enumerated numerous factors contributing to
disparities in treatment and diagnosis of PAOD.
a) Aside from socioeconomic disparities due to disadvantages
brought on the financially challenged,
b) Racial and ethnic minority groups are also at a disadvantage when
it was found that these groups receive greater amputation rates,
suggesting that they receive later diagnoses.
c) PAD is not a population health priority among health systems
(underlying causes such as diabetes and hypertension are more
prioritized).
(1) Lack of accountability, education or awareness on PAD
both of patients and clinicians is also a contributing factor.
(a) Some patients, due to limited knowledge of the
existence of this disease, dismiss symptoms as
normal leg pain.
(b) Clinicians, on the other hand, lack training on early
PAD.
(c) Physical examination and patient history are often
overlooked. It is also hard to assess patient history
(d) There is difficulty in diagnosis due to confusing
diagnosis codes, limitations in space for diagnosis,
and lack of physicians or staff availability in
hospitals. In addition, annual evaluations need to
be followed up.
 (e) There is also no quality performance measure that
helps in monitoring the provision of PAD care to
assess disparities.
d) It is also not a priority in primary care
(1) Diagnosis should not be the sole focus, but avenues for
further care must be diligently sought out for patents.
(2) Emergency room doctors need further education because
some incorrectly diagnose leg pain.
(3) Lack of time to look for early PAD signs through foot
examinations and pedal pulses assessment which are
important in early detection.
(4) Screening for PAD is not usually done because it was only
recently that medical therapy for PAD has been done
based on existing research and evidence.
(5) Lack of access to quality healthcare due to distance and
transportation which could lead to inequitable delays. This
is crucial due to unconsolidated visits in PAD treatment.
e) Lack of ownership of PAD makes it difficult to monitor the
progression of the disease since there is no specialty focused on
such disease.

2. PAOD in the Philippine public health setting

a) Asia-Pacific Consensus Statement (APCS) on the
Management of PAD (Abola et al., 2020)
(1) The Asian Pacific Society of Atherosclerosis and Vascular
Diseases (APSAVD) released the Asia-Pacific Consensus
Statement (APCS) on the Management of PAD that
contained 91 recommendations in accordance with the
2016 AHA/ACC guidelines on the Management of Patients
with Lower Extremity Peripheral Artery Disease to the
Asia-Pacific region and also raise awareness regarding the
disease. The included recommendations covered different
bases of PAD treatment such as history, examination,
diagnosis, treatment and prevention that are more relevant
to the Asia-Pacific Region.
(2) The Philippines was included as part of the discussion as
an APSAVD and was found to have the following risk
factors: Dyslipidemia, Diabetes, Hypertension, Obesity,
and Smoking.
(3) Some notable sections that have greater impacts in the
Philippines included recommendations on the use of
treatment methods such as antiplatelet therapy with aspirin
alone, clopidogrel, and Ticagrelor with the latter two more
expensive compared to ASA. In a study by Antithrombotic
 Trialists' Collaboration (2002), it was found that both ASA
or clopidogrel may be administered to patients with PAD to
prevent nonfatal and fatal vascular events which is
significant to the Philippines with large OOP funds in
healthcare. However, other trials showed that clopidogrel
was more beneficial in reducing the risks of vascular death
or ischemic stroke to up to 23% and is suggested as a
possible monotherapy. In addition, the use of clopidogrel
over Ticagrelor is recommended in the Philippines as there
was no significant evidence showing the superiority of
Ticagrelor which is more costly.
(4) As smoking is one of the risk factors prevalent in the
Philippines, recommendations included targeting this
problem by assisting PAD patients to quit smoking through
pharmacotherapy or smoking cessation referral. The
problem is that treatments that include pharmacotherapy
require bupropion or varenicline that are not readily
available in the Philippines.
(5) Different APSAVD member countries also have differences
in health systems, financial capacities, and availability of
resources, so the Consensus statement may be
customized to favor the current context of PAD in the
participating countries. It is to be disseminated to the
folliowing:
(a) Training institutions such as medical schools to
better equip medical students by incorporating the
recommendations in teaching curriculums as well
as to the cardiovascular departments of hospitals
(b) National health ministries, primary health agencies
and health insurance companies (such as
PHILHEALTH in our case), and other industry
partners
(c) And lastly, dissemination to the public and patients
for awareness on PAD. Currently, this has taken the
form of a pamphlet from the APSAVD which may
be found in the Philippine Heart Association
website with English and Filipino translations for
better understanding.
(6) There is currently no data on the monitoring and evaluation
if the above suggestions are followed through in the
different member countries. However, in general, there are
multiple recommendations for solutions for the
management of PAD (Grant et al., 2023).
 (a) Addressing the difficulty in PAD diagnosis due to
the constraints posed by ABI. It would be beneficial
to look into alternative diagnostics, multidisciplinary
teams to avoid lacking or unnecessary treatment
procedures, and the possibility of having an
advanced practice provided in vascular medicine or
surgery setting for better management and training
for other professionals.
(b) Disparities could be lessened through more
deliberate care coordination and the inclusion of
telehealth technology for better management,
especially in follow-up care for patients.
(c) Finally, health systems should invest more in
prevention and early diagnosis of PAD which could
prove more cost-effective for patients and helps
reduce further cardiovascular risk

B. Levels of Prevention
1. Primordial prevention
This level focuses on reducing risk factors for the entire population by
addressing social and environmental conditions, and measures
implemented for this level of prevention are usually incorporated through
laws and policies (Kisling & M Das, 2023). In the context of preventing
Peripheral Arterial Occlusive Disease (PAOD), manifestations of
primordial prevention can include government policies, such as increasing
taxes on cigarettes and decreasing marketability of tobacco. Furthermore,
as primordial prevention also usually targets the youth, another
manifestation could also include monitoring the physical development of
children who have a family history of atherosclerosis. It is important for
these children to have access to a stable supply of healthy food and be
able to exercise regularly to control possible risk factors that could
contribute to the development of PAOD. That said, it is critical to always
consider socioeconomic and environmental factors and conditions that
could promote disease onset. In another perspective, it is also equally
important to educate the general population about the risk factors of
PAOD, including smoking, diabetes, hypertension, and high cholesterol.
Simultaneously, they shall promote a healthy lifestyle that includes regular
physical activity, a balanced diet, and weight management.

2. Primary prevention
As people age, the likelihood of developing atherosclerosis or the
accumulation of plaque in the arterial walls increases, making PAOD
more common in the elderly. Subsequently, it is critical in the level of
primary prevention to eliminate risk factors for atherosclerosis, which
 includes controlling lifestyle diseases that can hinder physical activity
(American Heart Association, 2016). It is essential for adults to regularly
exercise to improve cardiovascular health and lose weight. In connection,
it is also important to consider one’s diet in conjunction with physical
activity, which is also related to controlling your sugar intake and
cholesterol levels. As such, it is implied that lifestyle choices that promote
diabetes and high blood pressure should be avoided. In that sense, it is
also advised to avoid tobacco use to further prevent development of
atherosclerosis (Hackam, 2005).

3. Secondary prevention
Partnered with early disease detection are efforts to remove any type of
stigma or discrimination amongst affected people of a certain disease.
That said, with lifestyle diseases, it is important for people close to
afflicted individuals with diabetes, high blood pressure, and abnormal
cholesterol levels to identify how to effectively help and assist said
individuals overcome their unhealthy lifestyle and ask for medical
assistance. Part of the challenge is to educate said individuals to
effectively determine if their condition is becoming more severe as time
goes on, which will bolster efforts of early diagnosis and prevention. As
such, the government may also target factors that can promote early
detection of cardiovascular diseases, such as improving the accessibility
and reach of screenings and physical check-ups and enhancing the
available technology for diagnosis, such as the Ankle Brachial Pressure
Index and Doppler Ultrasound (Zemaitis et al., 2023). These measures
will help identify individuals at risk for PAOD, especially those with risk
factors like age, family history, and existing cardiovascular conditions, and
develop early intervention strategies, such as promoting smoking
cessation and controlling blood pressure and cholesterol levels.

4. Tertiary Prevention
Once the onset of PAOD has begun, management of the disease aims to
lower cardiovascular risk and improve physical activity (Zemaitis et al.,
2023). Treatment for PAOD includes certain medical procedures such as
angioplasty, atherectomy, and bypass surgery to relieve symptoms and
prevent disease progression. That said, tertiary prevention usually
includes rehabilitative features such as lifestyle changes including quitting
smoking, lowering cholesterol, controlling hypertension and diabetes, and
supervised exercise programs. Other rehabilitative approaches include
pharmacotherapy involving the use of cilostazol, which is a medication
that promotes vasodilation and suppresses the proliferation of vascular
smooth muscle cells (American Heart Association, 2016). That said, with
rehabilitation, regular monitoring of the cardiovascular condition of
afflicted individuals is required to prevent further complications, such as
 critical limb ischemia, ulcers, and gangrene. Lastly, managing
comorbidities and possible complications through medication like
antiplatelet agents, statins, angiotensin-converting enzyme inhibitors, and
oral anticoagulants is also essential in tertiary prevention (Hackam, 2005).

Overall, all these levels of prevention target different stages of the onset of
disease and by addressing these levels of prevention, healthcare providers can
effectively reduce the incidence and impact of PAOD on patients' lives.
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