Mr. K., a man of 57 years, arrived with a suspicion of peripheral atherosclerosis. His symptoms include marked leg pains while playing golf, increased fatigue and discomfort in his legs, and reddening of the lower extremities and feet numbness if sitting for prolonged periods with his legs dangling. There are several predisposing factors for peripheral atherosclerosis in his case, such as smoking, overeating, and abnormal blood cholesterol, and further complications are also possible.
Development of Atherosclerosis: Pathophysiological Changes
While the exact etiology of atherosclerosis is not yet known, pathophysiological changes it brings are relatively well-studied. There is a broad consensus that hypercholesterolemia is one of the major triggers behind the development of the disease (Bergheanu, Bodde, & Jukema, 2017). Increased plasma cholesterol levels cause changes in endothelial permeability of the arteries, thus allowing the lipids to migrate into the arterial wall. The resulting accumulation of massive intracellular cholesterol leads to the buildup of plaques on arterial walls (Bergheanu et al., 2017). It leads to vessel narrowing with corresponding complications for circulation and a number of possible complications.
Development of Atherosclerosis: Risk Factors
The first risk factor for atherosclerosis in the case of Mr. K. is his abnormal cholesterol and other lipid levels. As mentioned above, the increase of plasma cholesterol levels is among the main triggers of atherosclerosis, including peripheral atherosclerosis (Bergheanu et al.). The patient’s relatively old age contributes to the risk as well since it means plaques could build up for a long time before Mr. K felt any symptoms. Thus, blood cholesterol level is the first and main risk factor for the patient.
According to Mr. K’s clinical history, he has been smoking cigarettes for some time. Smoking is one more risk factor associated with different types of atherosclerosis, such as carotid artery disease (Aboyans et al., 2017). However, smoking constitutes a particularly prominent risk factor for lower extremity arterial disease, which is another name for Mr. K’s suspected condition (Aboyans et al., 2017). It is also worth mentioning that risk increases with smoking intensity, which requires establishing just how much and for how long Mr. K.is smoking (Aboyans et al., 2017). Therefore, smoking is the second notable risk factor for peripheral atherosclerosis in Mr. K.
Aside from his smoking habit, Mr. K. is also chronically overweight. Excessive body mass and obesity are risk factors associated with atherosclerosis as well. It is not as prominent – or, at least, as frequently quoted – as blood cholesterol level or smoking, but there are studies that associate it with an increased probability of developing atherosclerosis (Roever et al., 2016). Thus, the patient’s body mass index may also be a risk factor for developing peripheral atherosclerosis. It may also indicate unhealthy dietary habits and the propensity for foods high in fats, cholesterol, sodium, and sugar, which is a risk factor in its own right.
Apart from these three factors, it is necessary to address other possible ones. Family clinical history should be accessed for the cases of coronary artery disease, aortic aneurysm, cerebrovascular disease, and lower extremity arterial disease (Aboyans et al., 2017). Physical activity, walking patterns, and other lifestyle habits require attention as well (Aboyans et al., 2017). It is also necessary to assess less typical factors, such as chronic kidney disease, heavy alcohol consumption, and systemic infection (A. Long, B. Long, & Koyfman, 2018). That being done, it would be possible to have a relatively full picture of risk factors for the development of peripheral atherosclerosis in the case of Mr. K.
Cardiovascular events are the major type of complications for patients with atherosclerosis, including lower extremity arterial disease. Plaque rupture and erosion pose a serious risk of coronary thrombi (Bergheanu et al., 2017). It may also lead to the development of chronic limb-threatening ischemia (Aboyans et al., 2017). Proper treatment is essential to avoid these complications or address them should the necessity arise.
The first approach to slow the progress of atherosclerosis relies on general prevention strategies. Smoking cessation is essential, as it both removes one of the most notable risk factors and provides the most notable improvement in patients with peripheral atherosclerosis (Aboyans et al., 2017). It is also necessary to address and prevent passive smoking (Aboyans et al., 2017). For a better result, smoking cessation should be accompanied by regular exercise (Aboyans et al., 2017). Management of other risk factors, such as unhealthy dietary habits or excessive alcohol consumption, is also crucial and should not be neglected.
Medical options for treating peripheral atherosclerosis include lipid-lowering drugs. It is generally advised for patients with atherosclerosis to lower their low-density lipoprotein cholesterol to < 1.8 mmol/L (Aboyans et al., 2017). Should the initial level of low-density lipoprotein cholesterol be between 1.8 and 3.5 mmol/L, it is advised to aim at a ≥ 50% reduction (Aboyans et al., 2017). Statin therapy is the primary means of lowering blood cholesterol.
To improve leg functioning and prevent walking impairment, several medications may be considered along with physical exercise therapy. The best-studied drugs are buflomedil, naftidrofuryl, cilostazol, carnitine, pentoxifylline, and propionyl-L-carnitine (Aboyans et al., 2017). However, the objective documentation of their positive impact is rather limited, and the effects themselves range from mild to moderate (Aboyans et al., 2017). With this in mind, general prevention strategies and statin therapy should be the primary option.
There are several approaches to potential cardiovascular complications. Statin therapy lowers the risk of and the mortality from cardiovascular events, with the effect being especially notable among the patients with lower extremity arterial disease (Aboyans et al., 2017). Antihypertensive and antithrombotic drugs are also beneficial in this respect (Aboyans et al., 2017). These options allow decreasing the risk of cardiovascular complications.
The development of chronic limb-threatening ischemia would require surgical intervention. If the imaging confirms the feasibility of revascularization, it should be attempted, followed by wound care, maintenance, new procedures if mandatory, and management of risk factors (Aboyans et al., 2017). If revascularization is not possible, but the amputation is not mandatory, the proper way to proceed is wound care, pain management, and management of risk factors (Aboyans et al., 2017). If both options listed above prove impossible, amputation with following rehabilitation becomes mandatory.
Mr. K has several evident risk factors for peripheral atherosclerosis, such as abnormal cholesterol levels, smoking, and excessive weight, and potentially several unidentified ones. Possible complications in his case include cardiovascular events and chronic limb-threatening ischemia. Treatment should rely on general prevention strategies and risk factor management combined with statin therapy and, possibly, additional medications to improve the functioning of the leg and reduce walking impairment. Lipid-lowering, antihypertensive, and antithrombotic drugs reduce the risks of cardiovascular events, while chronic limb-threatening ischemia would require surgical intervention.
Aboyans, V., Ricco, J.-B., Bartelink, M.-L. E. L., Björck, M., Brodmann, M., Cohnert, T., … ESC Scientific Document Group. (2017). 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. European Heart Journal, 39(9), 763–816.
Bergheanu, S. C., Bodde, M. C., & Jukema, J. W. (2017). Pathophysiology and treatment of atherosclerosis. Netherlands Heart Journal, 25, 231–242.
Long, A., long, B., & Koyfman, A. (2018). Non-traditional risk factors for atherosclerotic disease: A review for emergency physicians. The American Journal of Emergency Medicine, 36(3):494-497.
Roever, L. S., Resende, E. S., Diniz, A. L. D., Penha-Silva, N., Veloso, F. C., Casella-Filho, A., … Chagas, A. C. P. (2016). Abdominal obesity and association with atherosclerosis risk factors. Medicine (Baltimore), 95(11), e1357. Web.