Peripheral Artery Disease

Peripheral Artery Disease 

Treatment options for patients with peripheral artery disease (PAD) are limited, so working with these patients can be frustrating. PCNA has put together these helpful tools for clinicians who see patients with PAD.

Get Your Patients Walking



Exercise Program

Research in vascular exercise has demonstrated remarkable improvement in symptoms of leg pain (claudication) without expensive or invasive interventions. Regular walking programs are extremely helpful for patients with PAD and intermittent claudication.

Download the instruction sheet (PDF) for getting patients stated with an exercise program>

exercise_program_for_indivduals_with_pad

Patient Perspective



Link Between PAD and CAD




Cardiac Rehab Connections




A free tool kit on delivering SET for PAD, “Healthy Steps for Peripheral Artery Disease” has been made available for this purpose and can be accessed through the AACVPR website (PDF download).

Video Transcripts

Walking Program

Hello! I am Jane Nelson Worel, Nurse Practitioner and Director of Clinical Education at the Preventive Cardiovascular Nurses Association.

Our topic today is What You Can Do to Help Patients with PAD Feel Better Today. Because treatment options are limited, working with patients with peripheral artery disease, PAD, can be frustrating.

Symptoms such as leg pain or weakness when walking, known as claudication, limits the distance and duration the patient can walk without rest. This can make climbing stairs or activities of daily living difficult—and the pain may even persist when the individual is resting or lying down.

How can you help these patients feel better today?

Regular walking programs are extremely helpful for patients with PAD and intermittent claudication. 
Studies have demonstrated that participants in a walking program may be able to walk up to three or four times farther and have less leg pain within twelve weeks. This benefit can be a significant motivator for patients.

Walking may seem counter-intuitive to your patients, so it is important to provide guidance as to how to start, build and maintain their walking program.

A set of written instructions, such as those found on the PCNA web site at pcna.net/PAD, may help patients and their families/caregivers remember what you have discussed during the clinical visit. This is also a great way for patients to track progress. 

As you are discussing the walking program with your patient and perhaps their family/caregiver, it is important to assess their readiness to make changes and their perceived ability to change. You can assist by listening for potential barriers and helping the patient identify possible solutions.

Based on your patient, identify a starting place for their walking program. The goal is 30-45 minutes of total walking time (not counting rest breaks) and it may take several weeks to build to this level.
It is important to review the pain scale with your patient so that they can identify when to continue and when to stop walking. 

On a treadmill, the patient should set the speed and grade at a level that brings on claudication pain within 3 to 5 minutes. The patient should then walk at this rate until they experience claudication of moderate severity, rest until the pain improves, and then continue walking. 

Over time, the patient should be able to walk longer at the designated speed and grade. At this point, the speed and grade should be increased until the patient experiences the pain within 3 to 5 minutes once again. 

An example of your initial instructions to a patient might be, “Please begin your walking program with 5 to 7 minutes of walking 3 times per week. Remember to rest when your leg pain is an 8 to 9 on the pain scale.”

If your patient does not have access to a treadmill, a park or shopping mall that provides a level walking surface and comfortable spots to rest – such as a bench – will do. Apartment dwellers can also use the hallways of their buildings.

It is important to note that patients with PAD are at high risk for coronary artery disease. Make certain to provide your patients with instructions as to how to identify symptoms including chest pain or shortness of breath, and identify the steps they should take if they experience angina or heart attack-like symptoms. 

Managing risk factors associated with cardiovascular disease is important for those with PAD. Lowering cholesterol, quitting smoking and improving blood sugar and blood pressure control may improve claudication symptoms while reducing the risk of heart attack and stroke. 

In conclusion, you can help your patients with PAD feel better starting today. Thank you for taking time to join us, and please visit pcna.net/PAD for additional information and resources. 

Patient Perspectives

SUSAN: Welcome to today’s topic, How PAD Impacts Your Patients’ Lives. I am Susan from northern Colorado. In this video, we will cover the impacts of peripheral artery disease on patients, as well as their families and caregivers. 

Many of us take for granted that we can relatively easily move from point A to point B—whether we are traveling up or down stairs, grocery shopping, getting from the car into a friend’s house or even navigating through a shop or restaurant. For patients with PAD, even these tasks can seem insurmountable.

Let’s get the perspective of a patient. I’m here with Betty, and she’s had PAD for about a year. Betty, can you tell us about the types of symptoms you have experienced?

BETTY: You bet I can Susan. The first symptom I experienced was leg pain. When I was walking around places like the grocery store, my leg would start to hurt and even tingle. At first, I thought it might be because I was over-tired or had somehow pulled a muscle or something, since the pain went away when I stopped walking, but then it kept happening.

Then I figured it was just because I was getting older and that everyone had this type of pain. I didn’t know at first that it was PAD.

SUSAN: So Betty, did the symptoms impact your family in any way?

BETTY: At first, the symptoms weren’t as frequent and it didn’t make much of a difference. But as time went on and I wasn’t able to walk very far without any pain, my family definitely was impacted. I had to rely on help to even walk my dog!

I couldn’t walk up the stairs anywhere without pain, so I relied on my family to get things in and out of the basement when they were needed. We’d have to really consider our plans with friends in case there were stairs at their homes and decide if it was really worth the effort. In commercial buildings, I was always looking for an escalator or elevator if it was available—and often times, these are much further away than you expect and the additional walking would cause me pain, also.

And I often chose movie theater seats closer to the screen if it meant that I wouldn’t have to navigate any stairs. 

Parking also became more of a challenge—we were always looking for the closest spot for everyday errands and even special events. My family members and friends went out of their way to even drop me off and pick me up at the door of a store, and I’d sit—if possible—and wait for them to park the car and join me.

If I was having a particularly bad day, with pain after walking only a short distance, we’d sometimes miss out on planned activities such as concerts, festivals or other events. Even when I did get to go, I was always looking out for the next place to sit down—and sometimes tell my family or friends to simply go ahead without me.

SUSAN: Betty, were there any other impacts that you noticed?

BETTY: I sure did Susan, I noticed that I was giving up activities that I liked—golf, bowling, church and my service club—because of the walking that was involved. I really felt left out, and kind of angry that I had to make so many changes in my life. 

I also felt guilty because I know that some of my past choices, like years of smoking, have put me at risk for conditions like PAD. 

SUSAN: Betty, what advice would you give to someone who thinks they might have PAD symptoms?

BETTY: Susan, I would tell them to talk to your doctor or nurse like I did. When I was diagnosed with PAD, we decided on what to do together. For me, it worked to start with lifestyle changes to help get my underlying conditions under control. We’ll look at other treatment options if this isn’t enough.

Also, it has been helpful to talk with people about my experience—although it was tough at first because I was really embarrassed by my limitations. My clinic has a support group for patients—and I also talked with some friends at my service club about feeling left out of things. Everyone was very understanding and provided some great perspectives—and they made me feel better when I was having a bad day.

SUSAN: Well Betty, thank you so much for sharing your experience with us.  Understanding the impacts of PAD on patients, families and caregivers helps all of us provide the best possible care and continue to work towards the best patient outcomes.

For other topics in this series, additional information and resources, please visit pcna.net/PAD. Thank you for joining us. 

Link Between CAD and PAD

Hello, I am Kim Newlin from Sutter Health and PCNA, and I’d like to welcome you to today’s topic, the Link Between PAD and CAD.

Peripheral arterial disease (PAD) is the term used to describe atherosclerosis of the extremities and is estimated to be present in up to 20% of patients older than 60 years.

PAD most commonly occurs in the lower extremities and can range in severity from an asymptomatic drop in ankle pressures to life- and limb-threatening disease.

It is important to identify and treat individuals at risk for, or with PAD. Many patients may mistake the symptoms of PAD for something else, and the condition may be undiagnosed by healthcare professionals.

The risk factors for PAD include diabetes, hypertension, hypercholesterolemia, family history of PAD/CVD and, especially, smoking. It is important for nurses and advanced practice providers to assess patients for PAD especially when one or more of these risk factors are present.  

While untreated PAD may lead to gangrene and amputation, individuals with PAD are also at higher risk for coronary artery disease, heart attack or stroke. 

The link between PAD and CVD is significant. Just 1 to 2% of those with symptomatic PAD will progress to limb loss, but 75% will die from a cardiovascular event. 

Managing CVD risk factors is critical in PAD patients in order to prevent major cardiovascular events.  
Healthy lifestyle and medications are used to manage CVD risk factors. Patients should be advised to stop smoking, follow a heart-healthy diet and get regular exercise. Counsel patients in lifestyle change using accepted behavior change strategies such as goal setting, regular follow-up, feedback and relapse prevention. 

Medications to manage CVD risk in patients with PAD include aspirin or other antiplatelet therapies along with a statin. Treat blood pressure and blood glucose to accepted goals using guideline-recommended therapies.

It is important to frequently re-assess patient risk factors and assure compliance with lifestyle recommendations and prescribed medications. Regular lab monitoring and feedback regarding CVD health will help keep patients motivated and on track.

Because of the link between PAD and CAD, patients need to be mindful of the signs and symptoms of myocardial ischemia or angina and know what and when to report to health care providers and when it is important to call 9-1-1. Be sure to include this information as part of your patient teaching. Include family members and care givers as well.

For other topics in this series, additional information and resources, please visit pcna.net/PAD. Thank you for joining us. 

Cardiac Rehab Connections

Hello, I am Robin Wedell from Heart Fit for Life, and I’d like to welcome you to today’s topic, PAD: Cardiac Rehab Connections.

In 2017, the Centers for Medicare and Medicaid (CMS), agreed to reimbursement for Supervised Exercise Training (SET) for individuals with claudication due to Peripheral Arterial Disease (PAD). 

The decision from CMS is based on significant evidence demonstrating the benefits of SET that include improved functional capacity, longer pain free exercise times, and improved quality of life. 

CMS coverage includes up to 36 SET sessions over a 12-week period. The following components of SET must be met: 
  • Sessions last 30-60 minutes comprising a therapeutic exercise-training program for PAD in patients with claudication
  • Be conducted in a hospital outpatient setting, or a physicians’ office
  • Be delivered by qualified personnel necessary to ensure benefits exceed harms and who are trained in exercise therapy for PAD, and
  • Be under the direct supervision of a physician, physician assistant or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques.
A face-to-face visit with the physician responsible for PAD treatment is required so that the patient may obtain the referral for SET. 

This visit must also include information regarding cardiovascular disease and PAD risk factor reduction, which should include education counseling, behavioral interventions, or outcome assessments.

SET programs for individuals with claudication can easily be incorporated into Cardiac Rehabilitation programs. Cardiac rehab facilities have the exercise equipment necessary for SET including treadmills and arm ergometers. 

Cardiac rehabilitation nurses have the knowledge and tools to monitor PAD patients to ensure the safety and effectiveness of exercise training. In addition, these nurses are able to provide risk factor assessment and education including smoking cessation, cholesterol and blood pressure management, heart healthy eating and home exercise.

Cardiac rehabilitation staff can obtain the training required by CMS to deliver SET for PAD through AACVPR. A free tool kit, “Healthy Steps for Peripheral Artery Disease” has been made available for this purpose and can be accessed through the AACVPR website (PDF download).

The Healthy Step toolkit will provide cardiac rehab professionals with everything they need to set up PAD SET programing including medical clearance for PAD exercise, pre-exercise evaluation, how to design a PAD exercise program and outcome evaluation.

PCNA has additional resources available regarding PAD patient assessment, how to perform an ABI (ankle brachial index) and home exercise guidelines for patients with intermittent claudication. Find these resources at PCNA.net

With the assistance of the staff and resources of cardiac rehabilitation programs, patients with PAD can feel better, improve their ability to walk and exercise without pain for longer periods of time, and have improved quality of life.

Thank you for all you do with patients with PAD, and for joining us today.