PAD Awareness Month: An Interview With Emile Mohler, MD

September is PAD Awareness Month, and in recognitionVascular Disease Management  supports vascular specialists in their efforts to increase awareness. VDM interviewed PAD Coalition member Emile Mohler, MD, about PAD and how the healthcare community can educate colleagues and the public.

Q: Could you describe the general state of peripheral artery disease in the United States and globally?

A: Peripheral artery disease is a common, underdiagnosed, and undertreated condition. It is estimated that there are 8 million to 10 million people in the United States with peripheral artery disease, and this condition really deserves a lot of attention because of the associated morbidity and mortality.

Q: How have you been personally involved in increasing PAD awareness over the years?

A: I’ve been involved in organizations such as the PAD coalition, which is a division of the Vascular Disease Foundation that has tried to raise awareness for peripheral artery disease through several events, including PAD Awareness Month and also outreach to Congress to try to educate them on the need for screening for peripheral artery disease and for raising awareness for this condition. 

In addition, we’ve published a paper on a survey of people in the United States, and there’s also one in Canada, in which we evaluated the knowledge of people in the general public about PAD. Unfortunately we found that the public has a relatively low knowledge of PAD in comparison to even relatively rare diseases such as Lou Gehrig’s Disease or multiple sclerosis.     

Q: How do you recommend vascular specialists increase awareness of PAD for the general public and among their
patients? 

A: I recommend that vascular specialists network in their community to raise awareness of the susceptible patient to PAD, and that would be someone with diabetes, or cigarette smokers, certainly cigarette smokers over the age of 50 and even the general public greater than age 70. 

In their referral networks, vascular specialists should educate their colleagues on the need to be vigilant and ask patients simple questions such as, “Do you have calf-muscle discomfort when walking?” and “Is it relieved with rest?” That specific question can actually uncover a fair amount of disease in the population. 

Q: Are there any resources you suggest for vascular specialists to use to educate themselves and their patients on PAD?  

A: There is much published literature for physicians on PAD. For patients in particular, there is a book published called 100 Questions and Answers About PAD. It was authored by myself and Dr. Alan Hirsch to describe in lay terms the diagnosis and treatment of PAD. Another useful resource is the 2005 report “ACC/AHA Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)” which was also updated in 2011 (available at https://bit.ly/k6dwEJ).

Q: Are there any trials of devices that come to mind as most promising for PAD now and in the future?

A: There are 2 areas that are being investigated to try to improve the lives of patients with claudication. They include new stents that are being developed as well as drug-eluting balloons for treating atherosclerotic stenosis from PAD. In addition, there are regenerative therapy approaches using cell delivery or mature vascular cell delivery to stimulate angiogenesis and improve collaterals in patients with PAD.

Q: Is there anything I might have missed that you’d like to add?

A: I think regenerative therapy is the most novel therapy available. There are some clinical trials evaluating drugs for claudication but unfortunately only cilostazol (Pletal) has been proven somewhat effective. So there’s definitely further therapy needed for PAD.

I’d like to add that the recent publication of clinical trials evaluating exercise therapy have been impressive, particularly the CLEVR studies. This is an NIH-supported clinical trial randomizing patients to usual care, supervised exercise therapy, or iliac stenting. The results indicated after 6 months that the patients who received supervised exercise training 3 days a week had improved walking distance and, somewhat better than the improved walking distance seen in patients with iliac disease. Both of these treatments — supervised exercise or iliac stenting — were better than usual care and all patients received a background treatment of cilostazol. So, I think the most compelling message that I would have to patients with peripheral artery disease is to exercise, is to participate in an exercise program and that will likely improve their claudication symptoms and this should be done in the background of a vigorous approach to risk-factor modification including smoking cessation, lowering cholesterol, and controlling diabetes and hypertension. 

Emile R. Mohler, III, MD, is director of vascular medicine at the University of Pennsylvania Health System and professor of medicine at the Perelman School of Medicine, University of Pennsylvania. Dr. Mohler reports consultancy to Merck, Takeda, Pfizer, and GlaxoSmithKline; grants from NIH, Pluristem Therapeutics, Inc., CytoVas, and GlaxoSmithKline; royalties from UpToDate and Wolters Kluwer; and involvement as founder of CytoVas and Flox Medical.