Review: Peripheral arterial disease in diabetes: time for a co-ordinated approach to management

Abstract

Peripheral arterial disease (PAD) is a major manifestation of systemic atherosclerosis. A close association between PAD and diabetes mellitus has long been recognised. Substantial morbidity results from PAD-related intermittent claudication, ulceration and critical limb ischaemia, culminating for some patients in limb loss or death. While effective lifestyle and pharmacological treatments are available for intermittent claudication these approaches are widely underutilised. Surgical intervention is indicated in relatively few patients with stable intermittent claudication. However, the high risk of premature death from the consequences of generalised atherosclerosis, notably coronary heart disease, mandates identification and treatment of modifiable cardiovascular risk factors. Sub-optimal management of cardiovascular risk in patients with PAD may reflect disparate and poorly co-ordinated care. Among patients with diabetes, PAD poses additional dangers, arterial insufficiency being a major, and possibly underestimated, component of diabetic foot disease. The combination of PAD and diabetic neuropathy is common, particularly in the elderly, resulting in impaired infection control and delayed healing of foot ulcers. PAD may also cause ischaemic ulcers. The contribution of PAD to duration of hospitalisation and longer-term clinical outcomes remains uncertain. There appears to be scope for improving the efficiency of clinical care for patients with PAD. A co-ordinated multi-disciplinary approach is required to deliver optimal care to these patients. Modifiable cardiovascular risk factors should be identified and treated. Deficiencies in podiatry and related services in the UK need to be addressed.