Peripheral Artery Disease Care Is Focus of Novel Yale Research Program

Peripheral artery disease (PAD) can significantly impact an individual’s quality of life and, if left untreated, can be fatal. But while multiple treatment options are available, the medical community has not established a standard of care as the condition progresses, which leads to a wide variety of treatment outcomes.

Carlos Mena-Hurtado, MD, associate professor of medicine (cardiology) and Kim Smolderen, PhD, associate professor of medicine (cardiology and psychiatry) and a clinical psychologist by training, came together last year to launch the Vascular Medicine OutcomeS (VAMOS) research program. With its unusual combination of psychology and cardiology, the program is one of the few in the country that strive to quantify vascular health outcomes so that physicians can better understand how to optimize patient care.

“There are overwhelming amounts of patients who exist within our health system and are treated differently depending on where they show up,” says Mena-Hurtado. “One of the missions of VAMOS is to support our clinical program in finding the evidence that exists to treat patients with complex PAD.”

PAD is often a manifestation of atherosclerotic disease—in which a buildup of fatty deposits in the arteries restricts blood flow to vital organs like the brain, kidneys or extremities. In the early stages when it affects lower extremities, it may manifest itself as pain while walking due to a shortage of blood supply to the muscles of the legs. This is often when patients first notice something is wrong, says Smolderen, but they may not know attribute it to cardiovascular disease. “People may walk around with pain for months before they see a doctor,” she says.

Treatment options for PAD depend on its severity. Patients are often first advised to adopt lifestyle changes, such as increasing exercise, quitting smoking, or improving diet. In more advanced stages, physicians may recommend surgery to remove the blockage. Treatment of the disease is critical—if left unmanaged, reduced blood flow to the foot can result in serious consequences such as non-healing wounds or even limb loss. Individuals who are over age 70, have a family history of PAD, lead a sedentary lifestyle, are smokers, or are diabetic face the greatest risk. Although the prevalence of PAD is on the rise, it is an undertreated condition that tends to “live in the shadows” of more recognized conditions like coronary artery disease, says Smolderen.

“There is a lot of unawareness both on the patient side and in the medical community that having leg problems may be an indicator of a very aggressive disease,” she says. “As a result, many patients aren’t diagnosed until PAD has progressed to more advanced stages.”

The VAMOS program is dedicated to improving care for the 8.5 million individuals and counting in the U.S. who suffer from PAD. Through studying large national data sets as well as building its own vascular data warehouse based on Yale New Haven Health System information, the research team hopes to quantify the variability in quality of care that people receive in order to better understand improving treatment outcomes. Their work also includes conducting many hours of in-depth interviews and holding focus groups with individuals affected by the disease to gain a better sense of what the risk factors may be for experiencing adverse outcomes.

“We’re trying to connect with people in ways that would help us better understand what might have been overlooked during their limited times with their doctors,” says Smolderen. “By listening to as many stories as possible, we can put the bigger story out there and request the tailored support needed to help patients be more successful in attaining the quality of life they are hoping for.”

Since the establishment of the program, the researchers have already begun to identify emerging trends. The highest proportion of patients who are affected with late-stage disease, for instance, are younger individuals under 65. These individuals often present with mental health comorbidities such as depression that make it challenging to manage their disease. “Our work shows that if you have depression or another mental health condition early on in life, you are at increased risk of developing cardiovascular disease,” says Smolderen. “Managing stress and depression needs to be a part of cardiovascular disease management.”

The research program is also helping point to the barriers many patients face as they try to access care and how the most vulnerable populations are often at greatest risk for adverse outcomes. People of color, specifically Hispanic adults, for example, often get their vascular care through emergency room visits instead of planned procedures. And by the time they seek care, their disease has often progressed to a dangerous stage. The researchers presented their findings to the American Heart Association earlier this year.

“The dedicated nature of our outcomes research and its interdisciplinary nature open up new perspectives,” says Smolderen. “It is a big departure from the status quo.”