Arq Bras CardiolabcArquivos Brasileiros de CardiologiaArq. Bras. Cardiol.0066-782X1678-4170Sociedade Brasileira de Cardiologia - SBC6ZLrw7kGythsMQ9dnTYQ4rJS0066-782X201900090041710.5935/abc.20190208Short EditorialAspects of Non-Pharmacological Treatment in Peripheral Arterial Disease0000-0003-4877-3304AlvesMaria Janieire de N. NunesSouzaFrancis Ribeiro deUniversidade de São PauloFaculdade de MedicinaHospital das ClinicasSão PauloSPBrazilInstituto do Coração (InCor), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, SP - BrazilMailing Address: Maria Janieire de N. Nunes Alves, Av. Dr. Enéas de Carvalho Aguiar, 44 Jardim América - São Paulo, SP - Brazil. E-mail: janieire.ja@gmail.com101020190920191133417418This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.KeywordsPeripheral Arterial Disease/physiopathologyPeripheral Arterial Disease/drug therapyAgedIntermittent ClaudicationAnkle Brachial IndexExercisePrevention and Control
Peripheral arterial disease (PAD) is one of the main atherosclerotic diseases in the elderly population1 which limits the performance of physical activity. Patients with PAD who have intermittent claudication may have gait impairment, which compromises daily living activities.2 In addition, these patients have other comorbidities that may increase cardiovascular risk.1,3 Regular exercise is a non-drug treatment recommended for the prevention and treatment of cardiovascular disease. On the other hand, maintaining adherence to a physical training program becomes a major challenge.
The present study4 exposes the physical activity pattern of patients with PAD and demonstrates the high rate of a sedentary lifestyle with aging. In fact, the disease itself leads to physical limitation, which in turn is also a worsening factor of the disease, since the recommendation of vigorous physical activity has therapeutic effects that contribute, in addition to the chronic use of arterial vasodilator drugs. In addition, chronic arterial vasodilation due to the use of medications may lead to reduced long-term peripheral flow, as arterial vasodilation promoted by medication further reduces perfusion pressure in the lower limb peripheral muscles and intensifies the low level of physical activity in patients with PAD, according to current physical activity recommendations.
The assessment of the degree of physical activity was performed by a device over a period of 7 days, and the data are relevant in classifying the degree of physical limitation with aging, as well as, demonstrating the significance of sedentary lifestyle, may corroborate to further aggravate the disease and cardiovascular risk. On the other hand, the device does not evaluate or quantify localized muscular resistance training (strength), which may underestimate the results pointed out by the study.
Clearly, the importance of developing strategies for these patients to engage in regular exercise. The main reason for these patients with PAD not progressing with physical training is pain related to increased muscle energy demand, called intermittent claudication, especially in the calf region during walking.5 Moderate to vigorous exercise can precipitate the symptoms of intermittent claudication and this becomes a barrier for these patients to engage in physical activity. Thus, low intensity and progressive aerobic exercise can be used as a strategy to delay these symptoms. In addition, patients with intermittent claudication have muscle atrophy, and reduced muscle strength and endurance in the lower limbs increase the fragility of these patients, especially with aging.6 In this aspect, strength exercises and peripheral muscular endurance (bodybuilding) should be used.
Although the literature recommends exercises with aerobic characteristics, such as walking, as the main exercise modality for these patients with PAD, muscle overload exercises have also been recommended as part of a physical exercise program in this population.7,8
Regular exercise should be used as a non-pharmacological tool for the treatment and prevention of cardiovascular disease in patients with PAD and intermittent claudication, so it is important to develop a specific exercise program, especially to delay the onset of symptoms. intermittent claudication, because, besides preventing the onset of pain and the interruption of exercise, it can be a motivational factor that will imply the adherence of these patients to physical activity.
Short Editorial related to the article: Physical Activity Levels in Peripheral Artery Disease Patients
References1 Wang J, Zhou S, Bronks R, Graham J, Myers S. Effects of supervised treadmill-walking training on strength and endurance of the calf muscles of individuals with peripheral arterial disease. Clin J Sport Med. 2006;16(5):397-400.WangJZhouSBronksRGrahamJMyersSEffects of supervised treadmill-walking training on strength and endurance of the calf muscles of individuals with peripheral arterial diseaseClin J Sport Med20061653974002 Regensteiner JG1, Steiner JF, Hiatt WR. Exercise training improves functional status in patients with peripheral arterial disease. J Vasc Surg. 1996;23(1):104-15.RegensteinerJG1SteinerJFHiattWRExercise training improves functional status in patients with peripheral arterial diseaseJ Vasc Surg19962311041153 Fowkes FG1, Rudan D, Rudan I. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet.2013; 19;382(9901):1329-40.FowkesFG1RudanDRudanIComparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysisLancet201319382(9901)132913404 Gerage AM, Correia Ma, Oliveira PML, Palmeira AC, Domingues JR, Zeratti AE, et al. Níveis de atividade física em pacientes com doença arterial periférica. Arq Bras Cardiol. 2019; 113(3):410-416.GerageAMCorreiaMaOliveiraPMLPalmeiraACDominguesJRZerattiAENíveis de atividade física em pacientes com doença arterial periféricaArq Bras Cardiol201911334104165 Dormandy JA, Rutherford RB. Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Consensus (TASC). J Vasc Surg. 2000; 31(1 Pt 2):S1-S296.DormandyJARutherfordRBManagement of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Consensus (TASC)J Vasc Surg2000311Pt 2S1S2966 Regensteiner JG1, Wolfel EE, Brass EP, Carry MR, Ringel SP, Hargarten ME,et al. Chronic changes in skeletal muscle histology and function in peripheral arterial disease. Circulation.1993;87(2):413-21.RegensteinerJG1WolfelEEBrassEPCarryMRRingelSPHargartenMEChronic changes in skeletal muscle histology and function in peripheral arterial diseaseCirculation19938724134217 Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, et al. American Association for Vascular Surgery; Society for Vascular Surgery; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine and Biology; Society of Interventional Radiology; ACC/AHA Task Force on Practice Guidelines Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease; American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; Vascular Disease Foundation. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation.2006; 113(11):e463-654.HirschATHaskalZJHertzerNRBakalCWCreagerMAHalperinJLAmerican Association for Vascular SurgerySociety for Vascular SurgerySociety for Cardiovascular Angiography and InterventionsSociety for Vascular Medicine and BiologySociety of Interventional RadiologyACC/AHA Task Force on Practice Guidelines Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial DiseaseAmerican Association of Cardiovascular and Pulmonary RehabilitationNational Heart, Lung, and Blood InstituteSociety for Vascular NursingTransAtlantic Inter-Society ConsensusVascular Disease FoundationACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease FoundationCirculation200611311e463e6548 Hiatt WR1, Wolfel EE, Meier RH, Regensteiner JG. Superiority of treadmill walking exercise versus strength training for patients with peripheral arterial disease. Implications for the mechanism of the training response. Circulation.1994;90(4):1866-74.HiattWR1WolfelEEMeierRHRegensteinerJGSuperiority of treadmill walking exercise versus strength training for patients with peripheral arterial disease: Implications for the mechanism of the training responseCirculation199490418661874MinieditorialAspectos do Tratamento não Farmacológico em Doença Arterial Periférica0000-0003-4877-3304AlvesMaria Janieire de N. NunesSouzaFrancis Ribeiro deInstituto do Coração (InCor), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, SP - BrasilCorrespondência: Maria Janieire de N. Nunes Alves, Av. Dr. Enéas de Carvalho Aguiar, 44 Jardim América - São Paulo, SP - Brasil. E-mail: janieire.ja@gmail.comPalavras-chaveDoença Arterial Periférica/fisiopatologiaDoença Arterial Periférica/drug therayIdosoClaudicação IntermitenteÍndice Tornozelo-BraçoExercícioPrevenção e Controle
A doença arterial periférica (DAP) é uma das principais doenças ateroscleróticas na população idosa1 que limita à realização de atividade física. Pacientes com DAP que apresentam claudicação intermitente podem apresentar um comprometimento da marcha, que compromete as atividades da vida diária.2 Além disso, esses pacientes apresentam outras comorbidades que podem aumentar o risco cardiovascular.1,3 A prática regular de exercício físico é um tratamento não medicamentoso recomendado para prevenção e tratamento de doenças cardiovasculares. Por outro lado, manter a adesão a um programa de treinamento físico se torna um grande desafio.
O estudo em questão,4 expõe o padrão de atividade física de pacientes com DAP, e demonstra a alta taxa de sedentarismo com o envelhecimento. De fato, a própria doença leva a limitação física, o que por sua vez é também, um fator de piora da doença, haja vista que a recomendação de atividade física vigorosa tem efeitos terapêuticos que contribuem, adicionalmente ao uso crônico de drogas vasodilatadoras arteriais. Além disso, a vasodilatação arterial crônica decorrente do uso de medicamentos, pode trazer redução do fluxo periférico à longo prazo, uma vez que a vasodilatação arterial promovida pela medicação reduz, ainda mais, a pressão de perfusão na musculatura periférica de membros inferiores e, que intensifica o baixo nível de atividade física em pacientes com DAP, de acordo com recomendações atuais de atividade física.
A avaliação do grau de atividade física foi realizada por um dispositivo, durante um período de 7 dias, e os dados são relevantes em classificar o grau de limitação física com o avançar da idade, bem como, demonstraram também, a significância do sedentarismo, que pode corroborar para agravar ainda mais a doença e o risco cardiovascular. Por outro lado, o dispositivo não avalia ou quantifica o treinamento da resistência muscular localizada (força), o que pode subestimar os resultados apontados pelo estudo.
É clara, a importância de se elaborar estratégias para que esses pacientes se engajem na prática regular de exercício físico. O principal motivo desses pacientes com DAP não progredirem com o treinamento físico é a dor relacionada ao aumento da demanda energética do músculo, denominada, claudicação intermitente, principalmente na região da panturrilha durante a caminhada.5 Exercícios físicos de moderada à vigorosa intensidade podem precipitar os sintomas da claudicação intermitente e isso se torna uma barreira para que esses pacientes se envolvam em atividades físicas. Dessa maneira, os exercícios aeróbicos de baixa intensidade e de forma progressiva, podem ser utilizados como estratégia para retardar esses sintomas. Além disso, pacientes com claudicação intermitente apresentam atrofia muscular e a redução da força e resistência muscular nos membros inferiores aumenta a fragilidade desses doentes, principalmente com o avançar da idade.6 Nesse aspecto, exercícios de força e resistência muscular periférica (musculação) deveriam ser utilizados.
Embora a literatura recomende exercícios com características aeróbicas, como a caminhada, como principal modalidade de exercício para esses pacientes com DAP, exercícios de sobrecarga muscular, também tem sido recomendado como parte de um programa de exercício físico nessa população.7,8
A prática regular de exercício físico deve ser utilizada como ferramenta não farmacológica para o tratamento e prevenção das doenças cardiovasculares em pacientes com DAP e claudicação intermitente, portanto é importante se elaborar um programa de exercícios físicos específicos, principalmente com intuito de retardar o aparecimento dos sintomas de claudicação intermitente, pois, além de prevenir o desencadeamento de dor, a interrupção do exercício, pode ser um fator motivacional que implicará na aderência desses pacientes à prática de atividade física.
Minieditorial referente ao artigo: Níveis de Atividade Física Em Pacientes Com Doença Arterial Periférica