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Harvard Commentaries
35320
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


What Your Doctor Is Saying What Your Doctor Is Saying
 

Circulation Troubles -- What Do They Mean?


February 27, 2013

By Robert H. Shmerling M.D.

Beth Israel Deaconess Medical Center


Last reviewed February 27, 2013

Blood flows from the lungs and heart to other parts of the body through arteries. Veins bring blood back to the heart and lungs. This process, called circulation, is vital to deliver oxygen, sugar and other nutrients to organs and tissues. Circulation also helps remove waste products, such as carbon dioxide, from our bodies.

"Poor circulation" can describe many different problems with circulation. But they are all related to difficulties with blood flow through the body.

Three of the most common conditions associated with poor blood circulation are:

  1. Peripheral artery disease (PAD) – Lack of blood flow through the arteries of the extremities causes this painful condition.
  2. Venous insufficiency – When the veins in the legs aren’t working well, fluid accumulates in the feet and around the ankles.
  3. Raynaud's disease – Cold temperatures can trigger a temporary drop in blood flow to fingers and toes of people with this condition.

To learn more about what your doctor (or your friends and family) are saying when they mention poor circulation, here's a closer look at each of these conditions.

Peripheral Artery Disease

Causes

People with PAD complain of a particular pattern of leg pain when they walk. (It's called "claudication.") The pain develops because not enough blood flows to the leg muscles. Cholesterol deposits called plaque build up in the walls of the arteries. This narrows the blood vessels and limits the amount of blood that can flow through them. Something similar can happen in the arteries that bring blood to the heart muscle. Too little blood flow can lead to angina (chest pain due to poor blood supply) or a heart attack.

Resting tends to improve symptoms, but over time a person with PAD may have to limit his or her walking to shorter and shorter distances.

Prevention

You may be able to prevent PAD by doing the same things you do to reduce the risk of heart disease or stroke, such as:

  • Not smoking
  • Getting regular exercise
  • Keeping a healthy body weight
  • Eating a healthy diet
  • Keeping your blood sugar and cholesterol levels in an ideal range
  • Limiting alcohol to no more than two drinks daily for men or one drink daily for women

Treatment

Treatment of PAD may include:

  • Blood thinners (to encourage blood flow and reduce the risk that a blood clot will suddenly interrupt flow entirely)
  • Medicines to lower blood cholesterol

If PAD is severe, minor surgery (such as the insertion of a stent to keep the artery open) or major surgery (to bypass the narrowed artery) may be recommended. If surgery can't improve blood flow, amputation may be necessary. Given the limited options for treating advanced PAD, prevention is key.

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Venous Insufficiency

Cause

Veins bring oxygen-poor blood from the legs back to the lungs to pick up a fresh supply of oxygen. Tiny valves in these veins prevent blood from falling back down into the feet (despite the pull of gravity). But, as we age, these valves in our leg veins often fail. As a result, fluid builds up in the feet and around the ankles. This swelling (edema) can cause fragile skin, infections and difficulty walking.

Venous insufficiency rarely leads to amputation, so is generally less serious than PAD. But it can have a significant impact on quality of life.

Prevention

Most cases of venous insufficiency develop for no apparent reason. This makes it difficult to prevent the condition. However, keeping an ideal body weight and not standing for long periods of time may be helpful.

Treatment

Treatment options include:

  • Losing excess weight
  • Limiting excessive fluid intake
  • Reducing salt intake
  • Keeping the legs elevated (above the level of the heart, if tolerated)
  • Wearing compression stockings
  • Taking diuretic medications, which help get rid of excess fluid through urination
  • Having surgery (as a last resort)

Keep in mind that edema can develop for many reasons — venous insufficiency is just one of them. Other common causes include heart failure, kidney disease or liver problems. So, if your legs swell, be sure to see your doctor.

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Raynaud's Disease

Cause

Raynaud's disease is named after the French physician, A. G. Maurice Raynaud. He was the first person to describe this form of poor circulation in 1862.

Normally, the small arteries in the fingers and toes open up (dilate) or narrow (constrict) automatically. (This happens in response to signals from tiny nerves attached to the arteries.) If a person is hot, arteries tend to open up, allowing heat to be released through the skin. If a person is cold, the arteries constrict, helping the body conserve heat in its core.

With Raynaud's, the arteries in the hands and feet narrow (constrict) too much and too easily in response to cold. This causes the fingers or toes to become pale (or white), then blue and, when the artery opens up again, red. It can be painful, although some people with Raynaud's disease complain more about numbness, tingling and clumsiness than pain.

Prevention

There is no way to prevent Raynaud's disease. However, there are things a person can do to lessen the episodes of painful, blue fingers or toes:

  • Don't smoke
  • Avoid drugs that may encourage artery constriction (such as cocaine and caffeine); certain medications can worsen Raynaud’s as well.
  • Avoid unnecessary exposure to the cold.
  • Turn up the thermostat.
  • Wear a hat and mittens in cold weather.
  • Bundle up before you head out into the cold.
  • Use pot holders, mittens or a towel to remove items from the refrigerator.
  • Use a cup holder when drinking a cold beverage.

Treatment

Many people with Raynaud's disease don't need treatment (other than taking the preventive measures above). However, for more severe cases, there are medicines that can relieve symptoms by opening up blood vessels. These include:

  • Calcium channel blockers, such as amlodipine (Norvasc) or diltiazem (Cardizem, Dilacor)
  • Nitroglycerin cream or ointment
  • Hydralazine (Apresoline)
  • Prazosin (Minipress)
  • Losartan (Cozaar)
  • Sildenafil (Viagra, Revatio) or other medicines approved for erectile dysfunction

If these medicines don't help, some people may find relief with surgery to interrupt nerve signals to the arteries.

There are other causes of poor circulation. For example, a blood clot in an artery or vein can develop and suddenly halt blood flow. While this may occasionally complicate PAD, clots can also develop due to a "hypercoagulable state" (an increased tendency to form clots) such as certain genetic mutations, cancer or an immune disorder in which abnormal antibodies encourage blood clots to form. When circulation trouble is due to a blood clot in an artery, the organ supplied by that artery (such as the skin, the brain or the eye) can be quickly damaged.

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The Bottom Line

The circulation of blood through the body is vital to good health. But, there are many ways for things to go wrong. Perhaps that's why the term "poor circulation" may describe so many different things.

If your doctor tells you he's concerned about your circulation, ask whether you have PAD, venous insufficiency, Raynaud's or some other problem. Only then will you understand what your doctor is really saying.

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Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.

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