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Dr. Maciej Kazmierski
Mr Michał Tendera
PAD tends to coexist with atherosclerotic lesions in other vascular beds, especially in the elderly. The most frequent PAD symptom is intermittent claudication, however, typical symptoms of intermittent claudication in patients with diagnosed PAD are rather uncommon. History and physical examination are much less accurate than objective measurements, such as the ankle/brachial index. ABI measurement is a simple examination that takes 10-15 minutes and that can be performed in every outpatients clinic. Patients with PAD should then undergo thorough medical evaluation to exclude or confirm the coexistence of coronary heart disease, carotid artery stenosis or other lesions.
Peripheral arterial disease (PAD) is not always atherosclerotic in origin, but in today’s cardiology practice it is usually a sign of generalised, multilevel atherosclerosis.
In a study of 1802 men and women, mean age 80 years, 68% of subjects with PAD had coexistent CAD and 42% had prior ischemic stroke (1).
The most frequent PAD symptom is intermittent claudication, that is defined as muscle pain or weakness induced by exercise and relieved with rest, which occurs distal to the arterial obstruction.
Results of the PARTNERS study indicate that less than 11% of patients with PAD have “typical” intermittent claudication, while more than half have atypical symptoms of lower limb discomfort present at rest (7).
Contrary to a common belief, typical symptoms of intermittent claudication in patients with diagnosed PAD are rather uncommon. According to different authors they occur in 20-30% of patients (3).
Asymptomatic atherosclerotic narrowings are present in almost 20% of persons above 55 years of age, which makes it the most prevalent form of atherosclerosis (9).
Persons with advanced PAD of the lower extremities have diminished or absent arterial pulses, the diagnosis seems easy. However, history and physical examination are much less accurate than objective measurements, such as the ankle/brachial index. Pulses palpation is neither sensitive nor specific for peripheral arteries disease. In a study of males and females of mean age 66 years, among whom 11% had PAD; sensitivity of abnormal pulses examination was 77%, whereas specificity of normal pulses in the absence of disease was 86% (11). Noninvasive tests used to asses lower extremity arterial blood flow include :
Measurements of ankle and brachial artery systolic blood pressure using a Doppler probe and blood pressure cuffs allow calculation of the ankle/brachial index (ABI), which is normally 0.9 to 1.2. An ABI of less than 0.90 is 95% sensitive and 99% specific for the diagnosis of PAD (3). Using the ankle-brachial index (ABI) of less than 0.95 as indicative of PAD, the prevalence of 6.9% was observed in patients aged 45-74 years, and only 22% of them had symptoms. (8). The discrepancy between typical symptoms and the presence of PAD defined by ABI was shown in the Rotterdam study, a population-based analysis of 7715 patients (2). Although a prevalence of intermittent claudication ranged from about 1% in the group aged 55-60 years to 4.6% in the group aged 80-85 years, the PAD diagnosed on the basis of ABI was found in 16.9% of men and 20.5% of women aged 55 and older. ABI measurement should be widely used to detect PAD. According to Hirsch (12), this test should be done at least in the following patient categories:
PAD remains unrecognised too often or is discovered in advanced stage. ABI measurement is a simple examination that takes 10-15 minutes and that can be performed in every outpatients clinic. Early diagnosis of PAD allows for immediate implementation of measures to reduce atherosclerotic risk. The presence of PAD should be considered as an index of systemic atherosclerosis, as patients with PAD have a higher incidence of coronary heart disease and atherosclerotic abnormalities of cerebral circulation. Thus, patients with PAD should undergo thorough medical evaluation to exclude or confirm the coexistence of coronary heart disease, carotid artery stenosis or other lesions.
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.
1. Ness J, Aronow WS: Prevalence of coexistence of coronary artery disease, ischemic stroke, and peripheral arterial disease in older persons, mean age 80 years, in an academic hospital-based geriatrics practice. J Am Geriatr Soc 1999; 47: 1255-1256. 2. Newman AB, Shemanski L, Manolio TA, et al: Ankle-arm index as a predictor of cardiovascular disease and mortality in the Cardiovascular Health Study. Arterioscler Thromb Vasc Biol 1999; 19: 539-545. 3. Criqui MH, Fronek A, Barrett-Connor E, et al: The prevalence of peripheral arterial disease in a defined population. Circulation 1985; 71: 510-515. 4. Newman AB, Siscovick DS, Manolio TA, et al: Ankle-arm index as a marker of atherosclerosis in the Cardiovascular Health Study. Cardiovascular Heart Study (CHS) Collaborative Research Group. Circulation 1993; 88: 837-845. 5. Aronow WS: Management of Peripheral Arterial Disease of the Lower Extremities in Elderly Patients. Journal of Gerontology 2004; 59A: 172-177. 6. McDermott MM, Greenland P, Liu K, et al: Leg symptoms in peripheral arterial disease. JAMA 2001; 286: 1599-1606. 7. Hirsch At, Criqui MH, Treat-Jacobson D, et al: Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA 2001; 286: 1317-1324. 8. Ouriel K: Peripheral arterial disease. Lancet 2001; 358: 1257-1264 9. Meijer WT, Hoes AW, Rutgers AD, et al: Peripheral arterial disease in the elderly: The Rotterdam Study. Arterioscler ThrombVasc Biol 1998; 18: 185-192. 10. Garcia LA: Epidemiology and Pathophysiology of Lower Extremity Peripheral Arterial Disease. J Endovasc Ther 2006; 13 (Suppl II): II-3-II-9. 11. Criqui MH, Fronek A, Klauber MR, et al: The sensitivity, specificity, and predictive value of traditional clinical evaluation of peripheral arterial disease: results from noninvasive testing in a defined population. Circulation 1985; 71: 516-522 12. Hirsch A.T. Recognition and Management of Patients with Peripheral Arterial Disease. In Braunwald E, Goldman L: Primary Cardiology (2nd edition), Elsevier Science, 2003, p 696.
Maciej Kaźmierski, MD, and Michal Tendera, MD, FESC 3rd Division of Cardiology, Medical University of Silesia, Katowice, Poland
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