Screening for lower extremity peripheral artery disease
- Rodney A Hayward, MD
Rodney A Hayward, MD
- Professor of Medicine and Public Health
- University of Michigan
Peripheral artery disease (PAD) of the lower extremities is a common cause of impaired ambulation and is a leading cause of lower extremity wounds and amputations. It is also associated with atherosclerosis elsewhere in the body. Thus, individuals with PAD are at significantly increased risk of cardiovascular and cerebrovascular events and mortality.
There is substantial evidence that the majority of cases of PAD go undetected in routine clinical practice [1,2]. As a result, there is considerable interest in detection of PAD through routine screening [3-6]. However, a systematic review of guidelines for peripheral artery disease screening found divergent recommendations among the eight screening guidelines identified from major organizations . In the absence of a randomized trial evaluating outcomes of screening in asymptomatic individuals, critical questions regarding the objectives of screening, appropriateness of screening, and optimal approach to screening need to be addressed.
This topic will review the rationale and recommendations for screening for PAD with a focus on the use of the ankle-brachial index (ABI) as a screening test. Clinical features of lower extremity PAD and noninvasive diagnostic tests for PAD are discussed separately. (See "Clinical features and diagnosis of lower extremity peripheral artery disease" and "Noninvasive diagnosis of arterial disease".)
PREVALENCE OF PAD
Approximately 20 percent of adults older than 55 years have PAD , although estimates of the prevalence of PAD vary widely. Worldwide, the estimated prevalence in high-income countries ranged from 5.3 percent for individuals 45 to 49 years of age, to 18.5 percent for individuals 85 to 89 years old for data collected in 2000 to 2010 . A large study in the United States that was conducted in 1999 to 2004 estimated that about 7.1 million community-dwelling Americans were diagnosed with PAD . Globally, it is estimated that over 200 million people have peripheral arterial disease [9,11]. The incidence of PAD reportedly increased significantly over the preceding decade (by 28.7 percent in low- and middle-income countries, and by 13 percent in high-income countries).
It is well documented that undiagnosed PAD is common. In a study of almost 7000 primary care patients who were 70 years or older or 50 to 69 years with risk factors for atherosclerosis (history of cigarette use or diabetes), PAD was identified in 29 percent either through ankle-brachial index (ABI) screening or prior documentation; over half of these cases were previously undiagnosed . The prevalence of asymptomatic PAD in generally healthy populations, as opposed to clinic populations, is significantly lower. In a study sample of 1017 adults aged 60 to 69 years (average age 66 years) that excluded individuals with major chronic disease but did include smokers and patients with diabetes, the prevalence of PAD by ABI screening (ABI<0.90) was 2 percent, but the prevalence was 6.6 percent in current smokers . PAD was not significantly more common in subjects with diabetes.
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- PREVALENCE OF PAD
- Risk factors for PAD
- DIAGNOSING PAD
- Ankle-brachial index
- RATIONALE FOR SCREENING
- PAD as a risk factor for other cardiovascular disease
- INTERVENTIONS FOR ASYMPTOMATIC PAD
- Intervening for PAD outcomes
- Intervening for CVD outcomes
- - Aspirin
- - Walking
- - Statins
- RECOMMENDATIONS OF OTHERS
- The TASC II report
- American College of Cardiology/American Heart Association
- American College of Physicians
- US Preventive Services Task Force
- Synthesis of evidence and recommendations
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS