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.
- Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA 2001; 286:1317.
- Diehm C, Schuster A, Allenberg JR, et al. High prevalence of peripheral arterial disease and co-morbidity in 6880 primary care patients: cross-sectional study. Atherosclerosis 2004; 172:95.
- Hirsch AT, Haskal ZJ, Hertzer NR, et al. 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:e463.
- Beckman JA, Jaff MR, Creager MA. The United States preventive services task force recommendation statement on screening for peripheral arterial disease: more harm than benefit? Circulation 2006; 114:861.
- United States Preventive Services Task Force. Screening for peripheral arterial disease: recommendation statement 2005. Available at: www.preventiveservices.ahrq.gov (Accessed on October 10, 2011).
- United States Preventive Services Task Force. Recommendation Statement: Screening for Peripheral Arterial Disease. Agency for Healthcare Research and Quality, Washington, DC 2005.
- Ferket BS, Spronk S, Colkesen EB, Hunink MG. Systematic review of guidelines on peripheral artery disease screening. Am J Med 2012; 125:198.
- Hankey GJ, Norman PE, Eikelboom JW. Medical treatment of peripheral arterial disease. JAMA 2006; 295:547.
- Fowkes FG, Rudan D, Rudan I, et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet 2013; 382:1329.
- Pande RL, Perlstein TS, Beckman JA, Creager MA. Secondary prevention and mortality in peripheral artery disease: National Health and Nutrition Examination Study, 1999 to 2004. Circulation 2011; 124:17.
- Criqui MH, Aboyans V. Epidemiology of peripheral artery disease. Circ Res 2015; 116:1509.
- Taylor-Piliae RE, Fair JM, Varady AN, et al. Ankle brachial index screening in asymptomatic older adults. Am Heart J 2011; 161:979.
- Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999-2000. Circulation 2004; 110:738.
- Joosten MM, Pai JK, Bertoia ML, et al. Associations between conventional cardiovascular risk factors and risk of peripheral artery disease in men. JAMA 2012; 308:1660.
- Price JF, Mowbray PI, Lee AJ, et al. Relationship between smoking and cardiovascular risk factors in the development of peripheral arterial disease and coronary artery disease: Edinburgh Artery Study. Eur Heart J 1999; 20:344.
- Rooke TW, Hirsch AT, Misra S, et al. 2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2011; 58:2020.
- McDermott MM, Greenland P, Liu K, et al. Leg symptoms in peripheral arterial disease: associated clinical characteristics and functional impairment. JAMA 2001; 286:1599.
- McDermott MM, Guralnik JM, Ferrucci L, et al. Asymptomatic peripheral arterial disease is associated with more adverse lower extremity characteristics than intermittent claudication. Circulation 2008; 117:2484.
- Khan NA, Rahim SA, Anand SS, et al. Does the clinical examination predict lower extremity peripheral arterial disease? JAMA 2006; 295:536.
- Weitz JI, Byrne J, Clagett GP, et al. Diagnosis and treatment of chronic arterial insufficiency of the lower extremities: a critical review. Circulation 1996; 94:3026.
- Lijmer JG, Hunink MG, van den Dungen JJ, et al. ROC analysis of noninvasive tests for peripheral arterial disease. Ultrasound Med Biol 1996; 22:391.
- Vogt MT, McKenna M, Wolfson SK, Kuller LH. The relationship between ankle brachial index, other atherosclerotic disease, diabetes, smoking and mortality in older men and women. Atherosclerosis 1993; 101:191.
- Criqui MH, Langer RD, Fronek A, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med 1992; 326:381.
- Doobay AV, Anand SS. Sensitivity and specificity of the ankle-brachial index to predict future cardiovascular outcomes: a systematic review. Arterioscler Thromb Vasc Biol 2005; 25:1463.
- Steg PG, Bhatt DL, Wilson PW, et al. One-year cardiovascular event rates in outpatients with atherothrombosis. JAMA 2007; 297:1197.
- O'Hare AM, Katz R, Shlipak MG, et al. Mortality and cardiovascular risk across the ankle-arm index spectrum: results from the Cardiovascular Health Study. Circulation 2006; 113:388.
- Criqui MH, Ninomiya JK, Wingard DL, et al. Progression of peripheral arterial disease predicts cardiovascular disease morbidity and mortality. J Am Coll Cardiol 2008; 52:1736.
- Feringa HH, Karagiannis SE, Schouten O, et al. Prognostic significance of declining ankle-brachial index values in patients with suspected or known peripheral arterial disease. Eur J Vasc Endovasc Surg 2007; 34:206.
- Murabito JM, Evans JC, Larson MG, et al. The ankle-brachial index in the elderly and risk of stroke, coronary disease, and death: the Framingham Study. Arch Intern Med 2003; 163:1939.
- Murabito JM, Evans JC, Nieto K, et al. Prevalence and clinical correlates of peripheral arterial disease in the Framingham Offspring Study. Am Heart J 2002; 143:961.
- Leng GC, Fowkes FG, Lee AJ, et al. Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study. BMJ 1996; 313:1440.
- Ramos R, Quesada M, Solanas P, et al. Prevalence of symptomatic and asymptomatic peripheral arterial disease and the value of the ankle-brachial index to stratify cardiovascular risk. Eur J Vasc Endovasc Surg 2009; 38:305.
- van Kuijk JP, Flu WJ, Bax JJ, Poldermans D. Prevalence of (a)symptomatic peripheral arterial disease; the additional value of ankle-brachial index on cardiovascular risk stratification. Eur J Vasc Endovasc Surg 2009; 38:312.
- Ankle Brachial Index Collaboration, Fowkes FG, Murray GD, et al. Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. JAMA 2008; 300:197.
- Lin JS, Olson CM, Johnson ES, Whitlock EP. The ankle-brachial index for peripheral artery disease screening and cardiovascular disease prediction among asymptomatic adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2013; 159:333.
- Hooi JD, Stoffers HE, Knottnerus JA, van Ree JW. The prognosis of non-critical limb ischaemia: a systematic review of population-based evidence. Br J Gen Pract 1999; 49:49.
- McDermott MM, Liu K, Ferrucci L, et al. Physical performance in peripheral arterial disease: a slower rate of decline in patients who walk more. Ann Intern Med 2006; 144:10.
- Murphy TP, Cutlip DE, Regensteiner JG, et al. Supervised exercise versus primary stenting for claudication resulting from aortoiliac peripheral artery disease: six-month outcomes from the claudication: exercise versus endoluminal revascularization (CLEVER) study. Circulation 2012; 125:130.
- Fowler B, Jamrozik K, Norman P, et al. Improving maximum walking distance in early peripheral arterial disease: randomised controlled trial. Aust J Physiother 2002; 48:269.
- Aung PP, Maxwell HG, Jepson RG, et al. Lipid-lowering for peripheral arterial disease of the lower limb. Cochrane Database Syst Rev 2007; :CD000123.
- McDermott MM, Guralnik JM, Greenland P, et al. Statin use and leg functioning in patients with and without lower-extremity peripheral arterial disease. Circulation 2003; 107:757.
- Feringa HH, van Waning VH, Bax JJ, et al. Cardioprotective medication is associated with improved survival in patients with peripheral arterial disease. J Am Coll Cardiol 2006; 47:1182.
- Wong PF, Chong LY, Mikhailidis DP, et al. Antiplatelet agents for intermittent claudication. Cochrane Database Syst Rev 2011; :CD001272.
- Fowkes FG, Price JF, Stewart MC, et al. Aspirin for prevention of cardiovascular events in a general population screened for a low ankle brachial index: a randomized controlled trial. JAMA 2010; 303:841.
- Mora S, Redberg RF, Cui Y, et al. Ability of exercise testing to predict cardiovascular and all-cause death in asymptomatic women: a 20-year follow-up of the lipid research clinics prevalence study. JAMA 2003; 290:1600.
- Wei M, Kampert JB, Barlow CE, et al. Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight, and obese men. JAMA 1999; 282:1547.
- Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45 Suppl S:S5.
- Wilson JF, Laine C, Goldmann D. In the clinic. Peripheral arterial disease. Ann Intern Med 2007; 146:ITC3.
- Moyer, VA. Screening for peripheral artery disease and cardiovascular disease risk assessment with the ankle-brachial index in adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2013; 159:342.
- Andras A, Ferket B. Screening for peripheral arterial disease. Cochrane Database Syst Rev 2014; :CD010835.
- 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