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Chapter 263. Peripheral Arterial Disease

Catherine McGorrian, MB, BCh, LRCP&SI, MRCPI; Sonia Anand, MD, PhD, FRCP(c)

  1. Who is at risk for developing peripheral arterial disease (PAD)?

  2. How do you screen for asymptomatic PAD?

  3. What are the symptoms and signs of PAD?

  4. How do you diagnose PAD?

  5. How do you treat PAD?

Peripheral arterial diseases (PAD) refer to arterial pathologies that affect the vasculature outside the heart and likely affect at least 8 million people in the U.S. The prevalence of disease depends on the methodology used to define PAD. Intermittent claudication (IC) can be defined as an exertional pain, soreness, or fatigue involving a group of muscles that causes the patient to stop during walking and usually resolves within five minutes of rest. The symptoms do not cease during exertion and do not begin at rest. The prevalence of IC varies from 1% to 5% of the U.S. population. Studies using the ankle-brachial index (ABI) to screen for PAD describe a much higher prevalence of PAD than those relying on symptoms of IC, with PAD measured by an abnormal ABI affecting as many as 12% of people age 65 years or older compared to only 2% of participants in one survey with classic symptoms of IC.

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Case 263-1

A 64-year-old woman developed “sore legs” during walking, worse on her right side. At first she attributed the discomfort to her “arthritic hip” but over the last six months she noticed that she can hardly walk to the end of her apartment corridor and walking up inclines is particularly difficult. Stopping to rest relieves the discomfort, and she has had no pain during sitting or while sleeping. Her past medical history includes a first myocardial infarction (MI) at 56 years of age, hypertension, Type II diabetes, and hyperlipidemia. She has a past history of smoking.

Analysis

This patient has classic symptoms of IC. A complete physical examination including a vascular examination should be performed. She does not have symptoms consistent with critical limb ischemia or acute limb ischemia, which would require either referral to a vascular specialist or admission for emergency evaluation and limb salvage.

Diagnostic workup starts with a rest ABI +/– pulse volume recordings and/– segmental limb pressure examination.

For secondary prevention, she should be educated about symptoms of cardiovascular and cerebrovascular disease and receive the same secondary prevention as patients with coronary artery disease. Her doctor should emphasize the importance of not resuming smoking. She should be prescribed aspirin or clopidogrel taking into consideration patient specific factors such as comorbidity, cost, and tolerability. The target LDL is the same as for cardiovascular disease, the target LDL is < 100 mg/dL, and < 70 mg/dl in the highest risk patients. Because aggressive BP management reduces cardiovascular events in the highest risk patients (including those with diabetes), her target BP should be < 120/80 mm Hg starting with an ACE inhibitor. Beta-blockers are not contraindicated in patients with PAD, and she should receive a beta-blocker given her prior ...

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