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Peripheral Arterial Disease
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Essentials of Diagnosis
Common symptoms of leg discomfort with ambulation, rest pain, nonhealing ulcers, or gangrene.
Abnormal pulse exam in most patients.
Abnormal ankle-branchial index is diagnostic.
Evidence of systemic atherosclerosis is common.
History of diabetes mellitus, tobacco use, hypertension, or hyperlipidemia may be present.
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General Principles in Older Adults
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Peripheral vascular disease broadly defines any vascular disease of the extracranial carotid arteries, the aorta and its branches, and the extremities. However, peripheral arterial disease (PAD) is usually used to refer to atherosclerotic disease of the lower extremities. Atherosclerotic PAD is the most common form of PAD in older adults. But, the differential diagnosis for arterial vascular disease is quite broad (Table 32–1).
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The prevalence of PAD is >10% in individuals older than age 60 years and increases to >25% in people older than 75 years. Although PAD is associated with cardiovascular risk factors, a prevalence of approximately 9% has been documented in patients without traditional risk factors. Nontraditional risk factors, including ethnicity, also influence disease prevalence. Current guidelines call for screening all individuals who are older than age 65 years, patients older than age 50 years with a history of smoking or diabetes, and individuals with suspected PAD, including exertional leg symptoms and nonhealing wounds.
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There are 2 management issues in patients with PAD. Both are important to successful patient care. First is the need to adequately address underlying cardiovascular risk factors. Atherosclerosis is assumed to be a systemic process. Concomitant cerebrovascular or coronary disease has been demonstrated in up to 30% of patients. The second issue, which is usually more concerning to the patient, is the symptoms related to the vascular occlusive disease. Although most patients with PAD are asymptomatic or present with atypical ...