Lower Extremity Peripheral Artery Disease: Diagnosis and Treatment

 

Am Fam Physician. 2019 Mar 15;99(6):362-369.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/peripheral-arterial-disease-and-claudication/.

Author disclosure: No relevant financial affiliations.

Lower extremity peripheral artery disease (PAD) affects 12% to 20% of Americans 60 years and older. The most significant risk factors for PAD are hyperlipidemia, hypertension, diabetes mellitus, chronic kidney disease, and smoking; the presence of three or more factors confers a 10-fold increase in PAD risk. Intermittent claudication is the hallmark of atherosclerotic lower extremity PAD, but only about 10% of patients with PAD experience intermittent claudication. A variety of leg symptoms that differ from classic claudication affects 50% of patients, and 40% have no leg symptoms at all. Current guidelines recommend resting ankle-brachial index (ABI) testing for patients with history or examination findings suggesting PAD. Patients with symptoms of PAD but a normal resting ABI can be further evaluated with exercise ABI testing. Routine ABI screening for those not at increased risk of PAD is not recommended. Treatment of PAD includes lifestyle modifications—including smoking cessation and supervised exercise therapy—plus secondary prevention medications, including antiplatelet therapy, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins. Surgical revascularization should be considered for patients with lifestyle-limiting claudication who have an inadequate response to the aforementioned therapies. Patients with acute or limb-threatening limb ischemia should be referred immediately to a vascular surgeon.

Atherosclerotic lower extremity artery occlusive disease—commonly referred to as peripheral artery disease (PAD)—affects 12% to 20% of Americans 60 years and older, increasing to nearly 50% in those 85 years and older.1 Prevalence increases dramatically with age, and PAD disproportionately affects black persons. The global disease burden exceeds 200 million persons worldwide, and PAD increased in prevalence by 23.5% between 2000 and 2010.2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Patients at increased risk of PAD should be assessed for exertional leg symptoms, ischemic rest pain, and nonhealing wounds. Vascular examination should include palpation of lower extremity pulses and auscultation for femoral bruits.

C

9

Based on multiple well-designed, well-executed observational studies

Resting ABI testing should be performed for patients with history or examination findings suggestive of PAD. Exercise ABI testing should be considered for those with a normal resting ABI despite symptoms of exertional claudication.

C

9, 12

Based on a retrospective review of a vascular diagnostic laboratory database

ABI screening should not be performed in asymptomatic patients who are not at increased risk of PAD.

C

9

Based on data from population-based cohort studies demonstrating low prevalence of abnormal resting ABI in younger, asymptomatic individuals

The primary treatment strategies for lower extremity PAD include the following:

Lifestyle modifications

C

9, 2431

Based on expert opinion and consensus guidelines in the absence of clinical trials

Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers

A

9, 3033

Based on consistent evidence from RCTs showing reduced morbidity and mortality

Statins

A

9, 28, 29

Based on consistent evidence from RCTs showing reduced morbidity and mortality

Antiplatelet therapy

A

9, 2427

Based on consistent evidence from RCTs showing reduced morbidity and mortality.


ABI = ankle-brachial index; PAD = peripheral artery disease; RCTs = randomized controlled trials.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Patients at increased risk of PAD should be assessed for exertional leg symptoms, ischemic rest pain, and nonhealing wounds. Vascular examination should include palpation of lower extremity pulses and auscultation for femoral bruits.

C

9

Based on multiple well-designed, well-executed observational studies

Resting ABI testing should be performed for patients with history or examination findings suggestive of PAD. Exercise ABI testing should be considered for those with a normal resting ABI despite symptoms of exertional claudication.

C

9, 12

Based on a retrospective review of a vascular diagnostic laboratory database

ABI screening should not be performed in asymptomatic patients who are not at increased risk of PAD.

C

9

Based on data from population-based cohort studies demonstrating low prevalence of abnormal resting ABI in younger, asymptomatic individuals

The primary treatment strategies for lower extremity PAD include the following:

Lifestyle modifications

C

9, 2431

The Authors

show all author info

JONATHON M. FIRNHABER, MD, MA Ed, is an associate professor and residency program director in the Department of Family Medicine at the Brody School of Medicine at East Carolina University, Greenville, N.C....

C.S. POWELL, MD, is a professor in the Department of Cardiovascular Sciences at the Brody School of Medicine at East Carolina University and Chief of the Division of Vascular Surgery at the East Carolina Heart Institute, Greenville.

Address correspondence to Jonathon M. Firnhaber, MD, MA Ed, East Carolina University, Family Medicine Center, 101 Heart Dr., Greenville, NC 27834-8982 (e-mail: firnhaberj@ecu.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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show all references

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