Strength of recommendations (A, B, C, D, I) and quality of evidence (good, fair, poor) are defined at the end of the "Major Recommendations" field.
This guideline recommends against ankle-brachial index (ABI) routine screening in asymptomatic low risk patients. Routine screening in primary care setting may produce false positives and lead to unnecessary workups and thus more harm than benefit for the asymptomatic patient. (United States Preventive Services Task Force [USPSTF], 2006) (Grade: D; Evidence: Good)
In any patient with an identified risk factor and symptom of peripheral artery disease (PAD), the following is recommended:
- History of present illness (HPI):
- Onset, duration, location, severity, aggravating and alleviating factors related to clinical manifestations of lower extremity symptom complaints
- Lifestyle habits such as diet, exercise, smoking, alcohol or drug use
- Exercise assessment including 6 minute walk performance, walking velocity over 4 meters at usual and fastest pace
- PAD walking impairment questionnaire
- Review of systems
- Genitourinary (GU): erectile dysfunction
- Musculoskeletal (MS)
- Past medical history
- Note hospitalizations, surgeries, and any procedures
- History of trauma
- Co-morbid conditions such as: smoking, diabetes, hypertension, congestive heart failure/chronic heart failure (CHF), arrhythmias, cardiovascular disease, sedentary lifestyle, dyslipidemia, obesity, atherosclerosis
- Current prescription medications
- Any or all over the counter medications, including alternative medicines or herbal treatments
- Family history
- Cardiovascular disease
- Cerebrovascular accident (CVA)
- Psychosocial history
- Assess for depression and mental illness
- Socioeconomic status (occupation, education level, ethnicity)
- Support systems, coping strategies
- Smoking history
(Allison et al., 2010; Alzamora et al., 2010; Hayward, 2010; Hirsch et al., 2006; Jacobs et al., 2009; Johnson et al., 2010; Mazimba & Rank, 2010; McDermott et al., 2010; Rosero et al., 2010; Selby, 2008; Sugawara et al., 2010; Smolderen et al., 2009) (Grade: A; Evidence: Good)
Objective Assessment/Physical Examination
- Vital signs: Blood pressure, pulse, height, weight, body mass index (BMI) calculation
- Cardiovascular exam: assess for rhythm regularity, bruits, murmurs (high prevalence with cardiovascular disease [CVD], chronic heart failure [CHF], arrhythmias, and hypertension), peripheral pulses
- Pulmonary exam: assess breath sounds and quality of respirations
- Musculoskeletal: deformities, swelling, or pain with movement and at rest, strength
- Neurological exam: sensory function, mental status
- Skin: color, temperature, ulcerations
- Exercise assessment including 6 minute walk performance
(Armstrong, Tobin, & Mantangi, 2010; Hayward, 2010; Hirsch et al., 2006; Wilson, Laine, & Goldmann, 2007; Mazimba & Rank, 2010; Safar et al., 2009) (Grade: A; Evidence: Good)
- Laboratory studies
- Diabetes screening (fasting blood glucose, 2 hour oral glucose tolerance test, or hemoglobin A1c [HbA1c])
- Diagnostic tests
- ABI: normal 1.0-1.3, mild <0.90, moderate 0.5-0.7, severe <0.50. An ABI over 1.3 signifies non-compressible vessels and yields a false negative test; as seen in diabetes mellitus, end stage renal disease, and arterial calcifications (as in severe or diffuse PAD). If ABI is >1.3, alternative studies are recommended: Toe-brachial ratio, Doppler ultrasound, computed tomography (CT) angiography, or magnetic resonance (MR) angiography.
(American Diabetes Association [ADA], 2011; Espeland et al., 2008; Hayward, 2010; Hirsch et al., 2006; McDermott et al., 2010; Sugawara et al., 2010; Olin et al., 2010; Premanath & Raghunath, 2010) (Grade: A; Evidence: Good)
- Spinal stenosis
- Peripheral neuropathy
- Venous claudication
- Nerve root compression
- Symptomatic Baker's cyst
- Congestive heart failure/chronic heart failure
- Fibromyalgia/polymyalgia rheumatica
- Restless leg syndrome
- Ulceration or gangrene
- Peripheral venous disease (PVD)
- Compartment syndrome
(Hirsch et al., 2006; Wilson, Laine, & Goldmann, 2007; Mazimba & Rank, 2010) (Grade: B; Evidence: Good)
Refer patients with ABI >1.30 or less than or equal to 0.90 to cardiologist or vascular specialist. Further screening by specialist may include ultrasound, computed tomography (CT), angiography. (Mazimba & Rank, 2010) (Grade: C; Evidence: Fair)
Obtain records from referral physician, and assess patient's adherence to recommendations of management/treatment. (Hirsh et al., 2006) (Grade: I; Evidence: Poor)
Strength of Recommendations (Based on U.S. Preventive Services Task Force [USPSTF] Ratings)
A. There is good evidence that the recommendation improves important health outcomes. Benefits substantially outweigh harms.
B. There is at least fair evidence that the recommendation improves important health outcomes. Benefits outweigh harms.
C. There is at least fair evidence that the recommendation can improve health outcomes but the balance of benefits and harms is too close to justify a general recommendation.
D. There is at least fair evidence that the recommendation is ineffective or that harms outweigh benefits.
I. Evidence that the recommendation is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
Quality of Evidence (Based on USPSTF Ratings)
Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.
Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.
Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.