A review of simple, non-invasive means of assessing peripheral arterial disease and implications for medical management

Figures & data

Figure 1. The natural progression of symptoms in patients with peripheral arterial disease (PAD). (CLI = critical limb ischemia; CV = cardiovascular; MI = myocardial infarction.) Rreproduced with permission from Hirsch et al., J Am Coll Cardiol. 2006;47:1239–12 (3).

Table I. Types of ankle-brachial index (ABI) assessments and their diagnostic function.

Type	Procedure/cuff placement	Function
Single-level ABI	Cuffs on upper arms and ankles, with Doppler on brachial, posterior tibial, and dorsalis pedis arteries	Initial assessment of asymptomatic patients or those with claudication to confirm diagnosis and establish baseline
Multilevel/segmental ABI	Cuffs are placed on arms, ankles, each calf, above the knees, and at thighs	Identification of site of limb stenosis once PAD has been diagnosed
Stress ABI	ABI assessment at 1-minute intervals for 5 minutes after patient completes 5 minutes of treadmill walking or reaches maximal exercise tolerance on treadmill (whichever comes first)	Diagnostic for lower extremity PAD if resting ABI is normal

PAD = peripheral arterial disease.

Figure 2. a: Eevaluation of patients in whom peripheral arterial disease (PAD) is suspected; b: evaluation and treatment of patients with established PAD. (LDL = low-density lipoprotein; MWD = maximal walking distance; PFWD = pain-free walking distance; SF-36 = Medical Outcomes Study 36-Item Short Form; WIQ = Walking Impairment Questionnaire.) Rreproduced with permission from Hiatt, N Eengl J Med. 2001;344:1608–21 (34).

Table II. ACC/AHA guidelines for the management of peripheral arterial disease (PAD) (3).

Cardiovascular risk factor modification (Class/Level of evidence)	Claudication treatments (Class/Level of evidence)
Smoking cessation	Exercise and lower extremity PAD rehabilitation
•Behavior modification therapy, nicotine replacement, or bupropion (I/B)	•Supervised exercise (walking programs), minimum of 30–45 minutes/≥3 × week/12 weeks (I/A)
Diabetes therapy	Pharmacotherapy
•Proper foot care including daily foot hygiene and urgent attention to skin lesions and ulcerations to reduce the risk of amputation (I/B)	•Cilostazol in the absence of heart failure (I/A)
•Target HbA1C: <7.0% to reduce microvascular complications and potentially improve CV outcomes (IIa/C)	•Pentoxifylline (IIb/A)
Lipid-lowering agents	Revascularization
•Target LDL-C: <100 mg/dL (<2.59 mmol/L), or <70 mg/dL (<1.813 mmol/L) in high-risk patients with multiple risk factors, especially diabetes (I/B)	•Endovascular (I/A)
•Statins (IIa/B)	•Surgical (I/B)
Antihypertensive therapy
•Target BP: <140/90 mmHg (<130/80 mmHg in diabetes and chronic renal failure) (I/A)
•Beta-blockers (I/A)
•ACEI (IIa/B)
Antiplatelet therapy
•Aspirin 75–325 mg/day indefinitely (I/A)
•Clopidogrel 75 mg/day (I/B)

ACC = American College of Cardiology; ACEI = angiotensin-converting enzyme inhibitor; AHA = American Heart Association; BP = blood pressure; CV = cardiovascular; HbA_1C = glycosylated hemoglobin; LDL-C = low-density lipoproteincholesterol.