Leveraging the Cardiovascular Team in Peripheral Artery Disease Diagnosis: A Call to Action

Figures & data

Table 1 Pertinent Questions When Detecting for Peripheral Artery Disease

Common symptoms associated with PAD include lower extremity pain, claudication, weakness, nonhealing wounds or ulcers, and neurosensory complaints such as numbness and tingling. Claudication is defined as pain within a defined muscle group that is induced by exercise and relieved with rest and can be diffuse (eg in hip, thigh, calf, and foot). In more severe cases, patients may also experience ischemic rest pain.^Citation16 Symptoms vary based on several factors including degree of arterial narrowing, number of affected arteries, and level of activity of the patient.^Citation16 Importantly, many patients present with asymptomatic disease or atypical symptoms.

Does the patient have any pain with ambulation?

○ If so, how far can the patient walk before the pain occurs?

Does the pain cause the patient to stop walking?

○ If so, after how much time is the patient able to resume walking?

Does the pain recur after a similar walking distance?

Has the patient’s ability to walk diminished over time or altered the patient’s lifestyle in any way?

Does the patient experience any pain in the extremity that wakens them from sleep?

○ If so, where is the pain located?

Is the pain relieved once the foot is hung over the side of the bed?

Does pain cause the patient to sleep sitting in a chair?

Has the patient noticed any nonhealing wounds or ulcers (deep, “punch-out”, circular wounds that appear pale or necrotic) on the toes?

○ If so, how long have the wounds or ulcers been present?

If wounds have occurred in the past, what measures were used to promote healing?

Is skin discoloration or hair-loss on the lower limb present?

Table 2 Peripheral Artery Disease Testing Modalities^6,16–22

Test	Indication	Benefits	Limitations
Ankle Brachial Index (bedside/ without treadmill)	An ABI is the most common test performed to establish diagnosis in patients with history or physical examination findings consistent with PAD.	An ABI is a reliable, non-invasive, and widely used test that can be done either at the bedside or in a vascular lab. ABI has a high degree of sensitivity and specificity for PAD.	Some patients with severe PAD or painful wounds may not be able to tolerate the pressure cuffs. A resting ABI also does not always correlate well with physical symptoms and may not detect non-obstructive atherosclerotic lesions. Patients with calcified blood vessels (especially small vessels) can give abnormally high or unreadable results.
ABI with Treadmill/ Exercise Testing	Exercise testing is a reliable method for diagnosing PAD in patients with classic symptoms of claudication but found to have a normal resting ABI.	Exercise testing is very beneficial for distinguishing between arterial occlusive disease and neurological conditions such as spinal stenosis. The exercise test additional provides objective evidence of the functional limitations of patients with claudication.	This test needs to be done in a vascular lab with a treadmill. Patients must be able to walk on the treadmill for this exam. Patients should not have critical cardiovascular disease (eg, severe aortic stenosis, acute coronary syndrome).
Six-minute walk assessment	The six-minute walking test is indicated to quantify the speed and duration of ambulation to quantify the degree of claudication. It is not a screening tool.	This test does not require any equipment and is a great way to get a baseline assessment of claudication symptoms by measuring time of onset of pain, recovery of pain, and location of pain. It is a good alternative to Exercise Testing when a treadmill is not available.	This test is not as reliable as an ABI or Exercise Test because it does not provide objective data regarding circulation. Can easily be limited by other medical comorbidities such as cardiac/respiratory or musculoskeletal issues.
Audible Handheld Doppler Ultrasound	Non-palpable pedal pulse; pedal edema	A doppler assessment is a quick and easy exam to detect blood flow to lower extremity. It can be done at the bedside or during a clinic visit.	Operator variation /skill level; blood pressure dependent
Ultrasound/ Arterial duplex	Abnormal ABI or ongoing surveillance after intervention.	An arterial duplex is a diagnostic study often used in conjunction with an ABI to identify location and severity of arterial disease. This exam provides a visual of plaque morphology, as well as speed and flow of blood in arterial vessels.	Greater margin of error than a CTA or MRA.
CTA	Computed tomography angiography (CTA) is recommended for further evaluation of anatomic location and severity of stenosis in patients who are expected to undergo revascularization.	A CTA is a diagnostic exam that provides a high- resolution image of arterial vessels which is often used for surgical planning. CTA is more commonly used than MRA because it is more widely available, cheaper, and quicker.	This exam is reserved for highly symptomatic patients. It requires the use of iodinated contrast media which is nephrotoxic and a potential allergen. Not recommended for patient with kidney disease
MRA	Magnetic resonance angiography (MRA)is a widely used modality for imaging of peripheral artery occlusion diseases	This diagnostic exam provides evaluation of blood flow and structure of peripheral arteries. This can be done with or without contrast. This is a good alternative exam for patients with renal disease or patients with severe allergy to contrast dye.	This exam is not used as often, compared to CTA, due to factors of scanner availability, higher costs, patient tolerability, and incompatibility with certain metallic implants. This exam may have difficulty with imaging high grade stenosis. If the exam is not done properly there is a high likelihood for native artery stenosis to be overestimated.
Catheter Angiography/ Angiogram	Invasive procedure done to locate areas of high-grade stenosis for which revascularization is recommended. CTA or MRA are indicative of significant stenosis impacting lower extremity circulation.	An angiogram is a minimally invasive diagnostic procedure that can accurately identify specific areas of stenosis. Providers are often able to perform intervention while performing this exam. They can locate the exact areas of stenosis and then proceed with angioplasty, atherectomy, or stenting.	Invasive exam with greater risk of harm to patient. Requires contrast media, which is nephrotoxic.

Table 3 The Various Roles of the Cardiovascular Team in the Detection & Diagnosis of Peripheral Artery Disease

	Nurses / Nurse Practitioners	Pharmacists	Wound Care Specialist / Podiatrists / Exercise Physiologists	Physicians / Physician Assistants
Training & Specializations	Symptomatic assessment expert Advanced practice training in vascular medicine allows for highly skilled management of PAD patients	Medication expert Specialization in cardiovascular pharmacy allows for inpatient and outpatient specialized medication management	Physical assessment expert Highly specialized team with focus the lower extremity monitoring, disease progression and recovery	Diagnostic expert Specialization in vascular medicine and surgery allow for specialized care of PAD patients
Accessibility	Front-line personnel in the admission process of the inpatient and outpatient setting	Most-accessible clinician in community setting	Valuable support in both the healthcare and non-healthcare community setting	Care-providers in the inpatient and outpatient setting
Role on the CV Team in PAD Management	Vascular trained nurses are highly specialized in the assessment of common symptoms of PAD, claudication and ischemic rest pain Key to recommending ABI and further testing upon admission symptom evaluation	Experts in the association of medications with signs, and presentation of atherosclerotic disease Front-line clinical team in the detecting and triaging lower-extremity related symptoms vs OTC self-care	Clinicians most-closely associated with lower-extremity disease prevention and therapy Key members in the reporting of worsening lower extremity symptoms and disease progression	Key diagnostic experts in the differentiation of PAD from the presentation of other extremity disease states Order, interpret and recommend ABI testing and various forms of imaging secondary to ABIs
Rutherford Stage Involvement for Detection	1–6	0–4	2–6	0–6

Notes: Rutherford Staging (0 = Asymptomatic, 1 = Mild Claudication, 2 = Moderate Claudication, 3 = Severe Claudication, 4 = Rest Pain, 5 = Ischemic Ulcer of Digits of Foot, 6 = Severe Ischemic Ulcers of Gangrene).

Abbreviations: PAD, Peripheral Artery Disease; ABI, Ankle-Brachial Index; OTC, Over-The-Counter (medications).

Figure 1 The Collaboration of Cardiovascular Team Members for Peripheral Artery Disease Management at Each Phase of Care.

McDermott MM, Greenland P, Liu K, et al. Leg symptoms in peripheral arterial disease: associated clinical characteristics and functional impairment. JAMA. 2001;286(13):1599–1606. doi:10.1001/jama.286.13.1599

 PubMed Web of Science ®Google Scholar

Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the management of patients with lower extremity peripheral artery disease: a report of the American college of cardiology/American heart association task force on clinical practice guidelines. J Am Coll Cardiol. 2017;69(11):e71–e126. doi:10.1016/j.jacc.2016.11.007

 PubMed Web of Science ®Google Scholar