PVD: Overview

We would like to bring to your attention the PARTNERS Program described in JAMA 2001; 286: 1317-24. This study looked at the feasibility of detecting PAD in primary care clinics, the awareness of PAD by physicians in a primary care practice setting, and the intensity of risk-factor treatment and the use of antiplatelet therapies for patients with PAD.

Because claudication is a quite common complaint in the general population, it is a very useful indicator of systemic atherosclerotic disease. In particular, claudication is an important sign of significant coronary occlusive disease. Risk factors for claudication are identical to those for heart disease and stroke. Those risk factors include smoking, hypertension, hyperlipidemia, diabetes, sedentary lifestyle, and a previous history of PVD. The same disease process that causes lipid deposition in the periphery can cause similar deposits in the coronary and cerebral vasculature. Despite a relative lack of symptomatic vascular disease, these patients are well known to have an increased risk of myocardial infarction and stroke. Unfortunately the presence of peripheral vascular disease is under appreciated in routine patient assessment and evaluation. The opportunity for the early diagnosis of more serious and potentially lethal systemic atherosclerotic disease is easily missed.

The diagnosis of claudication is easily assessed using two relatively simple and universally available diagnostic tools. Routine physical examination of peripheral pulses may provide an excellent clue to presence of multisystem disease. Specifically, loss of the posterior tibial pulse correlates well with significant cardiac disease. The ankle-brachial index is a readily available screening diagnostic tool available to all physicians performing routine physical examinations. To accurately determine the ABI, the highest Doppler blood pressure measured is each foot is compared to the highest systolic blood pressure measured in the arms. The ratio (ankle to brachial) should be 1.0 if no obstructive process is present. An ABI less than 0.9 is indicative of significant PVD and should be investigated further. The lower the ABI, the more severe the peripheral occlusive process, and the greater the likelihood of significant systemic disease.  Despite significantly reduced ABI’s, patients may have minimal leg symptoms because of limiting dyspnea or chest pain of a cardiac origin. Therefore, the performance of ABI measurements should be part of the routine physical examination of all patients with the appropriate risk factors. Even in the absence of symptoms of claudication, significant and life threatening disease may be present.

We would encourage you to consider the presence of significant multisystem vascular disease in at risk patients. By careful and systemic approach to the at risk population, the overall morbidity and mortality of this disease process can be lessened.