PVD: Systemic Manifestations

Peripheral vascular disease is well recognized as a marker for systemic atherosclerosis. Patients with claudication are almost three times more likely to die than the general population, primarily from concomitant heart disease and stroke. Patients with asymptomatic peripheral arterial disease have the same increased risk of cardiovascular events and death as found in claudicants. Unfortunately the disease process in these patients is frequently under treated relative to patients with CVD in the use of statins, anti-platelet therapy, and blood pressure therapies. Because of the relative ease of screening for peripheral vascular disease is seems imperative to pursue that diagnosis in the at-risk patient population to decrease the overall morbidity and mortality produced by this disease process.

Screening for peripheral vascular disease is easily performed through a combination of directed questions, routine palpation of peripheral pulses, and the measurement of ankle-brachial indices in all at risk patients.

Obviously the focused initial patient interview will provide valuable information. We routinely employ a standard vascular screening questionnaire at our initial patient encounter to focus further evaluation.

Standard pulse palpation is a valuable adjunct in diagnosis. The absence of a palpable posterior tibial pulse strongly correlates with the presence of coronary artery disease.

The ABI is an easily performed screening test with broad prognostic and therapeutic implications. It is a simple yet powerful tool which is related to the extent of atherosclerosis in both peripheral and coronary arterial beds. Additionally, it is also a useful tool for predicting survival in patients with peripheral vascular disease. An ABI <0.90 was shown to be associated with a twofold increase in the risk of significant coronary artery disease. Furthermore, the ABI is consistently associated with all major manifestations of clinical CVD suggesting it is a very useful marker of atherosclerosis.

Recognition of the patient with multisystem CVD is clearly important to minimize their risk of future fatal events. Risk factor modification for patients at risk is clearly important. Specifically targeting of diabetics, smokers, hypertensives, and hyperlipidemics is of particular benefit.

We strongly encourage the persistent use of readily available office screening procedures to identify the patients at risk for multisystem vascular disease. Clearly modification of the systemic disease can have very significant implications for long term morbidity and mortality.

Risk factors associated with all vascular disease processes are similar and include smoking, diabetes, increasing age, non-white race. It is hypothesized the AAI is a strong predictor of future events. In women the risk of coronary heart disease, stroke, and cardiac failure was increased 3-4 times when diabetes and intermittent claudication occurred together compared with when either condition existed alone. In diabetic men the presence of IC doubled the risk of stroke, and cardiac failure was ~3 times more likely in subjects with both conditions compared with either alone.

The AHA has introduced a program called “Get with the Guidelines – GWTG” the goal of which is to assure that all patients with known vascular disease are discharged from the hospital with the secondary prevention guidelines addressed. The questionnaire helps to focus attention on the process. Absence of a palpable posterior pulse strongly correlates with major vessel central vascular disease. Measurement of the ABI’s provides a safe and very sensitive method of screening for the disease process.

In our practice, we specifically focus on diabetics, smokers, hypertensives, and those with hyperlipidemia. We are hopeful that the careful attention to risk factor modification in this patient population will beneficially affect the longterm outcome for these patients.