Screening Guidelines

The American College of Cardiology/American Heart Association (ACC/AHA) guidelines on PAD have identified the following groups with a higher prevalence of PAD where screening may be appropriate¹²:

• Age ≥65 years
• Age 50 to 64 years with risk factors for atherosclerosis (e.g., diabetes mellitus, history of smoking, hyperlipidemia, hypertension) or family history of PAD
• Age <50 with diabetes mellitus and one additional risk factor for atherosclerosis
• Known atherosclerosis at other sites (e.g., coronary, carotid, renal artery disease)
• A history of claudication, other non-joint related exertional lower extremity symptoms, impaired walking function, and/or ischemic rest pain
• Physical presentation with abnormal lower extremity pulses, vascular bruit, non-healing lower extremity wound or gangrene, or other suggestive physical findings (e.g., elevation pallor/dependent rubor)

Diagnosis of PAD

Patients at risk for PAD should undergo a comprehensive vascular examination and PAD screening should always include questions related to a history of walking impairment, extremity pain that might be due to ischemia, and the presence of non-healing wounds. Since the presentation of PAD can vary, patients with risk factors for PAD who report no or few symptoms should be asked about functional capacity and decline in activity over time, including exertional non-joint related pain.¹²

For many patients, a history of risk factors or symptoms of PAD, in combination with physical examination findings, is sufficient to establish a diagnosis of PAD. Patients with atypical symptoms or abnormal physical findings require confirmation with an Ankle-Brachial Index (ABI) to establish the diagnosis of PAD. The ACC/AHA guidelines recommend for patients with a history or physical examination findings suggestive of PAD, a resting ABI, with or without segmental pressures and waveforms, is recommended to establish the diagnosis.¹²

Clinical classification of chronic lower extremity PAD is based upon the severity of symptoms and differentiates the advanced signs of PAD, tissue loss, such as ulceration and gangrene. The later stages of the disease, ischemic rest pain and tissue loss, are considered critical limb ischemia (CLI).¹³

Rutherford Clinical Classification

Critical Limb Ischemia

Critical limb ischemia presents as ischemic rest pain with or without tissue loss, such as skin ulceration, diabetic ulcer or gangrene. CLI is estimated to occur in 1 to 2 percent of patients with symptomatic PAD.¹⁴

Patients with CLI are at risk for limb loss with an associated 1-year limb loss rate of 20% and a 1-year mortality rate of 20%.¹⁵ Estimates show that 33% of CLI patients with an amputation will have a contralateral amputation within 3 to 5 years.¹⁶ It has been reported in a retrospective analysis, however, that 54% of CLI patients had no vascular procedures performed in the year before major lower extremity amputation.¹⁷ Early intervention with the right network is key to reduce the chances of amputation.

Quality Of Life

People with limb loss due to CLI experience significantly lower health status, high rates of mortality, and increased risk for cardiovascular disease, obesity, joint and bone issues, plus high rates of depression, and emotional distress.^22-27

Studies estimate the 5-year mortality rate for people with an amputation, due to PAD, to be between 50% and 74%, which is higher than colorectal cancer, breast cancer and coronary artery disease (CAD).^28-29