Peripheral Arterial Disease Diagnosis and Management Updates

Guideline-directed medical therapy (GDMT) for the diagnosis and management lower of extremity peripheral arterial disease (PAD), when used appropriately for individualized patient needs and comorbidities, can assist nurse practitioners in clinical decision-making, management, and disease prevention for other cardiovascular diseases, according to a report on the 2016 American Heart Associate/American College of Cardiology PAD guidelines published in The Journal for Nurse Practitioners.

PAD — the third leading cause of atherosclerotic cardiovascular morbidity — is a marker for systemic atherosclerotic disease in vasculature, including coronary, carotid, renal, and abdominal vasculature, and is underdiagnosed and undertreated.

Compared with patients without PAD, patients with PAD have a 4-fold likelihood of experiencing a myocardial infarction and a 2- to 3-fold likelihood of experiencing stroke. Diagnosing PAD can lead to the early detection of coronary artery disease and cerebrovascular disease.

Individuals at risk include the following:

• Patients aged 65 years and older
• Patients aged 50 to 54 years with atherosclerotic risk factors including the following:
  
  • Hypertension
  • Diabetes
  • Dyslipidemia
  • History of smoking
  • Family history of PAD
• Patients younger than 50 years with diabetes, 1 other atherosclerotic risk factor, and known atherosclerosis
• Patients with heart failure or left ventricular dysfunction

Patients with PAD may present symptomatically (claudication, critical limb ischemia, or acute limb ischemia) or asymptomatically (adequate arterial supply at rest); the latter is present in approximately 50% of patients, in part because of declining physical activity caused by age-related joint problems, cardiopulmonary limitations, and neuropathy of the lower extremities.

In addition to physical examination, reviewing patient vascular history and asking patients about walking function, ischemic rest pain, tissue loss, or claudication is essential to diagnosis. Physical findings such as abnormal lower extremity pulse, vascular bruit, nonhealing foot/leg wound, gangrene, and elevation pallor/dependent rubor may be indicative of PAD. The differential diagnosis for leg pain includes venous claudication, spinal stenosis, nerve root compression, and arthritis.

The Rutherford Classification system, the most frequently used PAD reporting system to compare treatment outcomes, is divided into stages:

• Stage 0: Asymptomatic
• Stage 1: Mild claudication
• Stage 2: Moderate claudication
• Stage 3: Severe claudication
• Stage 4: Rest pain
• Stage 5: Minor tissue loss with ischemic nonhealing ulcer or focal gangrene, diffuse pedal ischemia
• Stage 6: Major tissue loss extending above transmetatarsal level, functional foot not salvageable

Screening tools for PAD include ankle-brachial index (ABI), toe-brachial index, rest and exercise ABIs, 6-minute walk (submaximal exercise) test, pulse volume recording, arterial duplex ultrasound, and additional anatomic testing such as computed tomography angiography, magnetic resonance angiography, and angiography.

Following a positive diagnosis of PAD, GDMT recommends exercise training, cardioprotective medications, lifestyle changes, and risk factor alterations to reduce cardiovascular events.

The author of the report suggests that clinicians urge patients with PAD, especially those with diabetes, to inspect their feet daily. Patients should avoid soaking their feet; if a patient has a history of neuropathy, walking without proper foot protection should be avoided.

In addition, clinicians assisting patients with risk factor management should instruct patients to optimize hypertension, diabetes, and dyslipidemia management; tobacco use should be discontinued. Patients should inform clinicians of any associated symptoms, such as nonhealing wounds, pain at rest, or abrupt changes in color or sensation of the feet.

According to the review, “there is a 30% all-cause mortality at 5 years after the diagnosis of lower extremity artery disease.”

“As the global population ages, PAD will be increasingly more common in the future,” the author wrote. “The goal should be to improve the detection of lower extremity PAD by providers and to facilitate guideline-based treatment that will improve cardiovascular outcomes, walking fitness, and quality of life of patients.”

Reference

Kohlman-Trigoboff D. Update: diagnosis and management of peripheral arterial disease. J Nurs Pract. 2019;15(1):87.e1-95.e1