Diagnosis and Treatment of Peripheral Arterial Disease
DUANE R. HENNION, MD, and KELLY A. SIANO, MD, Tripler Army Medical Center, Honolulu, Hawaii
Am Fam Physician. 2013 Sep 1;88(5):306-310
http://www.aafp.org/afp/2013/0901/p306.pdf
Peripheral arterial disease is basically just angina of the extremities. Distal arterial stenosis causes decreased blood flow and claudication of the legs. Claudication is defined as leg pain reproduced with exercise, which resolves within 10 minutes of resting. Risk factors are the same as the risk factors for cardiovascular disease; age, smoking, diabetes, hypertension, cholesterol, renal insufficiency, and race. Claudication can be differentiated from spinal stenosis by the fact that stenosis is worse when walking down stairs. It is also not resolved as quickly after rest. DVT's will often have a "hot leg", skin changes, and decreased distal pulses. The best test to check for PAD is the ABI (ankle brachial index). An ABI of 1 is normal. An ABI of less than 0.9 is interpreted as PAD. Patients with an ABI of less than 0.9 have a higher risk of CVA. Universal screening is not recommended by the USPSTF. Patients with risk factors may benefit from ABI screening.
Treatment of PAD starts with modification of risk factors. Smoking cessation, exercise, diet, statins, and antiplatelet therapy are first line therapies. Lipid therapy is done with a treatment goal of less than 100 mg/dL. Low dose aspirin (or clopidogrel) will lower the chances of a cardiovascular event. Supervised exercise, such as 30 minutes on the treadmill, 2-3 times a week, can increase overall walking time and walking distance. It is as effective as angioplasty. Cilostazol (a phosphodiesterase inhibitor) will cause arterial vasodilation and suppress platelet aggregation. It has been shown to increase walking distances. Surgery may be considered in patients who do not respond to medication or exercise.
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