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Nadia A. Khan, MD, MSc, discusses the clinical examination for peripheral arterial disease.
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Nadia A. Khan, MD, MSc, discusses the clinical examination for peripheral arterial disease.
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Segment:0 .
>> This is Ed Livingston, Deputy Editor of JAMA, talking to Nadia Khan, a general internist at the University of British Columbia and a member of the Vascular Disease Network in Canada. In today's JAMAevidence podcast, we're talking about peripheral artery disease. It's associated with the normal vascular risk factors such as age, diabetes, hypercholesterolemia, or the presence of atherosclerotic disease, such as having had a stroke or myocardial infarction.
When a patient presents with peripheral arterial disease, they may have signs such as a change in skin color or pallor, ulcers on their feet, or diminished pulses. Although many patients are asymptomatic, some may present with symptoms of claudication or rest pain. Dr. Kahn, how do you assess a patient for claudication? >> Well, the classical symptoms that we're all taught in medical school are patients develop calf pain that occurs with exertion, and is relieved usually within minutes, up to ten minutes with rest.
But the majority of patients do not actually have those classical symptoms. Most are either asymptomatic or have atypical symptoms like rest pain, pain that doesn't go away when they rest, and pain that starts at rest. >> Peripheral artery disease is very much a function of a person's age. Could you tell us the risk of having the disease as a function of age? >> Peripheral arterial disease occurs in between 5 and 12 percent of the general population aged 55 to 70 years.
But this number rises to over 20 percent in people that are over 70 years of age. >> Approximately how many patients with peripheral arterial disease are asymptomatic? >> At least half. >> In this Rational Clinical Examination article, there is a nice table that shows the differential diagnosis of the various disease entities that because lower extremity pain. This list includes nerve root pain or sciatica, spinal stenosis, and peripheral nerve pain from diabetic nephropathy.
Could you tell us how to make the distinction between those entities and the pain related to peripheral artery disease? >> Pain related to peripheral artery disease can be the typical pain where patients develop calf pain or other leg pain with exercise. Peripheral nerve pain like diabetic nephropathy, those types of pains are often described as burning pain. They're usually glove and stocking distribution, so they start in the foot and progress superiorly. And those pain symptoms are burning, and they're usually present with and without exertion.
Nerve root pain can often look like claudication, in fact, we call it pseudoclaudication because they can get nerve pain that occurs with activity. And those types of pain also can occur in the buttock and down that posterior aspect of the leg. Nerve root pain, like spinal stenosis, though, can be relieved someone by maneuvers like leaning forward, whereas ischemic peripheral arterial disease pain can be relieved with rest, although, again in some cases, this is not relieved with rest.
>> What about differentiating mechanical muscle pain from peripheral arterial disease? >> So mechanical muscle pain is usually identified as pain that gets worse with mechanical movements. So the patient might complain that the pain is worse going down the stairs, for example, when they're loading their joint, or when they're moving their joint, and that would be very different from patients with ischemic claudication, who'll get more exertional pain or rest pain. >> Dr. Khan, could you tell us about screening tests for peripheral arterial disease?
>> The screening tests for peripheral arterial disease are really more helpful in helping you rule in the disease, and that's mostly in patients that have some leg complaint. So those are the ones you mentioned, skin that's cool to touch, the presence of wounds, the presence of a lower extremity bruit, or an abnormal lower extremity pulse. And a lower extremity pulse is abnormal. It's either one that's reduced when you palpate or absent. But none of these tests are definitive in ruling out disease.
There is some combination, though. So if patients have no classic intermittent claudication, and normal peripheral pulses, that's moderately helpful in ruling out peripheral arterial disease. >> Could you tell us about the peripheral arterial disease screening score? >> Yes. The clinical exam, on its own, is only moderately helpful in ruling in disease, and also not so helpful in ruling out disease. But the additional use of the bedside doppler can give you greater accuracy than the clinical exam.
So Farkouh [phonetic] created this rapid clinical prediction rule that does use a bedside doppler. And basically, what you'll do is you measure the right and left posterior tibial pulse. You'll first palpate and grade them, again, absent, reduced, or normal, and then you'll also do an oscillatory evaluation using your handheld doppler of those two pulses. And you may not have noticed when you've listened for oscillatory pulses there before, but there really can be up to three components, so three separate sounds that you can hear.
I think mostly when you hear, you'll often hear two. The more sounds you hear or the more components you hear, the better the vasculature, let's say. So if you count up those points, those oscillatory components that you hear in both the right and left, and you add it to your palpated score, as well as whether or not that patient has a history of myocardial infarction, you come up with Farkouh's [phonetic] rapid clinical prediction rule score for peripheral arterial disease. And what this clinical prediction rule found is that if you have a score above or below 6, it helps you in determining whether or not the patients have peripheral arterial disease likely, and they need a screening exam, or that peripheral arterial disease is not likely, and they likely do not need a noninvasive screening test.
>> The bedside doppler instrument is an inexpensive device that can be very useful in assessing patients with peripheral arterial disease. One simply needs to listen to the sounds that come from the device to get a sense for whether a patient has disease or not. Let's listen to the normal pulses that are heard with a doppler device. [ Pulsing Sound ] Patients with peripheral arterial disease have diminished blood flow and muted sounds when their arteries are listened to with the doppler device.
Here is what it sounds like when listening to a patient with peripheral arterial disease with a doppler device. [ Pulsing Sound ] Aside from listening to the arteries and getting a sense for whether a patient has peripheral arterial disease or not, the same doppler device is used to measure the ankle-brachial index, or ABI, which is very important in the assessment of patients with peripheral arterial disease.
Dr. Kahn, can you tell us how you use the doppler device in your clinic to measure ABIs? >> The ankle-brachial index is actually quite easy to do. What you do is you take your blood pressure cuff, and you place the cuff about 2 or 3 centimeters above the pulse that you're going to be assessing. So most of us will assess the posterior tibial pulse, so that blood pressure cuff will fit around the ankle. And what you do is place a drop of the sonic gel, then place your probe anywhere between a 30 and 60-degree angle until you can hear a very nice clear, crisp arterial sound.
And you do have to adjust the probe until you get that very nice clear sound. Then what I think is very key is if you move that probe slightly, you can alter the arterial sound. The key is keeping your hand very steady while you're doing this procedure. Then what you do is inflate the cuff until the sound is no longer audible, and then lower the sphygmomanometer cuff pressure until you hear those sounds again, and then you record that as your ankle pressure.
Then measure the blood pressure in the arm. The measure of the blood pressure in the arm can be done using oscillometric devices, or you can also use a doppler probe to measure your arm pressure. That performs the denominator for the ankle-brachial index. So you take the pressure that you received in the ankle divided by the systolic blood pressure you got from the arm, and that's your ankle-brachial index. Usually, we find that the leg pressures and the arm pressures are very similar.
But once you start having ankle-brachial indexes below .09, and some say below .08, patients are more likely to have peripheral arterial disease. And the lower your ankle-brachial index, the greater the severity of the peripheral arterial disease. So if your ankle-brachial index is less than .05, or even .04, you're looking at moderate to severe peripheral artery disease. In some patients, you will not be able to compress the lower extremity peripheral arterial pressure.
So you'll keep your doppler, but you won't be able to extinguish the sound. Or if you extinguish the sound at quite high pressures, and you end up with an ankle-brachial index that's over 1.35 or 1.4, then that test is really not helpful because the patient likely has stiff peripheral arteries that are non-compressible. In those cases, those patients should be referred for proper noninvasive monitoring like toe pressures to get a better estimate of whether or not they have peripheral arterial disease.
Patients that have a falsely high ankle-brachial index also have increased cardiovascular risk. >> Patients with the stiff arteries are characteristically patients with diabetes. Are there other categories of patients who might have that problem. >> The classics are that patients with type 2 diabetes, or the patients with end stage renal disease or chronic kidney disease. >> A number of organizations have issued screening guidelines for peripheral arterial disease.
What's your take on screening for asymptomatic patients? >> Well, it is very controversial, and the U.S. Preventive Task Force has reviewed the topic and felt that there was not significant evidence to show that all at-risk patients need to be screened. I would say that patients with peripheral arterial disease, even those who are asymptomatic have an increased cardiovascular risk, in some of those patients, it may change their management.
For patients that don't have known vascular diseases or target vascular organ damage, screening for patients that have risk factors for peripheral arterial disease would change your management, and it's clear that secondary prevention in these patients are very effective in reducing cardiovascular endpoints. >> So let me see if I understand you. So the average patient that comes into your clinic, if they smoke, no matter what they have or don't have, you're going to recommend that they don't smoke anymore.
If they have diabetes or hypertension, you'll control it. If they're not exercising, you'll recommend that they should exercise. And if they're obese, that they should lose weight. So you're going to do that for any patient walking into your clinic anyway. The question I have is if you identify peripheral arterial disease by some screening test, what are you going to do that's any different? >> Well, someone with peripheral arterial disease is in a high-risk category. So for example, you might have more aggressive lipid targets if patients are high risk.
So say the patient is a smoker, but they don't have a diagnosis of peripheral arterial disease. Without those multiple risk factors, in the Canadian Hypertension Guidelines for example, they might not necessarily warrant anti-hypertensive therapy unless their blood pressure levels were quite high. If they have peripheral arterial disease evidence and target organ damage, then those patients would need anti-hypertensive therapy at a lower threshold.
So this diagnosis can place some individuals in a high risk category. Then I think the physician has to use their clinical judgment. If the patient already has vascular disease, then screening for peripheral arterial disease likely won't change your management, unless of course the patient has leg complaints. In that case, those patients would benefit from exercise therapy and addressing issues of functional decline that can happen in those patients.
If your patients do not have vascular damage or vascular target organ damage, and you suspect that they might, peripheral arterial disease diagnosis is fairly noninvasive, quick to arrange, quick to identify, and can put them on that secondary prevention pathway at a more aggressive level than if you didn't have that diagnosis. >> In the U.S., two drugs are approved for claudication resulting from peripheral arterial disease Pentoxifylline and Cilostazol.
Their efficacy has only been demonstrated for enabling patients to walk further distance. These drugs don't really do much beyond that. Do you recommend the use of these drugs at all? >> I do in patients that have leg complaints and difficulty walking because I think that we have to understand that for our patients walking and changing the amount of distance that patients can walk is very important in their lives, although it doesn't mean that it changes your cardiovascular mortality. Those endpoints, I think are really relevant your patients, and again, physicians would need to discuss with their individual patient and see if this would be important for them.
>> For the assessment of peripheral artery disease, the clinical examination, by itself, is not sufficient. What tests should be performed in addition to a physical examination. >> Beyond the clinical examination to definitively rule in or rule out peripheral arterial disease, those patients need noninvasive testing like ankle-brachial index, which is a very high specificity for diagnosing peripheral arterial disease and can also grade the severity of peripheral arterial disease. >> What about the capillary refill test?
How effective is that? >> Although a lot of our students and trainees do the capillary refill test, this test has actually been shown to have very little clinical utility in either ruling in or ruling out peripheral arterial disease. >> Thank you very much, Dr. Kahn, for this helpful review of peripheral arterial disease. Additional information about this topic is available in the Rational Clinical Examination chapter on peripheral arterial disease. This had been Ed Livingston of JAMA talking with Dr. Nadia Khan for JAMAevidence.
Segment:0 .
>> This is Ed Livingston, Deputy Editor of JAMA, talking to Nadia Khan, a general internist at the University of British Columbia and a member of the Vascular Disease Network in Canada. In today's JAMAevidence podcast, we're talking about peripheral artery disease. It's associated with the normal vascular risk factors such as age, diabetes, hypercholesterolemia, or the presence of atherosclerotic disease, such as having had a stroke or myocardial infarction.
When a patient presents with peripheral arterial disease, they may have signs such as a change in skin color or pallor, ulcers on their feet, or diminished pulses. Although many patients are asymptomatic, some may present with symptoms of claudication or rest pain. Dr. Kahn, how do you assess a patient for claudication? >> Well, the classical symptoms that we're all taught in medical school are patients develop calf pain that occurs with exertion, and is relieved usually within minutes, up to ten minutes with rest.
But the majority of patients do not actually have those classical symptoms. Most are either asymptomatic or have atypical symptoms like rest pain, pain that doesn't go away when they rest, and pain that starts at rest. >> Peripheral artery disease is very much a function of a person's age. Could you tell us the risk of having the disease as a function of age? >> Peripheral arterial disease occurs in between 5 and 12 percent of the general population aged 55 to 70 years.
But this number rises to over 20 percent in people that are over 70 years of age. >> Approximately how many patients with peripheral arterial disease are asymptomatic? >> At least half. >> In this Rational Clinical Examination article, there is a nice table that shows the differential diagnosis of the various disease entities that because lower extremity pain. This list includes nerve root pain or sciatica, spinal stenosis, and peripheral nerve pain from diabetic nephropathy.
Could you tell us how to make the distinction between those entities and the pain related to peripheral artery disease? >> Pain related to peripheral artery disease can be the typical pain where patients develop calf pain or other leg pain with exercise. Peripheral nerve pain like diabetic nephropathy, those types of pains are often described as burning pain. They're usually glove and stocking distribution, so they start in the foot and progress superiorly. And those pain symptoms are burning, and they're usually present with and without exertion.
Nerve root pain can often look like claudication, in fact, we call it pseudoclaudication because they can get nerve pain that occurs with activity. And those types of pain also can occur in the buttock and down that posterior aspect of the leg. Nerve root pain, like spinal stenosis, though, can be relieved someone by maneuvers like leaning forward, whereas ischemic peripheral arterial disease pain can be relieved with rest, although, again in some cases, this is not relieved with rest.
>> What about differentiating mechanical muscle pain from peripheral arterial disease? >> So mechanical muscle pain is usually identified as pain that gets worse with mechanical movements. So the patient might complain that the pain is worse going down the stairs, for example, when they're loading their joint, or when they're moving their joint, and that would be very different from patients with ischemic claudication, who'll get more exertional pain or rest pain. >> Dr. Khan, could you tell us about screening tests for peripheral arterial disease?
>> The screening tests for peripheral arterial disease are really more helpful in helping you rule in the disease, and that's mostly in patients that have some leg complaint. So those are the ones you mentioned, skin that's cool to touch, the presence of wounds, the presence of a lower extremity bruit, or an abnormal lower extremity pulse. And a lower extremity pulse is abnormal. It's either one that's reduced when you palpate or absent. But none of these tests are definitive in ruling out disease.
There is some combination, though. So if patients have no classic intermittent claudication, and normal peripheral pulses, that's moderately helpful in ruling out peripheral arterial disease. >> Could you tell us about the peripheral arterial disease screening score? >> Yes. The clinical exam, on its own, is only moderately helpful in ruling in disease, and also not so helpful in ruling out disease. But the additional use of the bedside doppler can give you greater accuracy than the clinical exam.
So Farkouh [phonetic] created this rapid clinical prediction rule that does use a bedside doppler. And basically, what you'll do is you measure the right and left posterior tibial pulse. You'll first palpate and grade them, again, absent, reduced, or normal, and then you'll also do an oscillatory evaluation using your handheld doppler of those two pulses. And you may not have noticed when you've listened for oscillatory pulses there before, but there really can be up to three components, so three separate sounds that you can hear.
I think mostly when you hear, you'll often hear two. The more sounds you hear or the more components you hear, the better the vasculature, let's say. So if you count up those points, those oscillatory components that you hear in both the right and left, and you add it to your palpated score, as well as whether or not that patient has a history of myocardial infarction, you come up with Farkouh's [phonetic] rapid clinical prediction rule score for peripheral arterial disease. And what this clinical prediction rule found is that if you have a score above or below 6, it helps you in determining whether or not the patients have peripheral arterial disease likely, and they need a screening exam, or that peripheral arterial disease is not likely, and they likely do not need a noninvasive screening test.
>> The bedside doppler instrument is an inexpensive device that can be very useful in assessing patients with peripheral arterial disease. One simply needs to listen to the sounds that come from the device to get a sense for whether a patient has disease or not. Let's listen to the normal pulses that are heard with a doppler device. [ Pulsing Sound ] Patients with peripheral arterial disease have diminished blood flow and muted sounds when their arteries are listened to with the doppler device.
Here is what it sounds like when listening to a patient with peripheral arterial disease with a doppler device. [ Pulsing Sound ] Aside from listening to the arteries and getting a sense for whether a patient has peripheral arterial disease or not, the same doppler device is used to measure the ankle-brachial index, or ABI, which is very important in the assessment of patients with peripheral arterial disease.
Dr. Kahn, can you tell us how you use the doppler device in your clinic to measure ABIs? >> The ankle-brachial index is actually quite easy to do. What you do is you take your blood pressure cuff, and you place the cuff about 2 or 3 centimeters above the pulse that you're going to be assessing. So most of us will assess the posterior tibial pulse, so that blood pressure cuff will fit around the ankle. And what you do is place a drop of the sonic gel, then place your probe anywhere between a 30 and 60-degree angle until you can hear a very nice clear, crisp arterial sound.
And you do have to adjust the probe until you get that very nice clear sound. Then what I think is very key is if you move that probe slightly, you can alter the arterial sound. The key is keeping your hand very steady while you're doing this procedure. Then what you do is inflate the cuff until the sound is no longer audible, and then lower the sphygmomanometer cuff pressure until you hear those sounds again, and then you record that as your ankle pressure.
Then measure the blood pressure in the arm. The measure of the blood pressure in the arm can be done using oscillometric devices, or you can also use a doppler probe to measure your arm pressure. That performs the denominator for the ankle-brachial index. So you take the pressure that you received in the ankle divided by the systolic blood pressure you got from the arm, and that's your ankle-brachial index. Usually, we find that the leg pressures and the arm pressures are very similar.
But once you start having ankle-brachial indexes below .09, and some say below .08, patients are more likely to have peripheral arterial disease. And the lower your ankle-brachial index, the greater the severity of the peripheral arterial disease. So if your ankle-brachial index is less than .05, or even .04, you're looking at moderate to severe peripheral artery disease. In some patients, you will not be able to compress the lower extremity peripheral arterial pressure.
So you'll keep your doppler, but you won't be able to extinguish the sound. Or if you extinguish the sound at quite high pressures, and you end up with an ankle-brachial index that's over 1.35 or 1.4, then that test is really not helpful because the patient likely has stiff peripheral arteries that are non-compressible. In those cases, those patients should be referred for proper noninvasive monitoring like toe pressures to get a better estimate of whether or not they have peripheral arterial disease.
Patients that have a falsely high ankle-brachial index also have increased cardiovascular risk. >> Patients with the stiff arteries are characteristically patients with diabetes. Are there other categories of patients who might have that problem. >> The classics are that patients with type 2 diabetes, or the patients with end stage renal disease or chronic kidney disease. >> A number of organizations have issued screening guidelines for peripheral arterial disease.
What's your take on screening for asymptomatic patients? >> Well, it is very controversial, and the U.S. Preventive Task Force has reviewed the topic and felt that there was not significant evidence to show that all at-risk patients need to be screened. I would say that patients with peripheral arterial disease, even those who are asymptomatic have an increased cardiovascular risk, in some of those patients, it may change their management.
For patients that don't have known vascular diseases or target vascular organ damage, screening for patients that have risk factors for peripheral arterial disease would change your management, and it's clear that secondary prevention in these patients are very effective in reducing cardiovascular endpoints. >> So let me see if I understand you. So the average patient that comes into your clinic, if they smoke, no matter what they have or don't have, you're going to recommend that they don't smoke anymore.
If they have diabetes or hypertension, you'll control it. If they're not exercising, you'll recommend that they should exercise. And if they're obese, that they should lose weight. So you're going to do that for any patient walking into your clinic anyway. The question I have is if you identify peripheral arterial disease by some screening test, what are you going to do that's any different? >> Well, someone with peripheral arterial disease is in a high-risk category. So for example, you might have more aggressive lipid targets if patients are high risk.
So say the patient is a smoker, but they don't have a diagnosis of peripheral arterial disease. Without those multiple risk factors, in the Canadian Hypertension Guidelines for example, they might not necessarily warrant anti-hypertensive therapy unless their blood pressure levels were quite high. If they have peripheral arterial disease evidence and target organ damage, then those patients would need anti-hypertensive therapy at a lower threshold.
So this diagnosis can place some individuals in a high risk category. Then I think the physician has to use their clinical judgment. If the patient already has vascular disease, then screening for peripheral arterial disease likely won't change your management, unless of course the patient has leg complaints. In that case, those patients would benefit from exercise therapy and addressing issues of functional decline that can happen in those patients.
If your patients do not have vascular damage or vascular target organ damage, and you suspect that they might, peripheral arterial disease diagnosis is fairly noninvasive, quick to arrange, quick to identify, and can put them on that secondary prevention pathway at a more aggressive level than if you didn't have that diagnosis. >> In the U.S., two drugs are approved for claudication resulting from peripheral arterial disease Pentoxifylline and Cilostazol.
Their efficacy has only been demonstrated for enabling patients to walk further distance. These drugs don't really do much beyond that. Do you recommend the use of these drugs at all? >> I do in patients that have leg complaints and difficulty walking because I think that we have to understand that for our patients walking and changing the amount of distance that patients can walk is very important in their lives, although it doesn't mean that it changes your cardiovascular mortality. Those endpoints, I think are really relevant your patients, and again, physicians would need to discuss with their individual patient and see if this would be important for them.
>> For the assessment of peripheral artery disease, the clinical examination, by itself, is not sufficient. What tests should be performed in addition to a physical examination. >> Beyond the clinical examination to definitively rule in or rule out peripheral arterial disease, those patients need noninvasive testing like ankle-brachial index, which is a very high specificity for diagnosing peripheral arterial disease and can also grade the severity of peripheral arterial disease. >> What about the capillary refill test?
How effective is that? >> Although a lot of our students and trainees do the capillary refill test, this test has actually been shown to have very little clinical utility in either ruling in or ruling out peripheral arterial disease. >> Thank you very much, Dr. Kahn, for this helpful review of peripheral arterial disease. Additional information about this topic is available in the Rational Clinical Examination chapter on peripheral arterial disease. This had been Ed Livingston of JAMA talking with Dr. Nadia Khan for JAMAevidence.
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