The fastest screening tool for peripheral arterial disease

It is everything that you are looking for in a medical device – a fast, simple, accurate and objective screening tool for the diagnosis of peripheral arterial disease.

TASC II – Inter-society consensus for the management of PAD

Journal of Vascular Surgery, January 2007
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The Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC) was published in January 2000 as a result of cooperation between fourteen medical and surgical vascular, cardiovascular, vascular radiology and cardiology societies in Europe and North America. This comprehensive document had a major impact on vascular care amongst specialists. In subsequent years, the field has progressed with the publication of the CoCaLis document and the American College of Cardiology/American Heart Association Guidelines for the Management of Peripheral Arterial Disease. Aiming to continue to reach a readership of vascular specialists, but also physicians in primary health care who see patients with Peripheral Arterial Disease (PAD), another consensus process was initiated during 2004.

ACC/AHA 2005 Practice guidelines for the management of patients with Peripheral Arterial Disease

Circulation, March 21, 2006
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In particular, these guidelines are designed to aid primary care clinicians, vascular and cardio-vascular specialists, trainees in the primary care and vascular specialties, nurses, physical therapists, and rehabilitative personnel who seek clinical tools that can improve the proper evaluation and management of patients with PAD and associated thromboembolic disease. This document provides recommendations and supporting evidence for the short- and long-term management of patients with PAD in both inpatient and outpatient settings. Recommended diagnostic and therapeutic strategies are supported by the best available evidence and expert opinion. The application of these strategies, combined with carefully reasoned clinical judgment, promotes the use of preventive strategies, improves the rates of diagnosis of each syndrome, and decreases the rates of amputation, ischemic renal failure, mesenteric ischemia, aneurysmal rupture, MI, stroke, and death. The ultimate goal of the guideline is to improve the quality of life for people with PAD.

2011 ACCF/AHA Focused update of the guideline for the management of patients with Peripheral Artery Disease (Updating the 2005 guideline)

Circulation, November 1, 2011
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The results of late-breaking clinical trials presented at the annual scientific meetings of the ACC, AHA, European Society of Cardiology, Society for Vascular Surgery, Society of Interventional Radiology, and Society for Vascular Medicine, as well as selected other data/articles published through December 2010, were reviewed by the 2005 guideline writing committee along with the Task Force and other experts to identify those trials and other key data that may impact guideline recommendations. On the basis of the criteria/considerations noted above, recent trial data and other clinical information were considered important enough to prompt a focused update of the “ACC/AHA 2005 Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)”. Because clinical research and clinical care of vascular disease have a global investigative and international clinical care tradition, efforts were made to harmonize this update with the Trans-Atlantic Inter-Society Consensus document on Management of Peripheral Arterial Disease (TASC) and the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) Steering Committee guideline writing efforts.

Critical issues in Peripheral Arterial Disease detection and management

American Medical Association, 2003
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THIS CALL-TO-ACTION document is an initiative of the Prevention of Atherothrombotic Disease Network, an international, multidisciplinary network, adjoined by the mutual goal of increasing awareness, detection, and treatment rates of Peripheral Arterial Disease (PAD) and increasing awareness of the interrelationship between PAD and the risk of ischemic events. Although the prevalence of PAD in Europe and North America is estimated at approximately 27 million people, PAD remains a largely underdiagnosed and undertreated disease. Several recent epidemiologic studies have revealed PAD detection rates of 20% to 30% when specific at-risk populations were screened. In an effort to guide diagnostic and treatment protocols, the Prevention of Atherothrombotic Disease

Network has recommended 5 action items. These are to (1) increase awareness of PAD and its consequences; (2) improve the identification of patients with symptomatic PAD; (3) initiate a screening protocol for patients at high risk for PAD; (4) improve treatment rates among patients who have been diagnosed with symptomatic PAD; and (5) increase the rates of early detection among the asymptomatic population.

Prognostic value of a low post-exercise ankle-brachial index as assessed by primary care physicians

Atherosclerosis, February 2011
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We aimed to investigate whether the post-exercise ankle brachial index (ABI) performed by primary care physicians offers useful information for the prediction of death or cardiovascular events, beyond the traditional resting ABI. An additional focus was on patients with intermittent claudication and normal resting ABI.

Mean post-exercise ABI in the total cohort was 0.977 and resting ABI was 1.034. For post-exercise ABI, a threshold value of 0.825 had nearly the same sensitivity (28.6%) and specificity (85.7%) as the conventionally used resting ABI with a cut-off value of 0.9 to predict death. Compared to patients with normal post-exercise ABI, a low post-exercise ABI was associated with an almost identical risk increase for mortality (hazard ratio [HR] 1.56, 95% confidence interval [CI] 1.30–1.86) as a low resting ABI (HR 1.65; CI 1.39–1.97) and/or myocardial infarction/stroke. Slight differences were observed for coronary/carotid revascularisation and peripheral revascularisation/amputation. In combined models it could not be shown that post-exercise ABI yielded relevant additional information for the prognosis of mortality and/or myocardial infarction/stroke, not even in the subgroup analysis of patients with intermittent claudication and normal resting ABI.

Interobserver variability of ankle–brachial index measurements at rest and post exercise in patients with intermittent claudication

Vascular Medicine, August 3, 2009
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The ankle–brachial index (ABI) post exercise is claimed to play a complementary role in the diagnosis or exclusion of intermittent claudication (IC). The interobserver variability of ABI measurements at rest and post exercise in patients with typical symptoms of IC is the subject of this study with emphasis on ABI post exercise. ABI at rest and post exercise were measured in both legs of 20 patients with typical symptoms of IC. After 15 minutes of rest these measurements were repeated by another observer. Analysis according to Bland–Altman was performed on 40 paired leg measurements at rest and 40 paired leg measurements post exercise.

Hypertension in pregnancy is a risk factor for Peripheral Arterial Disease decades after pregnancy

Atherosclerosis, April 18, 2013
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An ankle-brachial index (ABI) (the ratio of ankle to brachial artery systolic blood pressure) value ≤0.9 identifies patients with Peripheral Arterial Disease (PAD) and elevated cardiovascular event risk. This study examined whether women with a history of hypertension in pregnancy are more likely to have an ABI ≤0.9 decades after pregnancy.

Ankle-brachial index combined with Framingham risk score to predict cardiovascular events and mortality: a meta-analysis

JAMA, July 9, 2008
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The objective of our study was to determine if the ABI provides information on the risk of cardiovascular events and mortality independently of the Framingham Risk Score and can improve risk prediction. In order to enhance the representativeness of our study and to maximize subject numbers, we formed the Ankle Brachial Index (ABI) Collaboration with the intent of including all major observational studies which had investigated longitudinally the ABI and incidence of cardiovascular events and mortality in general populations. At the same time we wished to identify a normal (low risk) level of the ABI which might be used in future studies and in clinical practice.

Measurement and interpretation of the ankle-brachial index: a acientific statement from the American heart association

Circulation, December 11, 2012
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The ankle-brachial index (ABI) is the ratio of the systolic blood pressure (SBP) measured at the ankle to that measured at the brachial artery. Originally described by Winsor1 in 1950, this index was initially proposed for the noninvasive diagnosis of lower-extremity Peripheral Artery Disease (PAD). Later, it was shown that the ABI is an indicator of atherosclerosis at other vascular sites and can serve as a prognostic marker for cardiovascular events and functional impairment, even in the absence of symptoms of PAD.

Specific guidelines for the diagnosis and treatment of Peripheral Arterial Disease in a patient with diabetes and ulceration of the foot

Diabetes/Metabolism Research and Review, 2012
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These guidelines are based upon two companion International Working Group on the Diabetic foot papers: ‘A Systematic Review of the Effectiveness of Revascularisation of the Ulcerated Foot in Patients with Diabetes and Peripheral Arterial Disease’ and ‘Diagnosis and treatment of Peripheral Arterial Disease in diabetic patients with a foot ulcer. A progress report’.

An analysis of the relationship between ankle–brachial index and estimated glomerular filtration rate in type 2 fiabetes

Vascular Medicine, August 7, 2008
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We investigated the relationship between Peripheral Arterial Disease (PAD) and renal function in patients with type 2 diabetes mellitus (T2DM). We enrolled 2057 hospitalized patients with T2DM and measured kidney function and ankle–brachial index (ABI). The estimated glomerular filtration rate (eGFR) was derived using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and ABI was grouped as low (<0.9), low-normal (0.9-1.09), normal (1.1-1.3), and high (>1.3). Logistic regression was used to evaluate the associations of eGFR with ABI. Generally speaking, the ABI was negatively correlated with systolic blood pressure, fasting C-peptide, total cholesterol, and low-density lipoprotein cholesterol while positively correlated with body mass index (P < .05 to <.01). Only a low ABI was positively correlated with eGFR (P < .01). In addition to the association of the ABI with cardiovascular events, stroke, and PAD, ABI may also predict the change in renal function in patients with T2DM.

ESC guidelines on the diagnosis and treatment of Peripheral Artery Diseases

European Heart Journal, 2011
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This is the first document produced by the ESC addressing different aspects of Peripheral Artery Diseases (PAD). This task has been undertaken because an increasing proportion of patients with heart disease need to be assessed for vascular problems in other territories, both symptomatic and asymptomatic, that may affect their prognosis and treatment strategy. It is also recognized that patients with PAD will probably die from CAD.

Mortality over a period of 10 years in patients with Peripheral Arterial Disease

The New England Journal of Medicine, February 6, 1992
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Previous investigators have observed a doubling of the mortality rate among patients fourfold increase in the overall mortality rate among subjects with large-vessel Peripheral Arterial Disease, as diagnosed by noninvasive testing. In this study, we investigated the association of large-vessel peripheral arterial disease with rates of mortality from all cardiovascular diseases and from coronary heart disease.

Peripheral Arterial Disease: A guide for nephrologists

Clinical Journal of the American Society of Nephrology, 2007
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Cardiovascular disease is a major source of morbidity and mortality for patients with chronic kidney disease (CKD). Peripheral Arterial Disease (PAD) is a strong predictor of coronary artery disease and a risk factor for mortality in the general population. This is of particular interest to nephrologists because the risk for PAD is increased in CKD. Often, PAD is overlooked as a source of morbidity and as a cardiovascular risk factor in this population. This review serves as an overview of the epidemiology, screening, diagnosis, and treatment of PAD with an emphasis on CKD.

Subclinical peripheral arterial disease in patients with chronic kidney disease – Prevalence and related risk factors

Kidney International, 2005
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Patients with chronic kidney disease (CKD) are highly predisposed for developing accelerated atherosclerosis, even in the absence of certain traditional cardiovascular risk factors [1]. Moreover, frequently these patients not only present traditional risk factors such as hypertension, diabetes, or dyslipidemia, but also other nontraditional factors such as inflammation, malnutrition, and oxidative stress, which enhance and accelerate atherosclerosis. Minor renal dysfunction influences cardiovascular risk [2–5]. Although the relationship between myocardial infarction, stroke, and cardiovascular death with renal dysfunction is well established, there are few data on the prevalence of Peripheral Arterial Disease (PAD) in the lower extremities in patients with CKD. PAD is associated with high mortality, 3 times higher than that of the general population [6], even in patients without CKD, and its prevalence appears to be much higher among end-stage renal disease patients, as evidenced by the high amputation rates in this group compared to the general population [7].

ABC of wound healing – Venous and arterial leg ulcers

BMJ, February 11, 2006
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Arterial ulceration is due to a reduced arterial blood supply to the lower limb. The most common cause is atherosclerotic disease of the medium and large sized arteries. Other causes include diabetes, thromboangiitis, vasculitis, pyoderma gangrenosum, thalassaemia, and sickle cell disease, some of which may predispose to the formation of atheroma. Further damage to the arterial system occurs with concurrent hypertension through damage of the intimal layer of the artery. The reduction in arterial blood supply results in tissue hypoxia and tissue damage. Thrombotic and atheroembolic episodes may contribute to tissue damage and ulcer formation.

Asymptomatic low ankle-brachial index in vascular surgery patients: a predictor of perioperative myocardial damage

European Journal of Vascular & Endovascular Srugery, 2010
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This study demonstrated that asymptomatic low ABI has a prognostic value to predict perioperative myocardial damage in vascular surgery patients, incremental to risk factors imbedded in conventional cardiac risk indices.

Vascular hospitalization rates and costs in patients with Peripheral Artery Disease in the United States

Circulation, November, 2010
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Peripheral Artery Disease (PAD) of the lower extremities has become increasingly recognized as a major contributor to the cardiovascular public health burden because it is associated with high rates of morbidity and impairment in quality of life and identifies a cohort of patients that is at increased risk of major cardiovascular ischemic events. Lower-extremity PAD is estimated to affect 12% to 15% of patients over age 65 years and between 8 and 10 million people in the United States, with the expectation that the prevalence will increase significantly as the population ages, becomes more obese, and as diabetes becomes more common. As a result, there has been an increased effort toward establishing greater awareness of the clinical burden and risks conferred by PAD. Similarly, associated efforts are now directed toward establishing more effective diagnostic methods (including screening) and disease management guidelines aimed at increasing the use of therapies proven to reduce these risks. In addition to the clinical burden on patients and their families, PAD is associated with a significant economic burden—in part related to the treatment of advanced disease aimed at alleviating symptoms as well as preventing and treating ischemic events.

Muscle denervation in Peripheral Arterial Disease

Neurology, May, 1992
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Muscle function is often severely impaired in Peripheral Arterial Disease (PAD), but the effects of repeated ischemic events upon nerve and muscle are incompletely characterized. We performed comprehensive electrophysiologic studies and skeletal muscle histologic analysis in six patients with unilateral PAD and five control subjects matched for age and activity level. In the PAD patients, all ischemic legs showed both electrophysiologic and histologic evidence of chronic partial denervation-reinnervation restricted to distal muscles. Two of the PAD patients had evidence of milder distal denervation in the nonischemic legs. Two of the controls had denervation in at least one leg, but in each case electrophysiologic findings were pathognomonic of L-5 and S-1 radiculopathies. All other control legs and nonischemic legs were normal. These results suggest that recurrent ischemia associated with PAD may cause muscle denervation, which may be one of the mechanisms responsible for decreased exercise performance in these patients.

Concomitant neurological and orthopaedic diseases in the presence of Peripheral Arterial Disease: a prospective study

VASA, January 7, 2013
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The symptoms of Peripheral Arterial Disease (PAD) can be masked by neurological or orthopaedic diseases with identical symptoms, which may result in faulty therapy decisions, if the diagnosis is solely based on the reported complaints and angiographic or duplex ultrasonographic findings. A prospective study was therefore performed to find out how often established PAD is accompanied by neurological or orthopaedic pictures that can blend into the PAD symptoms.

The prevalence of occult Peripheral Arterial Disease among patients referred for orthopedic evaluation of leg pain

Vascular Medicine, August 7, 2008
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Lower extremity Peripheral Arterial Disease (PAD) and musculoskeletal conditions both produce symptoms of leg pain, and may coexist. This study assesses the prevalence of PAD among patients referred to orthopedic surgery for evaluation of lower extremity pain. Fifty consecutive patients aged 50 years or more who had a chief complaint of leg pain, no history of trauma, and no previous history of PAD were studied prospectively. The presence of known risk factors for PAD and classic claudication symptoms was assessed by telephone interview and medical record review. Individuals were then evaluated by measurement of the ankle–brachial index (ABI) using Doppler and pulse volume recordings (PVR). A patient was deemed to have PAD if the ABI was below 0.9 or if the PVR demonstrated significant abnormalities. Occult PAD was detected in 10 of the 50 patients (20%) on the basis of the noninvasive vascular studies. There were no differences between patients with PAD and those without PAD regarding the presence of risk factors for PAD. None of the patients without PAD had claudication, while only one of the 10 patients with PAD had symptoms of classic claudication. In conclusion, 20% of patients referred by primary care providers to the orthopedic surgery clinic for lower extremity pain were discovered to have occult PAD. The majority of these patients did not have claudication. Orthopedic surgeons and primary care providers must maintain an appropriately high index of suspicion for PAD when evaluating patients with non-traumatic lower extremity pain.