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  • Review Article
  • Published:

Peripheral artery disease. Part 1: clinical evaluation and noninvasive diagnosis

Nature Reviews Cardiology volume 8, pages 405–418 (2011)Cite this article

Subjects

Abstract

Peripheral artery disease (PAD) is a marker of systemic atherosclerosis. Most patients with PAD also have concomitant coronary artery disease (CAD), and a large burden of morbidity and mortality in patients with PAD is related to myocardial infarction, ischemic stroke, and cardiovascular death. PAD patients without clinical evidence of CAD have the same relative risk of death from cardiac or cerebrovascular causes as those diagnosed with prior CAD, consistent with the systemic nature of the disease. The same risk factors that contribute to CAD and cerebrovascular disease also lead to the development of PAD. Because of the high prevalence of asymptomatic disease and because only a small percentage of PAD patients present with classic claudication, PAD is frequently underdiagnosed and thus undertreated. Health care providers may have difficulty differentiating PAD from other diseases affecting the limb, such as arthritis, spinal stenosis or venous disease. In Part 1 of this Review, we explain the epidemiology of and risk factors for PAD, and discuss the clinical presentation and diagnostic evaluation of patients with this condition.

Key Points

  • Most patients with peripheral artery disease (PAD) also have concomitant coronary artery disease; morbidity and mortality in patients with PAD are often related to myocardial infarction and ischemic stroke

  • Risk factors for coronary artery and extracranial cerebrovascular disease also promote the development of PAD; smoking and diabetes mellitus are particularly prevalent among patients with PAD

  • Only a small percentage of patients with PAD present with classic Rose claudication, as approximately 70–90% have atypical leg symptoms or are asymptomatic

  • The ankle–brachial index remains the initial noninvasive diagnostic tool of choice for PAD screening, with 95% sensitivity and 99% specificity

  • Segmental limb pressures, pulse–volume recordings, and exercise treadmill testing can help localize the diseased arterial segment(s), and provide information about the functional limitations of the patient

  • Duplex ultrasound can identify the site, extent, and severity of PAD from the aorta to the feet

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Figure 1: Clinical presentation, natural history, and outcomes in patients with atherosclerotic PAD.
Figure 2: Risk factors for the development of peripheral artery disease.
Figure 3: Diagnostic algorithm for the patient with suspected PAD.
Figure 4: Measuring the ankle–brachial index using a hand-held continuous wave Doppler device.
Figure 5: Segmental blood pressure, ABI, and PVRs at rest and after exercise.
Figure 6: Duplex ultrasonography of a left superficial femoral artery after stent implantation.
Figure 7: CTA of a patient with PAD.
Figure 8: 3 Tesla gadolinium-enhanced MRA of a patient with PAD.

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Acknowledgements

C. P. Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape, LLC-accredited continuing medical education activity associated with this article.

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Authors and Affiliations

  1. The Zena and Michael A. Wiener Cardiovascular Institute & Marie-José and Henry R. Kravis Cardiovascular Health Center, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1033, New York, 10029-6574, NY, USA

    Joe F. Lau, Mitchell D. Weinberg & Jeffrey W. Olin

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  1. Joe F. Lau
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Contributions

J. F. Lau researched the data, J. F. Lau and J. W. Olin wrote the article, and all authors contributed substantially to the discussion of content, reviewed, and edited the manuscript before submission.

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Correspondence to Jeffrey W. Olin.

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Competing interests

J. W. Olin declares associations with the following companies: Bristol-Myers Squibb, Genzyme, Merck & Co., and Sanofi–Aventis. See the article online for full details of the relationships. J. F. Lau, M. D. Weinberg, the journal Chief Editor B. Mearns and CME questions author C. P. Vega declare no competing interests.

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Lau, J., Weinberg, M. & Olin, J. Peripheral artery disease. Part 1: clinical evaluation and noninvasive diagnosis. Nat Rev Cardiol 8, 405–418 (2011). https://doi.org/10.1038/nrcardio.2011.66

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