This is the current release of the guideline.

Lower extremity peripheral artery disease (PAD)

To provide evidence-based guidelines for screening of lower extremity peripheral artery disease in the primary care setting

Adults with increased risk for lower extremity peripheral artery disease seen in primary care

Risk factors include:

• Age >50 years with diabetes and one additional risk factor (smoking, dyslipidemia, hypertension, or homocysteinemia)
• Age 50-69 years with history of smoking or diabetes
• Age ≥70 years
• Abnormal lower extremity pulses
• Cramping, leg pain that is gradual and predictable in onset; it is relieved by rest and is localized to an area in a single limb
• Known coronary, carotid, or renal atherosclerosis

Screening/Diagnosis

1. Subjective assessment including past medical and family history, and symptoms and questionnaires
2. Objective assessment including ankle brachial index (ABI) and palpation of peripheral pulses
3. Diagnostic tests if appropriate, including screening patients at risk for peripheral artery disease (PAD) using Walking Impairment Questionnaire, ABI testing, lipids
4. Differential diagnosis

Management

1. Referral to cardiology or vascular surgery
2. Follow-up

Online searches were performed for dates January 2006-January 2011 of the following databases: CINAHL, Medline, PubMed, Cochrane, EBSCO, UpToDate. Major keywords used in searches: Ankle-Brachial Index (ABI), Peripheral Artery Disease, Screening, Risk Factors, Incidence, Prevalence, Outcomes, Primary Care. Position statements from the American Heart Association (AHA) and American College of Cardiology (ACC) were also reviewed. Additional resources were identified by review of published guidelines.

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Quality of Evidence

The U.S. Preventive Services Task Force (USPSTF) grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor).

Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.

Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

Not stated

Strength of Recommendations (Based on U.S. Preventive Services Task Force [USPSTF] Ratings)

A. There is good evidence that the recommendation improves important health outcomes. Benefits substantially outweigh harms.

B. There is at least fair evidence that the recommendation improves important health outcomes. Benefits outweigh harms.

C. There is at least fair evidence that the recommendation can improve health outcomes but the balance of benefits and harms is too close to justify a general recommendation.

D. There is at least fair evidence that the recommendation is ineffective or that harms outweigh benefits.

I. Evidence that the recommendation is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

A formal cost analysis was not performed and published cost analyses were not reviewed.

The guideline was developed by a group of family nurse practitioner (FNP) students and submitted for review to FNP program faculty and expert reviewers. Before submitting to the guideline committee, revisions were made based on reviewer recommendations.

Strength of recommendations (A, B, C, D, I) and quality of evidence (good, fair, poor) are defined at the end of the "Major Recommendations" field.

Subjective Assessment

This guideline recommends against ankle-brachial index (ABI) routine screening in asymptomatic low risk patients. Routine screening in primary care setting may produce false positives and lead to unnecessary workups and thus more harm than benefit for the asymptomatic patient. (United States Preventive Services Task Force [USPSTF], 2006) (Grade: D; Evidence: Good)

In any patient with an identified risk factor and symptom of peripheral artery disease (PAD), the following is recommended:

1. History of present illness (HPI):
   • Onset, duration, location, severity, aggravating and alleviating factors related to clinical manifestations of lower extremity symptom complaints
   • Lifestyle habits such as diet, exercise, smoking, alcohol or drug use
   • Exercise assessment including 6 minute walk performance, walking velocity over 4 meters at usual and fastest pace
   • PAD walking impairment questionnaire
2. Review of systems
   • General
   • Endocrine
   • Heart/vascular
   • Lungs
   • Genitourinary (GU): erectile dysfunction
   • Musculoskeletal (MS)
   • Neurological
   • Skin
3. Past medical history
   • Note hospitalizations, surgeries, and any procedures
   • History of trauma
   • Co-morbid conditions such as: smoking, diabetes, hypertension, congestive heart failure/chronic heart failure (CHF), arrhythmias, cardiovascular disease, sedentary lifestyle, dyslipidemia, obesity, atherosclerosis
4. Medications
   • Current prescription medications
   • Any or all over the counter medications, including alternative medicines or herbal treatments
5. Family history
   • Atherosclerosis
   • Diabetes
   • Hypertension
   • Cardiovascular disease
   • Cerebrovascular accident (CVA)
   • Dyslipidemia
6. Psychosocial history
   • Assess for depression and mental illness
   • Socioeconomic status (occupation, education level, ethnicity)
   • Support systems, coping strategies
   • Smoking history

(Allison et al., 2010; Alzamora et al., 2010; Hayward, 2010; Hirsch et al., 2006; Jacobs et al., 2009; Johnson et al., 2010; Mazimba & Rank, 2010; McDermott et al., 2010; Rosero et al., 2010; Selby, 2008; Sugawara et al., 2010; Smolderen et al., 2009) (Grade: A; Evidence: Good)

Objective Assessment/Physical Examination

• Vital signs: Blood pressure, pulse, height, weight, body mass index (BMI) calculation
• Cardiovascular exam: assess for rhythm regularity, bruits, murmurs (high prevalence with cardiovascular disease [CVD], chronic heart failure [CHF], arrhythmias, and hypertension), peripheral pulses
• Pulmonary exam: assess breath sounds and quality of respirations
• Musculoskeletal: deformities, swelling, or pain with movement and at rest, strength
• Neurological exam: sensory function, mental status
• Skin: color, temperature, ulcerations
• Exercise assessment including 6 minute walk performance

(Armstrong, Tobin, & Mantangi, 2010; Hayward, 2010; Hirsch et al., 2006; Wilson, Laine, & Goldmann, 2007; Mazimba & Rank, 2010; Safar et al., 2009) (Grade: A; Evidence: Good)

Diagnostic Procedures

1. Laboratory studies
   • Lipids
   • Diabetes screening (fasting blood glucose, 2 hour oral glucose tolerance test, or hemoglobin A1c [HbA1c])
2. Diagnostic tests
   • ABI: normal 1.0-1.3, mild <0.90, moderate 0.5-0.7, severe <0.50. An ABI over 1.3 signifies non-compressible vessels and yields a false negative test; as seen in diabetes mellitus, end stage renal disease, and arterial calcifications (as in severe or diffuse PAD). If ABI is >1.3, alternative studies are recommended: Toe-brachial ratio, Doppler ultrasound, computed tomography (CT) angiography, or magnetic resonance (MR) angiography.

(American Diabetes Association [ADA], 2011; Espeland et al., 2008; Hayward, 2010; Hirsch et al., 2006; McDermott et al., 2010; Sugawara et al., 2010; Olin et al., 2010; Premanath & Raghunath, 2010) (Grade: A; Evidence: Good)

Differential Diagnoses

1. Spinal stenosis
2. Peripheral neuropathy
3. Arthritis
4. Venous claudication
5. Nerve root compression
6. Symptomatic Baker's cyst
7. Congestive heart failure/chronic heart failure
8. Anemia
9. Fibromyalgia/polymyalgia rheumatica
10. Restless leg syndrome
11. Ulceration or gangrene
12. Peripheral venous disease (PVD)
13. Compartment syndrome

(Hirsch et al., 2006; Wilson, Laine, & Goldmann, 2007; Mazimba & Rank, 2010) (Grade: B; Evidence: Good)

Referral

Refer patients with ABI >1.30 or less than or equal to 0.90 to cardiologist or vascular specialist. Further screening by specialist may include ultrasound, computed tomography (CT), angiography. (Mazimba & Rank, 2010) (Grade: C; Evidence: Fair)

Follow Up

Obtain records from referral physician, and assess patient's adherence to recommendations of management/treatment. (Hirsh et al., 2006) (Grade: I; Evidence: Poor)

Definitions:

Strength of Recommendations (Based on U.S. Preventive Services Task Force [USPSTF] Ratings)

A. There is good evidence that the recommendation improves important health outcomes. Benefits substantially outweigh harms.

B. There is at least fair evidence that the recommendation improves important health outcomes. Benefits outweigh harms.

C. There is at least fair evidence that the recommendation can improve health outcomes but the balance of benefits and harms is too close to justify a general recommendation.

D. There is at least fair evidence that the recommendation is ineffective or that harms outweigh benefits.

I. Evidence that the recommendation is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Quality of Evidence (Based on USPSTF Ratings)

Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.

Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

None provided

The type of supporting evidence is specifically stated for each recommendation (see the "Major Recommendations" field).

Potential harms of screening include false-positive results, labeling, and the adverse events/cost associated with further work-up.

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program

University of Texas at Austin Family Nurse Practitioner Student Practice Guidelines Committee

Authors: Tracy Brazziel, RN, MSN, FNP; Lindsie Cox, RN, MSN, FNP; Christa Drury, RN, MSN, FNP; Maria Guerra RN, MSN, FNP

Internal Reviewers: Lisa Doggett, MD, MPH; Angela P. Clark, PhD, RN, CNS, FAAN, FAHA and Frances Sonstein, RN, MSN, FNP, CNS

External Reviewer: David Morris, MD, FACC and Roberta "Bobby" Richards, RN, MSN, FNP-C, ACNP-BC

None

This is the current release of the guideline.

Electronic copies: Request at fsonstein@mail.nur.utexas.edu

Print copies: Available from the University of Texas at Austin, School of Nursing. 1700 Red River, Austin, Texas, 78701-1499, Attn: Nurse Practitioner Program

None available

None available

This NGC summary was completed by ECRI Institute on November 10, 2011.

This NGC summary is based on the original guideline, which may be subject to the guideline developer's copyright restrictions.