Diagnostic testing for lower extremity peripheral arterial disease: Difference between revisions

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==Recommendations for Diagnostic Testing for the Patient with Suspected Lower Extremity PAD (Claudication or Chronic Limb Ischemia)==
==Recommendations for Diagnostic Testing for the Patient with Suspected Lower Extremity PAD (Claudication or Chronic Limb Ischemia)==
===Recommendations for Resting ABI (Ankle-Brachial Index) for Diagnosing PAD:===
===Recommendations for Resting [[ABI]] (Ankle-Brachial Index) for Diagnosing PAD:===
{|class="wikitable"  
{|class="wikitable"  
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In patients with history or physical examination findings suggestive of PAD (Table 1), the resting ABI, with or without segmental pressures and waveforms, is recommended to establish the diagnosis.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In patients with history or physical examination findings suggestive of PAD (Table 1), the resting [[ABI]], with or without segmental pressures and waveforms, is recommended to establish the diagnosis.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Resting ABI results should be reported as abnormal (ABI ≤0.90), borderline (ABI 0.91–0.99), normal (1.00–1.40), or noncompressible (ABI >1.40). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Resting [[ABI]] results should be reported as abnormal (ABI ≤0.90), borderline (ABI 0.91–0.99), normal (1.00–1.40), or noncompressible (ABI >1.40). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki>
|-
|-
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| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' In patients not at increased risk of PAD and without history or physical examination findings suggestive of PAD (Table 1), the ABI is not recommended. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' In patients not at increased risk of [[Peripheral arterial disease|PAD]] and without history or physical examination findings suggestive of [[PAD]] (Table 1), the ABI is not recommended. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
|-
|-
|}
|}
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients at increased risk of PAD but without history or physical examination findings suggestive of PAD (Table 1), measurement of the resting ABI is reasonable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients at increased risk of [[PAD]] but without history or physical examination findings suggestive of [[PAD]] (Table 1), measurement of the resting [[ABI]] is reasonable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
|-
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|}
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|
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====History====
====History====
* Claudication
* [[Claudication]]
* Other non–joint-related exertional lower extremity symptoms (not typical of claudication)
* Other non–joint-related exertional lower extremity symptoms (not typical of claudication)
* Impaired walking function
* Impaired walking function
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*Vascular bruit
*Vascular bruit
* Nonhealing lower extremity wound
* Nonhealing lower extremity wound
* Lower extremity gangrene
* Lower extremity [[gangrene]]
* Other suggestive lower extremity physical findings (e.g., elevation pallor/dependent rubor)
* Other suggestive lower extremity physical findings (e.g., elevation pallor/dependent rubor)
|-
|-
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Toe-brachial index (TBI) should be measured to diagnose patients with suspected PAD when the ABI is greater than 1.40. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Toe-brachial index (TBI) should be measured to diagnose patients with suspected [[PAD]] when the ABI is greater than 1.40. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Patients with exertional non–joint-related leg symptoms and normal or borderline resting ABI (>0.90 and ≤1.40) should undergo exercise treadmill ABI testing to evaluate for PAD. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Patients with exertional non–joint-related leg symptoms and normal or borderline resting ABI (>0.90 and ≤1.40) should undergo exercise treadmill [[ABI]] testing to evaluate for [[Peripheral arterial disease|PAD]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
|-
|-
|}
|}
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''In patients with PAD and an abnormal resting ABI (≤0.90), exercise treadmill ABI testing can be useful to objectively assess functional status. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''In patients with [[Peripheral arterial disease|PAD]] and an abnormal resting ABI (≤0.90), exercise treadmill ABI testing can be useful to objectively assess functional status. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' In patients with normal (1.00–1.40) or borderline (0.91–0.99) ABI in the setting of nonhealing wounds or gangrene, it is reasonable to diagnose CLI by using TBI with waveforms, transcutaneous oxygen pressure (TcPO2), or skin perfusion pressure (SPP). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' In patients with normal (1.00–1.40) or borderline (0.91–0.99) ABI in the setting of nonhealing wounds or gangrene, it is reasonable to diagnose CLI by using TBI with waveforms, transcutaneous oxygen pressure (TcPO2), or skin perfusion pressure (SPP). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' In patients with PAD with an abnormal ABI (≤0.90) or with noncompressible arteries (ABI >1.40 and TBI ≤0.70) in the setting of nonhealing wounds or gangrene, TBI with waveforms, TcPO2, or SPP can be useful to evaluate local perfusion. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' In patients with [[Peripheral arterial disease|PAD]] with an abnormal ABI (≤0.90) or with noncompressible arteries (ABI >1.40 and TBI ≤0.70) in the setting of nonhealing wounds or gangrene, TBI with waveforms, TcPO2, or SPP can be useful to evaluate local perfusion. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
|-
|-
|}
|}
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Duplex ultrasound, computed tomography angiography (CTA), or magnetic resonance angiography (MRA) of the lower extremities is useful to diagnose anatomic location and severity of stenosis for patients with symptomatic PAD in whom revascularization is considered.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Duplex ultrasound, computed tomography angiography ([[CT angiography|CTA]]), or magnetic resonance angiography ([[Magnetic resonance angiography|MRA]]) of the lower extremities is useful to diagnose anatomic location and severity of stenosis for patients with symptomatic [[Peripheral arterial disease|PAD]] in whom [[revascularization]] is considered.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Invasive angiography is useful for patients with CLI in whom revascularization is considered.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Invasive angiography is useful for patients with critical limb ischemia(CLI) in whom revascularization is considered.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''<nowiki>"</nowiki>
|-
|-
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| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' IInvasive and noninvasive angiography (i.e., CTA, MRA) should not be performed for the anatomic assessment of patients with asymptomatic PAD. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''<nowiki>"</nowiki>
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' IInvasive and noninvasive [[angiography]] (i.e., CTA, MRA) should not be performed for the anatomic assessment of patients with asymptomatic [[Peripheral arterial disease|PAD]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''<nowiki>"</nowiki>
|-
|-
|}
|}
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Invasive angiography is reasonable for patients with lifestyle-limiting claudication with an inadequate response to GDMT for whom revascularization is considered.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''<nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Invasive [[angiography]] is reasonable for patients with lifestyle-limiting claudication with an inadequate response to [[GDMT]] for whom revascularization is considered.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''<nowiki>"</nowiki>
|-
|-
|}
|}

Revision as of 20:13, 22 November 2016


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AHA/ACC Guidelines on Management of Lower Extremity PAD

Guidelines for Clinical Assessment of Lower Extremity PAD

Guidelines for Diagnostic Testing for suspected PAD

Guidelines for Screening for Atherosclerotic Disease in Other Vascular Beds in patients with Lower Extremity PAD

Guidelines for Medical Therapy for Lower Extremity PAD

Guidelines for Structured Exercise Therapy for Lower Extremity PAD

Guidelines for Minimizing Tissue Loss in Lower Extremity PAD

Guidelines for Revascularization of Claudication in Lower Extremity PAD

Guidelines for Management of CLI in Lower Extremity PAD

Guidelines for Management of Acute Limb Ischemial in Lower Extremity PAD

Guidelines for Longitudinal Follow-up for Lower Extremity PAD

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease[1]

Recommendations for Diagnostic Testing for the Patient with Suspected Lower Extremity PAD (Claudication or Chronic Limb Ischemia)

Recommendations for Resting ABI (Ankle-Brachial Index) for Diagnosing PAD:

Class I
"1. In patients with history or physical examination findings suggestive of PAD (Table 1), the resting ABI, with or without segmental pressures and waveforms, is recommended to establish the diagnosis.(Level of Evidence: B-NR)"
"2. Resting ABI results should be reported as abnormal (ABI ≤0.90), borderline (ABI 0.91–0.99), normal (1.00–1.40), or noncompressible (ABI >1.40). (Level of Evidence: C-LD)"
Class III (No Benefit)
"1. In patients not at increased risk of PAD and without history or physical examination findings suggestive of PAD (Table 1), the ABI is not recommended. (Level of Evidence: B-NR)"
Class IIa
"1. In patients at increased risk of PAD but without history or physical examination findings suggestive of PAD (Table 1), measurement of the resting ABI is reasonable. (Level of Evidence: B-NR)"
Table1: History and/or Physical Examination Findings Suggestive of PAD*

History

  • Claudication
  • Other non–joint-related exertional lower extremity symptoms (not typical of claudication)
  • Impaired walking function
  • Ischemic rest pain

Physical Examination

  • Abnormal lower extremity pulse examination
  • Vascular bruit
  • Nonhealing lower extremity wound
  • Lower extremity gangrene
  • Other suggestive lower extremity physical findings (e.g., elevation pallor/dependent rubor)
*Adapted from 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease

Recommendations for Physiological Testing for Diagnosing PAD:

Class I
"1. Toe-brachial index (TBI) should be measured to diagnose patients with suspected PAD when the ABI is greater than 1.40. (Level of Evidence: B-NR)"
"2. Patients with exertional non–joint-related leg symptoms and normal or borderline resting ABI (>0.90 and ≤1.40) should undergo exercise treadmill ABI testing to evaluate for PAD. (Level of Evidence: B-NR)"
Class IIa
"1.In patients with PAD and an abnormal resting ABI (≤0.90), exercise treadmill ABI testing can be useful to objectively assess functional status. (Level of Evidence: B-NR)"
"2. In patients with normal (1.00–1.40) or borderline (0.91–0.99) ABI in the setting of nonhealing wounds or gangrene, it is reasonable to diagnose CLI by using TBI with waveforms, transcutaneous oxygen pressure (TcPO2), or skin perfusion pressure (SPP). (Level of Evidence: B-NR)"
"3. In patients with PAD with an abnormal ABI (≤0.90) or with noncompressible arteries (ABI >1.40 and TBI ≤0.70) in the setting of nonhealing wounds or gangrene, TBI with waveforms, TcPO2, or SPP can be useful to evaluate local perfusion. (Level of Evidence: B-NR)"

Recommendations for Imaging for Anatomic Assessment for Diagnosing PAD:

Class I
"1. Duplex ultrasound, computed tomography angiography (CTA), or magnetic resonance angiography (MRA) of the lower extremities is useful to diagnose anatomic location and severity of stenosis for patients with symptomatic PAD in whom revascularization is considered.(Level of Evidence: B-NR)"
"2. Invasive angiography is useful for patients with critical limb ischemia(CLI) in whom revascularization is considered.(Level of Evidence: C-EO)"
Class III (Harm)
"1. IInvasive and noninvasive angiography (i.e., CTA, MRA) should not be performed for the anatomic assessment of patients with asymptomatic PAD. (Level of Evidence: B-R)"
Class IIa
"1. Invasive angiography is reasonable for patients with lifestyle-limiting claudication with an inadequate response to GDMT for whom revascularization is considered.(Level of Evidence: C-EO)"

References

  1. Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE; et al. (2016). "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000471. PMID 27840333.