Recommendation Statement
This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendation on screening for peripheral arterial disease, and updates the 1996 recommendation contained in the Guide to Clinical Preventive Services, Second Edition.11
Summary of Recommendation
- The USPSTF recommends against routine screening for peripheral arterial disease (PAD).
Rating: D Recommendation.
Rationale: The USPSTF found fair evidence that screening with ankle brachial index can detect adults
with asymptomatic PAD. The evidence is also fair that screening for PAD among asymptomatic
adults in the general population would have few or no benefits because the prevalence of PAD in
this group is low and because there is little evidence that treatment of PAD at this asymptomatic
stage of disease, beyond treatment based on standard cardiovascular risk assessment, improves
health outcomes.
The USPSTF found fair evidence that screening asymptomatic adults with the ankle brachial
index could lead to some small degree of harm, including false-positive results and unnecessary
work-ups. Thus, the USPSTF concludes that, for asymptomatic adults, harms of routine
screening for PAD exceed benefits.
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Contents
Clinical Considerations
Discussion
Recommendations of Other Groups
Members of the Task Force
References
Copyright and Source Information
Clinical Considerations
- The ankle brachial index, a ratio of Doppler-recorded systolic pressures in the lower and
upper extremities, is a simple and accurate noninvasive test for the screening and diagnosis
of PAD. The ankle brachial index has demonstrated better accuracy than other methods of
screening, including history-taking, questionnaires, and palpation of peripheral pulses. An
ankle-brachial index value of less than 0.90 (95% sensitive and specific for angiographic
PAD) is strongly associated with limitations in lower extremity functioning and physical
activity tolerance.
- Smoking cessation and lipid-lowering agents improve claudication symptoms and lower
extremity functioning among patients with symptomatic PAD. Smoking cessation and
physical activity training also increase maximal walking distance among men with early
PAD. Counseling for smoking cessation, however, should be offered to all patients who
smoke, regardless of the presence of PAD. Similarly, physically inactive patients should be
counseled to increase their physical activity, regardless of the presence of PAD.
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Discussion
PAD refers to atherosclerotic occlusive disease of the arterial system distal to the aortic
bifurcation, and is a relatively common disorder in the elderly.1 The American Heart Association
estimates that as many as 8 to 12 million Americans have PAD and that nearly 75 percent of them are
asymptomatic.2 An estimated 1 million Americans develop symptomatic PAD every year.
Specifically, the prevalence of lower-extremity PAD based on ankle brachial blood pressure
ratios is approximately 10 to 20 percent of community-dwelling individuals aged 65 and older and
18 percent to 29 percent of patients aged 50 and older in general medical practices.3-5 The disease spectrum
ranges from mild, intermittent claudication resulting in calf pain to severe, chronic leg ischemia
requiring arterial bypass or amputation. Risk factors associated with PAD include older age,
cigarette smoking, diabetes mellitus, hypercholesterolemia, hypertension, and (possibly) genetic
factors.1 There are no significant gender differences in the overall prevalence of PAD in the
general population. Over a 5-year period, 25 percent to 35 percent of persons with PAD will suffer a
myocardial infarction or stroke and an additional 25 percent will die, usually from cardiovascular
causes.6-8
Screening may be conducted by such instruments as history-taking, questionnaires, or the
ankle brachial index. Results from 1 study found that the sensitivity and positive predictive value
of a classic history of claudication were only 54 percent and 9 percent, respectively, when using the ankle
brachial index as the gold standard.9 The Edinburgh Claudication Questionnaire (ECQ), which is
a modification of the World Health Organization/Rose Questionnaire, has been validated in a
study of approximately 300 patients older than 55 who saw their physician for any complaint.
When compared with the independent assessment of 2 blinded clinicians, the ECQ showed a
sensitivity of 91 percent and a specificity of 99 percent for the diagnosis of intermittent claudication.10 Ankle
brachial index has demonstrated better accuracy than the combination of history-taking and
physical examination. The sensitivity of an abnormal posterior pulse was 71 percent, the positive
predictive value was 48 percent, and the specificity was 91 percent. An abnormal dorsalis pedis had a
sensitivity of only 50 percent; this artery is congenitally absent in 10 to 15 percent of the population.11
Both the sensitivity and specificity of ankle brachial index less than 0.9 (the accepted cut-off for
the presence of PAD) is about 95 percent for detecting angiographic arterial disease.12 The accuracy of
this screening tool increases as lower extremity stenotic lesions worsen.
One randomized clinical trial (RCT) of treatment of men with early PAD detected by
screening investigated the impact of population-based screening.13 The control group received
usual care and the intervention group received "stop smoking and keep walking" advice. The
study found improved ambulation in the intervention group; however, the study did not address
the impact of interventions on PAD or cardiovascular disease events. In another RCT of primary
prevention of intermittent claudication, a subgroup analysis of 26,289 male smokers aged 50 to
69, who had no history or symptoms of intermittent claudication, there was no benefit of using
vitamin E, beta-carotene, or both, to prevent intermittent claudication.14
Potential harms of screening include false-positive results, labeling, and the adverse events
associated with an angiographic workup, including contrast-related events, arterial perforations,
hematomas, thromboses, and distal embolizations; the harms of treatment include the adverse
events associated with medical (antithrombotic medications) and surgical treatments
(angioplasty, femoral bypass procedures).
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Recommendations of Other Groups
The American Diabetes Association currently recommends annual screening for PAD in people
with diabetes that includes a history of claudication and palpation of pedal pulses.15 The
American Academy of Family Physicians recommends against the use of Doppler or duplex
ultrasound or other vascular laboratory tests in asymptomatic persons for PAD.16 A few
organizations, such as the American Heart Association and the Society of Interventional
Radiology, support the use of the ankle brachial index in the evaluation of suspected PAD.
For
further information, please refer to the following Web sites:
- American Heart Association, http://www.americanheart.org.
- American College of Surgeons, http://www.facs.org/index.html.
- Society of Interventional Radiology, http://www.sirweb.org/.
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Members of the Task Force
Corresponding Author: Ned Calonge, M.D., M.P.H., Chair, U.S. Preventive Services Task Force; c/o Program Director, USPSTF; 540 Gaither Road; Rockville, MD 20850; E-mail: info@ahrq.gov.
Members of the U.S. Preventive Services Task Force* are Ned Calonge, M.D., M.P.H., Chair, USPSTF (Acting
Chief Medical Officer and State Epidemiologist, Colorado Department of Public
Health and Environment, Denver, CO); Janet D. Allan, Ph.D., R.N., C.S., Vice-chair,
USPSTF (Dean, School of Nursing, University of Maryland, Baltimore, Baltimore,
MD); Alfred O. Berg, M.D., M.P.H. (Professor and Chair, Department of Family
Medicine, University of Washington, Seattle, WA); Paul S. Frame, M.D. (Family
Physician, Tri-County Family Medicine, Cohocton, NY, and Clinical Professor
of Family Medicine, University of Rochester, Rochester, NY); Leon Gordis,
M.D., M.P.H., Dr.P.H. (Professor, Epidemiology Department, Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD); Kimberly D. Gregory, M.D., M.P.H.
(Director, Women's Health Services Research and Maternal-Fetal Medicine, Department
of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA);
Russell Harris, M.D., M.P.H. (Professor of Medicine, Sheps Center for Health
Services Research, University of North Carolina School of Medicine, Chapel
Hill, NC); Jonathan D. Klein, M.D., M.P.H. (Associate
Professor, Department of Pediatrics, University of Rochester School of Medicine,
Rochester, NY); Carol Loveland-Cherry, Ph.D., R.N. (Executive Associate Dean,
Office of Academic Affairs, University of Michigan School of Nursing, Ann
Arbor, MI); Virginia A. Moyer, M.D., M.P.H. (Professor, Department of Pediatrics,
University of Texas Health Science Center, Houston, TX); Judith K. Ockene,
Ph.D. (Professor of Medicine and Chief of Division of Preventive and Behavioral
Medicine, University of Massachusetts Medical School, Worcester, MA); Diana
B. Petitti, M.D., M.P.H. (Senior Scientific Advisor for Health Policy and
Medicine, Regional Administration, Kaiser Permanente Southern California,
Pasadena, CA); Albert L. Siu, M.D., M.S.P.H. (Professor and Chairman, Brookdale
Department of Geriatrics and Adult Development, Mount Sinai Medical Center,
New York, NY); and Barbara P. Yawn, M.D, M.Sc. (Director of Research,
Olmstead Research Center, Rochester, MN).**
* Member of the USPSTF at the time this recommendation was finalized. For a list of current Task Force members, go to http://www.ahrq.gov/clinic/uspstfab.htm.
**Members who recused themselves from voting on this topic: Steven M. Teutsch, M.D., M.P.H.
(Executive Director, Outcomes Research and Management, Merck & Company, Inc., West
Point, PA); Mark S. Johnson, M.D., M.P.H. (Professor and Chair, Department of Family Medicine,
University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ).
This statement summarizes the U.S. Preventive Services Task Force (USPSTF)
recommendations on screening for peripheral arterial disease and the supporting
scientific evidence, and updates the 1996 recommendations contained in the Guide to
Clinical Preventive Services, second edition.11 Explanations of the ratings and of the
strength of overall evidence are given at http://www.ahrq.gov/clinic/uspstf/gradespre.htm.
The complete information on which this statement is based, including evidence tables
and references, is included in the brief evidence update17 on this topic, available on the
USPSTF Web site (http://www.preventiveservices.ahrq.gov). The recommendation is also
posted on the Web site of the National Guideline Clearinghouse™ (http://www.guideline.gov).
Recommendations made by the USPSTF are independent of the U.S. Government. They should not be construed as an official position of AHRQ or the U.S. Department of Health and Human Services.
This recommendation statement was first published by: Agency for Healthcare
Research and Quality, Rockville, MD. August 2005.
http://www.preventiveservices.ahrq.gov.
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References
1. Meijer WT, Grobee DE, Hunink MGM, Hofman A,
Hoes AW. Determinants of peripheral arterial disease
in the elderly: the Rotterdam Study. Arch Int Med 2000;160(19):2934-8.
2. American Heart Association. PAD Quick Facts.
Diseases and Conditions. Available at:
http://www.americanheart.org/presenter.jhtml?identifier=3020248. Accessed July 9, 2004.
3. Fowkes FG. Edinburgh Artery Study: prevalence of
asymptomatic and symptomatic peripheral arterial
disease in the general population. International
Journal of Epidemiology 1991;20:384-92.
4. Schroll M, Munck O. Estimation of peripheral
arteriosclerotic disease by ankle blood pressure
measurements in a population study of 60 year-old
men and women. J Chronic Dis 1981;34:261-9.
5. Meijer WT, Hoes AW, Rutgers D, Bots ML, Hofman
A, Grobbee DE. Peripheral arterial disease in the
elderly: the Rotterdam Study. Arterioscler Thromb
Vasc Biol 1998;18(2):185-92.
6. McDermott MM. Peripheral arterial disease:
epidemiology and drug therapy. Am J Geriatr Cardiol
2002;11(4):258-66.
7. Weitz JI, Byrne J, Clagett GP, et al. Diagnosis and
treatment of chronic arterial insufficiency of the lower
extremities: a critical review. Circulation 1996;94(11):3026-49.
8. Criqui MH, Langer RD, Fronek A, et al. Mortality
over a period of 10 years in patients with peripheral
arterial disease. N Engl J Med 1992;326(6):381-6.
9. Criqui MH, Fronek A, Klauber MR, Barrett-Connor E,
Gabriel S. The sensitivity, specificity, and predictive
value of traditional clinical evaluation of peripheral
arterial disease: results from noninvasive testing in a
defined population. Circulation 1985;71(3):516-22.
10. Leng GC, Fowkes FG. The Edinburgh Claudication
Questionnaire: an improved version of the WHO/Rose
Questionnaire for use in epidemiological surveys. J
Clin Epidemiol 1992;45(10):1101-9.
11. U.S. Preventive Services Task Force. Guide to
Clinical Preventive Services, 2nd ed. Washington,
DC: Office of Disease Prevention and Health
Promotion; 1996.
12. Hummel BW, Hummel BA, Mowbry A, Maixner W,
Barnes RW. Reactive hyperemia vs treadmill exercise
testing in arterial disease. Arch Surg 1978;113(1):95-8.
13. Fowler B, Jamrozik K, Norman P, Allen Y, Wilkinson
E. Improving maximum walking distance in early
peripheral arterial disease: randomised controlled trial.
Aust J Physiother 2002;48(4):269-75.
14. Tornwall ME, Virtamo J, Haukka JK, et al. Effect of
alpha-tocopherol (vitamin E) and beta-carotene
supplementation on the incidence of intermittent
claudication in male smokers. Arterioscler Thromb
Vasc Biol 1997;17(12):3475-80.
15. Mayfield JA, Reiber GE, Sanders LJ, Janisse D,
Pogach LM. Preventive foot care in diabetes. Diabetes
Care 2004;27 Suppl 1:S63-S64.
16. American Academy of Family Physicians.
Recommendations for periodic health examinations.
Clinical Care and Research. Available at:
http://www.aafp.org/x24973.xml. Accessed July 13,
2004.
17. U.S. Preventive Services Task Force: Screening for
peripheral arterial disease: brief evidence update. 2005. Available at: http://www.ahrq.gov/clinic/uspstf05/pad/padup.htm.
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Copyright and Source Information
This document is in the public domain within the United States. For information on reprinting, contact Randie Siegel, Director, Division of Printing and Electronic Publishing, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850. Requests for linking or to incorporate content in electronic resources should be sent to: info@ahrq.gov.
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AHRQ Publication No. 05-0583-A-EF
Current as of August 2005
Internet Citation:
U.S. Preventive Services Task Force. Screening for Peripheral Arterial Disease: Recommendation Statement. AHRQ Publication No. 05-0583-A-EF, August 2005. Agency for Healthcare
Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/uspstf05/pad/padrs.htm