Peripheral Arterial Disease Section important reason for such a vicious disease to evade diagnosis is the frequently insidious nature of symptom progression to where patients assume them to be a natural part of the aging process. The lack of awareness among the public and providers is leading to many preventable amputations, complications and deaths. People are suffering; yet often they are suffering in silence. Approximately one half of the lower limb amputations that are performed in the United States are done without even a simple, non-invasive test to check for arterial circulation.1 Procedures such as angioplasty, stenting and bypass are well-recognized terms and procedures when discussing coronary arterial disease. The same procedures are available to those with advanced PAD of the lower extremities, and despite this, the first line treatment offered to many is amputation based on this author’s experience.
Recognizing PAD Patients often do not know they have PAD. More alarming is the fact that quite frequently the medical providers are not aware either. The PARTNERS study is a community survey of 6,979 patients with one or more risk factors for PAD in 350 primary care clinics across America. Results show that 29 percent of the patients had PAD, yet only 49 percent of providers were aware of those patients. Only 11 percent of those PAD patients had classic claudication. Overall, less than half of the PAD patients were vigorously treated to reduce risk factors (anti-platelet, lipid lowering and anti-hypertension therapies).2 Also notable is the fact that PAD was equally prevalent between men and women. This data suggests that clinicians who only utilize a classic history of claudication to detect PAD are likely to miss 85 to 90 percent of the PAD diagnoses. Since many patients who are afflicted with PAD also suffer from
diabetes and peripheral neuropathy, it is important to recognize the similarities and overlapping symptoms. Neuropathy may mask symptoms of PAD. Conversely, symptoms of PAD may be mistaken for those of neuropathy. PAD in the Asymptomatic State Unfortunately the vast majority of PAD patients present with no symptoms and are only detected on physical examination when the pedal pulses are specifically checked and the Ankle Brachial Index (ABI) is performed. Claudication Intermittent Claudication is a dull cramping or pain most commonly in the calf muscles, but sometimes in the hips and thighs while walking, climbing stairs or exercising. It is relieved by cessation of activity. Claudication may also be characterized by fatigue in the legs, which may require a patient to stop and rest while walking. Patients may also exhibit a slow or antalgic gait and may have difficulty keeping up with others when ambulating. An example of claudication would be that of someone being able to walk for two city blocks, but then having to stop to rest due to pain in the calves. After resting for a few minutes, the pain subsides and the person is able to walk again for about the same distance, with the cycle repeating. The distance threshold for discomfort is specific to the individual and fairly predictable. One person may be able to walk five blocks while another person may only be able to walk 50 yards. Classic claudication as detailed above was only present in 11 to 15 percent of PAD patients in the PARTNERS study.2 The differential diagnosis for claudication includes the following etiologies: The author does not list or discuss the differential. There should be discussion regarding other etiologies that mimic claudication; e.g. neurogenic claudication, venous insufficiency, etc. (Table I)
Table 1 Differentiating Leg Pain Symptoms Pain Symptoms
PAD Claudication
Pain from other causes “Pseudo-claudication”
Description
Fatigue to severe pain, less commonly weakness. No sensory deficits
Frequent occurrence of weakness, tingling, or numbness Same, yet pain frequently extends to the middle of the back
Location
Most common in calf & feet, may also affect buttocks, hip and thigh
Exercise Related
Always
May also occur at rest or with prolonged sitting
Distance to Claudication
Same each time. May vary with speed.
Quite variable
Effect of Standing
Brings Relief
Frequently elicits the pain
Relief
Stop walking for few minutes
Most often can only be obtained by sitting or changing body position
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