Connect
MJA
MJA

Peripheral arterial disease: prognostic significance and prevention of atherothrombotic complications

Paul E Norman, John W Eikelboom and Graeme J Hankey
Med J Aust 2004; 181 (3): 150-154.

Summary

  • The prevalence of peripheral arterial disease (PAD) in people aged over 55 years is 10%–25% and increases with age; 70%–80% of affected individuals are asymptomatic; only a minority ever require revascularisation or amputation.

  • Patients with PAD alone have the same relative risk of death from cardiovascular causes as those with coronary or cerebrovascular disease, and are four times more likely to die within 10 years than patients without the disease.

  • The ankle–brachial pressure index (ABPI) is a simple, non-invasive bedside tool for diagnosing PAD — an ABPI less than 0.9 is considered diagnostic of PAD.

  • About half of patients with PAD (defined by an abnormal ABPI) have symptomatic coronary or cerebral vascular disease.

  • The ABPI is an independent predictor of coronary and cerebrovascular morbidity and mortality.

  • Patients with PAD require medical management to prevent future coronary and cerebral vascular events.

  • There are currently insufficient data to recommend routine population screening for asymptomatic PAD using the ABPI.

Please login with your free MJA account to view this article in full

  • Paul E Norman1
  • John W Eikelboom2
  • Graeme J Hankey3

  • 1 School of Surgery and Pathology, University of Western Australia, Fremantle Hospital, Fremantle, WA.
  • 2 Royal Perth Hospital, Perth, WA.

Correspondence: 

Competing interests:

None identified.

  • 1. Ogren M, Hedblad B, Isacsson S, et al. Ten year cerebrovascular morbidity and mortality in 68 year old men with asymptomatic carotid stenosis. BMJ 1995; 310: 1294-1298.
  • 2. Tsai A, Folsom A, Rosamond W, Jones D. Ankle–brachial index and 7-year ischemic stroke incidence. The ARIC Study. Stroke 2001; 32: 1721-1724.
  • 3. Bainton D, Sweetnam P, Baker I, Elwood P. Peripheral vascular disease: consequence for survival and association with risk factors in the Speedwell prospective heart disease study. Br Heart J 1994; 72: 128-132.
  • 4. Newman A, Shemanski L, Manolio T, et al. Ankle–arm index as a predictor of cardiovascular disease and mortality in the Cardiovascular Health Study. Arterioscler Thromb Vasc Biol 1999; 19: 538-545.
  • 5. Hirsch A, Criqui M, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA 2001; 286: 1317-1324.
  • 6. Newman AB, Arnold AM, Naydeck BL, et al. “Successful Aging”. Effect of subclinical cardiovascular disease. Arch Intern Med 2003; 163: 2315-2322.
  • 7. Zheng Z, Sharrett A, Chambless LE, et al. Associations of ankle–brachial index with clinical coronary heart disease, stroke, and preclinical carotid and popliteal atherosclerosis: the Atherosclerosis Risk in Communities (ARIC) Study. Atherosclerosis 1997; 131: 115-125.
  • 8. Leng GC, Fowkes FGR, Lee AJ, et al. Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study. BMJ 1996; 313: 1440-1444.
  • 9. Teh L, Sieunarine K, Eikelboom J, et al. Suboptimal preventive practices in patients with carotid and peripheral vascular occlusive disease in a tertiary referral setting. ANZ J Surg 2003; 73: 932-937.
  • 10. Trans Atlantic Inter-Society Consensus (TASC) on the management of peripheral arterial disease. Eur J Vasc Endovasc Surg 2000; 19(Suppl A): S1-S244.
  • 11. Hiatt WR. Medical treatment of peripheral arterial disease and claudication. N Engl J Med 2001; 344: 1608-1621.
  • 12. Newman AB, Shemanski L, Manolio TA, et al. Ankle–arm index as a predictor of cardiovascular disease and mortality in the Cardiovascular Health Study. Arterioscler Thromb Vasc Biol 1999; 19: 538-545.
  • 13. Fowkes FGR. The measurement of atherosclerotic peripheral arterial disease in epidemiological surveys. Int J Epidemiol 1988; 17: 201-207.
  • 14. Hiatt W, Hoag S, Hamman R. Effect of diagnostic criteria on the prevalence of peripheral arterial disease. Circulation 1995; 91: 1472-1479.
  • 15. Meijer W, Hoes A, Rutgers D, et al. Peripheral arterial disease in the elderly. The Rotterdam Study. Arterioscler Thromb Vasc Biol 1998; 18: 185-192.
  • 16. Stoffers H, Rinkens P, Kester A, et al. The prevalence of asymptomatic and unrecognised peripheral arterial occlusive disease. Int J Epidemiol 1996; 25: 282-290.
  • 17. Fowler B, Jamrozik K, Norman P, Allen Y. Prevalence of peripheral arterial disease: persistence of excess risk in former smokers. Aust N Z J Pub Health 2002; 26: 219-224.
  • 18. Criqui M, Langer R, Fronek A, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med 1992; 326: 381-386.
  • 19. Dormandy JA, Heeck L, Vig S. The fate of patients with critical leg ischaemia. Semin Vasc Surg 1999; 12: 142-147.
  • 20. National Health and Medical Research Council. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra: NHMRC, 1999.
  • 21. Rosenberg L, Palmer J, Shapiro S. Decline in the risk of myocardial infarction among women who stop smoking. N Engl J Med 1990; 322: 213-217.
  • 22. Fowkes G, Housley E, Riemersma R, et al. Smoking, lipids, glucose intolerance and blood pressure as risk factors for peripheral atherosclerosis compared with ischaemic heart disease in the Edinburgh Artery Study. Am J Epidemiol 1992; 135: 331-340.
  • 23. Hobbs S, Bradbury A. Smoking cessation strategies in patients with peripheral artery disease: an evidence-based approach. Eur J Vasc Endovasc Surg 2003; 26: 341-347.
  • 24. Shephard R, Balady G. Exercise as cardiovascular therapy. Circulation 1999; 99: 963-972.
  • 25. Leng G, Fowler B, Ernst E. Exercise for intermittent claudication. Cochrane Database Syst Rev 2000; 2: CD000990.
  • 26. Stewart A, Lamont P. Exercise for intermittent claudication. BMJ 2001; 323: 703-704.
  • 27. Fowler B, Jamrozik K, Norman P, et al. Improving maximum walking distance in early peripheral arterial disease: randomised controlled trial. Aust J Physiother 2002; 48: 269-275.
  • 28. Mohler E, Hiatt W, Creager M. Cholesterol reduction with atorvastatin improves walking distance in patients with peripheral arterial disease. Circulation 2003; 108: 1481-1486.
  • 29. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20 536 high-risk individuals: a randomised placebo–controlled trial. Lancet 2002; 360: 7-22.
  • 30. Schedule of Pharmaceutical Benefits, February 2004. Canberra: Australian Government Department of Health and Ageing, 2004.
  • 31. Donnelly R, Yeung J. Management of intermittent claudication: the importance of secondary prevention. Eur J Vasc Endovasc Surg 2002; 23: 100-107.
  • 32. Chobanian A, Bakris G, Black H, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289: 2560-2572.
  • 33. Lehto S, Niskanen L, Suhonen M, et al. Medial artery calcification. A neglected harbinger of cardiovascular complications in non-insulin-dependent diabetes mellitus. Arterioscler Thromb Vasc Biol 1996; 16: 978-985.
  • 34. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352: 837-853.
  • 35. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. Antithrombotic Trialists’ Collaboration. BMJ 2002; 324: 71-86.
  • 36. Goldhaber S, Manson J, Stampfer M, et al. Low-dose aspirin and subsequent peripheral arterial surgery in the Physicians’ Health Study. Lancet 1992; 340: 143-145.
  • 37. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996; 348: 1329-1339.
  • 38. Yusuf S, Sleight P, Pogue J, et al. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000; 342: 145-153.
  • 39. Ostergren J, Sleight P, Dagenais G, et al. Impact of ramipril in patients with evidence of clinical or subclinical peripheral arterial disease. Eur Heart J 2004; 25: 17-24.
  • 40. Smith SC, Greenland P, Grundy SM. Improving coronary heart disease risk assessment in asymptomatic people. Role of traditional risk factors and non-invasive cardiovascular tests. Circulation 2001; 104: 1863-1867.
  • 41. Fowkes F, Price J, Leng G. Targeting subclinical atherosclerosis. BMJ 1998; 316: 1764.
  • 42. Leng G, Lee A, Fowkes F, et al. Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. Int J Epidemiol 1996; 25: 1172-1181.
  • 43. Mosca L. C-reactive protein — to screen or not to screen? N Engl J Med 2002; 347: 1615-1617.

Author

remove_circle_outline Delete Author
add_circle_outline Add Author

Comment
Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Responses are now closed for this article.