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Final Recommendation Statement

Peripheral Arterial Disease (PAD): Screening

August 08, 2005

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

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

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 (https://www.uspreventiveservicestaskforce.org). 

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  • 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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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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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:

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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.uspreventiveservicestaskforce.org/about.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).

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This document is in the public domain within the United States. Requests for linking or to incorporate content in electronic resources should be sent via the USPSTF contact form.

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2. American Heart Association. PAD Quick Facts. Diseases and Conditions. Available at: http://www.americanheart.org/presenter.jhtml?identifier=3020248. Accessed July 9, 2004.
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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: 

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