Peripheral arterial disease (PAD) becomes increasingly common with age. An estimated 12-17% of the population over age 50 have PAD.^1-4 Increased mortality has been well documented in patients with PAD, a disease that is strongly associated with coronary artery disease and that shares many of the same risk factors.^1,2,5-9 Although only a small proportion of individuals with PAD and intermittent claudication develop skin breakdown or limb loss, pain and associated disability often restrict ambulation and the overall quality of life.^1,5 Persons at increased risk for PAD include cigarette smokers and persons with diabetes mellitus or hypertension.^1,5,9,10 Diabetic PAD is responsible for about 50% of all amputations.¹ 

There is evidence that a history of intermittent claudication and the palpation of peripheral pulses are unreliable techniques for the detection of PAD.^1,3,8,11 In one study, a battery of noninvasive tests for PAD was administered to 624 hyperlipidemic subjects aged 38-82.⁷ In this population, the sensitivity and positive predictive value of a classic history of claudication were only 54% and 9%, respectively, when compared with the results of formal noninvasive testing. The sensitivity of an abnormal posterior tibial pulse was 71%, the positive predictive value was 48%, and the specificity was 91%. An abnormal dorsalis pedis pulse had a sensitivity of only 50% this artery is congenitally absent in 10-15% of the population.¹¹ The authors concluded that symptoms and abnormal pulses are not pathognomonic for PAD.⁷ Greater accuracy has been achieved with noninvasive testing using Doppler ankle-arm pressure ratios, measurement of reactive hyperemia after exercise, pulse reappearance time, ultrasound duplex scanning, and plethysmography.^1,5,12,13 At present, however, additional data on sensitivity, specificity, and positive predictive value of these tests in asymptomatic populations are needed before noninvasive testing can be considered for routine screening.

Because surgery for PAD is offered only to patients with symptomatic disease, the rationale for the early detection of asymptomatic PAD is that risk factor modification following detection might lower subsequent morbidity and mortality from PAD and systemic atherosclerotic disease. By virtue of its strong association with coronary atherosclerosis and coronary events,⁵ the early diagnosis of PAD might also lead to the detection of asymptomatic coronary heart disease. Evidence of these benefits is lacking, however. There has been no research to examine whether the detection and treatment of asymptomatic persons with PAD reduces the morbidity or mortality observed in symptomatic patients. It is clear that certain interventions are beneficial in symptomatic persons. There is evidence, for example, that patients who stop smoking have marked improvement in PAD symptoms and reduced overall cardiovascular mortality.^1,14 Certain antithrombotic drugs may also be of benefit.¹⁵ It is unknown whether treatment measures used in symptomatic patients are beneficial in asymptomatic patients.^1,6 Examples include walking programs, control of weight and blood pressure, correction of elevated serum lipids and glucose, proper foot care, and certain drugs. 

There are no official recommendations for physicians to screen asymptomatic persons for PAD, although inspection of the skin and palpation of peripheral pulses are often included in the physical examination of the extremities. A recent international workshop sponsored by the American Diabetes Association and American Heart Association recommends annual screening for PAD in patients with diabetes.¹⁶ 

Evidence is lacking that routine screening for PAD in asymptomatic persons is effective in reducing morbidity or mortality from this disease. Many of the behavioral interventions that might be prescribed after detecting PAD — smoking cessation (Chapter 54), blood pressure control (Chapter 3), and exercise (Chapter 55) — can be recommended without screening and are of proven value in the prevention of other atherosclerotic conditions, such as coronary heart and cerebrovascular disease. Screening by physical examination in the general population of asymptomatic adults, where the prevalence of PAD is low, is likely to produce a substantial number of false-positive results. Positive screening results will necessitate expensive noninvasive tests and may lead to potentially hazardous invasive tests such as arteriography. At the same time, it is not known whether the early detection of PAD in asymptomatic patients will result in more effective treatment of risk factors or better outcomes.

Routine screening for peripheral arterial disease in asymptomatic persons is not recommended ("D" recommendation). Clinicians should screen for hypertension (see Chapter 3) and hypercholesterolemia (Chapter 2), and they should provide appropriate counseling regarding the use of tobacco products (Chapter 54), physical activity (Chapter 55), and nutritional risk factors for atherosclerotic disease (Chapter 56). Clinicians should be alert to symptoms of PAD in persons at increased risk (persons over age 50, smokers, diabetics) and evaluate patients who have clinical evidence of vascular disease.

The draft update of this chapter was prepared for the U.S. Preventive Services Task Force by Stephen Tabet, MD, MPH, and Alfred O. Berg, MD, MPH. 

1. Strandness DE, Didisheim P, Clowes AW, et al, eds. Orlando, FL; 1987. Vascular diseases: current research and clinical applications.
2. Criqui MH, Fronek A, Barrett-Connor E, et al. The prevalence of peripheral arterial disease in a defined population. Circulation. 1985;71:510–515. [PubMed]
3. Lombardi G, Polotti R, Polizzi N, et al. Prevalence of asymptomatic peripheral vascular disease in a group of patients older than 50. J Am Geriatr Soc. 1986;34:551–552. [PubMed]
4. Fowkes FGR, Housley E, Cawood EHH, et al. Edinburgh artery study: prevalence of asymptomatic and symptomatic peripheral arterial disease in the general population. Int J Epidemiol. 1991;20:384–392. [PubMed]
5. Vogt MT, Cauley JA, Newman AB, et al. Decreased ankle/arm blood pressure index and mortality in elderly women. JAMA. 1993;270:465–469. [PubMed]
6. Kannel WB, McGee DL. Update on some epidemiologic features of intermittent claudication: the Framingham study. J Am Geriatr Soc. 1985;33:13–18. [PubMed]
7. Criqui MH, Fronek A, Klauber MR, et al. The sensitivity, specificity, and predictive value of traditional clinical evaluation of peripheral arterial disease: results from noninvasive testing in a defined population. Circulation. 1985;71:516–522. [PubMed]
8. Criqui MH, Coughlin SS, Fronek A. Noninvasively diagnosed peripheral arterial disease as a predictor of mortality: results from a prospective study. Circulation. 1985;72:768–773. [PubMed]
9. Krupski WC. The peripheral vascular consequences of smoking. Ann Vasc Surg. 1991;5:291–304. [PubMed]
10. McGill HC. The cardiovascular pathology of smoking. Am Heart J. 1988;115:250–257. [PubMed]
11. Kappert A, Winsor T. Diagnosis of peripheral vascular diseases. Philadelphia: FA Davis, 1972.
12. Barnes RW. Noninvasive diagnostic techniques in peripheral vascular disease. Am Heart J. 1979;97:241–244. [PubMed]
13. Moneta GL, Strandness DE. Peripheral arterial duplex scanning. J Clin Ultrasound. 1987;15:645–651. [PubMed]
14. Jonason T, Bergstrom R. Cessation of smoking in patients with intermittent claudication: effects on the risk of peripheral vascular complications, myocardial infarction and mortality. Acta Med Scand. 1987;221:253–260. [PubMed]
15. Arcan JC, Blanchard J, Boissel JP, et al. Multicenter double-blind study of ticlopidine in the treatment of intermittent claudication and the prevention of its complications. Angiology. 1988;39:802–811. [PubMed]
16. American Heart Association. Assessment of peripheral vascular disease in diabetes. Circulation. 1993;88:819–827. [PubMed]