Diagnostic testing for lower extremity peripheral arterial disease

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AHA/ACC Guidelines on Management of Lower Extremity PAD
Guidelines for Clinical Assessment of Lower Extremity PAD
Guidelines for Diagnostic Testing for suspected PAD
Guidelines for Screening for Atherosclerotic Disease in Other Vascular Beds in patients with Lower Extremity PAD
Guidelines for Medical Therapy for Lower Extremity PAD
Guidelines for Structured Exercise Therapy for Lower Extremity PAD
Guidelines for Minimizing Tissue Loss in Lower Extremity PAD
Guidelines for Revascularization of Claudication in Lower Extremity PAD
Guidelines for Management of CLI in Lower Extremity PAD
Guidelines for Management of Acute Limb Ischemial in Lower Extremity PAD
Guidelines for Longitudinal Follow-up for Lower Extremity PAD
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease

Recommendations for Diagnostic Testing for the Patient with Suspected Lower Extremity PAD (Claudication or Chronic Limb Ischemia)

Recommendations for Resting ABI (Ankle-Brachial Index) for Diagnosing PAD:

Class I

"1. In patients with history or physical examination findings suggestive of PAD (Table 1), the resting ABI, with or without segmental pressures and waveforms, is recommended to establish the diagnosis.(Level of Evidence: B-NR)"

"2. Resting ABI results should be reported as abnormal (ABI ≤0.90), borderline (ABI 0.91–0.99), normal (1.00–1.40), or noncompressible (ABI >1.40). (Level of Evidence: C-LD)"

Class III (No Benefit)

"1. In patients not at increased risk of PAD and without history or physical examination findings suggestive of PAD (Table 1), the ABI is not recommended. (Level of Evidence: B-NR)"

Class IIa

"1. In patients at increased risk of PAD but without history or physical examination findings suggestive of PAD (Table 1), measurement of the resting ABI is reasonable. (Level of Evidence: B-NR)"

Table1: History and/or Physical Examination Findings Suggestive of PAD*
History Claudication Other non–joint-related exertional lower extremity symptoms (not typical of claudication) Impaired walking function Ischemic rest pain Physical Examination Abnormal lower extremity pulse examination Vascular bruit Nonhealing lower extremity wound Lower extremity gangrene Other suggestive lower extremity physical findings (e.g., elevation pallor/dependent rubor)
*Adapted from 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease

Recommendations for Physiological Testing for Diagnosing PAD:

Class I

"1. Toe-brachial index (TBI) should be measured to diagnose patients with suspected PAD when the ABI is greater than 1.40. (Level of Evidence: B-NR)"

"2. Patients with exertional non–joint-related leg symptoms and normal or borderline resting ABI (>0.90 and ≤1.40) should undergo exercise treadmill ABI testing to evaluate for PAD. (Level of Evidence: B-NR)"

Class IIa

"1.In patients with PAD and an abnormal resting ABI (≤0.90), exercise treadmill ABI testing can be useful to objectively assess functional status. (Level of Evidence: B-NR)"

"2. In patients with normal (1.00–1.40) or borderline (0.91–0.99) ABI in the setting of nonhealing wounds or gangrene, it is reasonable to diagnose CLI by using TBI with waveforms, transcutaneous oxygen pressure (TcPO2), or skin perfusion pressure (SPP). (Level of Evidence: B-NR)"

"3. In patients with PAD with an abnormal ABI (≤0.90) or with noncompressible arteries (ABI >1.40 and TBI ≤0.70) in the setting of nonhealing wounds or gangrene, TBI with waveforms, TcPO2, or SPP can be useful to evaluate local perfusion. (Level of Evidence: B-NR)"

Recommendations for Imaging for Anatomic Assessment for Diagnosing PAD:

Class I

"1. Duplex ultrasound, computed tomography angiography (CTA), or magnetic resonance angiography (MRA) of the lower extremities is useful to diagnose anatomic location and severity of stenosis for patients with symptomatic PAD in whom revascularization is considered.(Level of Evidence: B-NR)"

"2. Invasive angiography is useful for patients with critical limb ischemia(CLI) in whom revascularization is considered.(Level of Evidence: C-EO)"

Class III (Harm)

"1. IInvasive and noninvasive angiography (i.e., CTA, MRA) should not be performed for the anatomic assessment of patients with asymptomatic PAD. (Level of Evidence: B-R)"

Class IIa

"1. Invasive angiography is reasonable for patients with lifestyle-limiting claudication with an inadequate response to GDMT for whom revascularization is considered.(Level of Evidence: C-EO)"