Asymptomatic Disease

More than 50% of patients with PVD are asymptomatic and only identified by noninvasive testing, such as the ankle-brachial index (ABI). Most epidemiologic studies have used a resting ABI less than 0.9 as the criterion for the diagnosis of PVD. However, this definition has several limitations and also leads to an underestimation of the true prevalence of disease. For example, this definition will miss mild to moderate disease in patients with normal resting ABIs, but who may have a considerable ischemic drop in the ABI with exercise. Furthermore, heavily calcified vessels, particularly in diabetic patients, will have falsely elevated ABIs from inability to compress the vessel. Nonetheless, the Systolic Hypertension in the Elderly Program (SHEP) found a prevalence of asymptomatic PVD in 25.5% of 1537 patients (Newman et al., 1993), using a resting ABI <0.9 as the diagnostic criteria. The Peripheral Arterial Disease Detection, Awareness, and Treatment in Primary Care (PARTNERS) program evaluated 6979 patients age 70 years and older, or age 50 to 69 with a history of either diabetes or cigarette smoking, by history and ABI. The diagnosis of PVD was made based on a resting ABI <0.9, a documented medical history of PVD, or a prior lower extremity revascularization. The PARTNERS program found a prevalence of PVD in 29% of patients. More concerning, however, is that 83% of patients with a known prior history of PVD were aware of their diagnosis, whereas only 49% of their physicians were aware of this diagnosis (Hirsch et al., 2001).

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