Peripheral Vascular Disease

Introduction to Risk Factors

A family history of premature cardiovascular disease is a risk factor for Peripheral Vascular Disease (PVD), according to the American Heart Association 1
Genetic factors and variations in prevalence across different ethnic groups are associated with PVD, as noted by the American Heart Association 2

High LDL cholesterol, low HDL cholesterol, and elevated triglycerides increase the risk of PVD, as stated by the American College of Cardiology 1
The presence of multiple risk factors, including hypertension, cardiovascular disease, hyperlipidemia, diabetes, tobacco use, obesity, and stroke, significantly increases the likelihood of developing PVD, according to the American Heart Association 1

Variations in prevalence across different ethnic groups are associated with PVD, as indicated by the American Heart Association 2
Men are affected slightly more than women, and the prevalence is higher in high-risk groups, such as those aged 70 years or older, or those with a 10 pack-year smoking history or diabetes, according to the American College of Cardiology 3

Peripheral artery disease (PAD) affects approximately 12% of the adult population, with a higher prevalence in high-risk groups, and nearly 20% of adults over 70 years having PAD, as reported by the American College of Cardiology 3
PAD affects approximately 8.5 million people in the US, and often goes undiagnosed due to variable presentation, with up to 50% of patients being asymptomatic, according to the American College of Cardiology 3
The American College of Cardiology recommends the ankle-brachial index (ABI) as the first-line diagnostic test for PAD, with an ABI ≤0.90 being diagnostic of PAD 3, 4, 5, 6
The interpretation of ABI values is as follows:
ABI Value Category
1.0-1.4 Normal
0.91-0.99 Borderline
0.41-0.90 Mild-moderate PAD
≤0.40 Severe PAD
4, 5, 6

If resting ABI is normal but symptoms persist, exercise ABI testing is recommended, according to the American College of Cardiology 5, 7
For non-compressible vessels (ABI >1.40), the toe-brachial index should be used instead, as recommended by the American College of Cardiology 5, 7
The American College of Cardiology recommends duplex ultrasound if PAD is suspected based on ABI, and considers CT angiography or MR angiography if revascularization is being considered or duplex ultrasound is inconclusive 5

The American College of Cardiology recommends treatment goals that include reducing cardiovascular risk and improving leg symptoms and functional capacity, with key interventions including smoking cessation, structured exercise therapy, and high-intensity statin therapy 3
The American Heart Association recommends ensuring appropriate antiplatelet therapy to reduce cardiovascular risk, and the American College of Cardiology recommends optimizing statin therapy to achieve LDL <70 mg/dL for very high-risk patients with PAD and lower extremity edema 8, 7
Risk factor modification, including smoking cessation, diabetes control, and hypertension management, is essential for managing PVD, with antiplatelet therapy, such as low-dose aspirin, recommended for all patients with type 2 diabetes and cardiovascular disease, according to the American College of Cardiology 9
Revascularization (surgical or endovascular) is recommended for severe disease or critical limb ischemia, and considered for patients with significant disability who have not responded to conservative measures, as recommended by the American College of Cardiology 9, 7

PAD is a marker of systemic atherosclerosis and is associated with an increased risk of myocardial infarction, ischemic stroke, and cardiovascular death, as well as a decreased quality of life and functional capacity, according to the American Heart Association, as cited in Circulation 10
Patients with PVD have an increased risk of cardiovascular events, including myocardial infarction, stroke, and vascular death, with a 3-fold increased risk of MI, stroke, and vascular death compared to patients with intermittent claudication alone, as reported by the American College of Cardiology 9, 6

Underdiagnosis is a significant issue, with more than 70% of primary care providers being unaware of PAD in affected patients, according to the American College of Cardiology 3
Common pitfalls in the management of intermittent claudication include misdiagnosis with pseudoclaudication, underestimating cardiovascular risk, focusing only on leg symptoms, and premature invasive intervention, as noted by the American College of Cardiology 7
Peripheral neuropathy and PVD can coexist, particularly in patients with diabetes, and neuropathy can mask symptoms of PVD, leading to delayed diagnosis, according to the American College of Cardiology 9