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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 June 11, 2024 e1323

at increased risk of PAD, assess for lower extremity symptoms, and assess for pulse deficits and other signs of PAD, including lower extremity wounds. Suggestive clinical history or the presence of any abnormal physical examination finding concerning for PAD requires prompt evaluation with the ankle-brachial index (ABI) to establish the diagnosis of PAD (see Section 3, “Diagnostic Testing for PAD”). For patients in whom the diagnosis of PAD has been established, longitudinal care includes periodic reassessment of lower extremity symptoms, assessment of pulses, and foot inspection and preventive care (see Section 5.8, “Preventive Foot Care for PAD” and Section 12, “Longitudinal Follow-Up of PAD”).

Recommendation-Specific Supportive Text

1 Patients at risk for PAD are identified based on

demographic features, cardiovascular risk factors, or the presence of atherosclerotic vascular disease in other vascular beds (Table 5). Black race is associated with increased risk for PAD, even after adjustment for conventional risk factors, and is also associated with major adverse cardiovascular events (MACE) and major adverse limb events (MALE; see Section 4.1, “Amplifiers of Cardiovascular and Limb-Related Risk in Patients With PAD” and Section 4.2, “Health Disparities in PAD”).9,10 The clinical presentation of PAD varies and can be classified into clinical subsets (Table 4). It is estimated that only one-third of patients with PAD present with symptoms of typical claudication, while most patients with PAD present with other exertional leg symptoms not typical of claudication.1,4 All patients with chronic symptomatic PAD, including those with atypical symptoms, have walking impairment.4 Thus, careful consideration of all exertional leg symptoms with a meticulous clinical history assessment that highlights site, quality, exacerbating factors, relieving factors, timing, and progression of leg symptoms is key (Table 6).11 The differential diagnosis of PAD is broad, and leg symptoms with exertion may be due to multiple other causes (Table 7). The approach to diagnostic testing for patients with suspected PAD is discussed in Section 3, “Diagnostic Testing for PAD.” 2.	 Patients at increased risk of PAD require a thor-

ough vascular examination with a focus on the lower extremities. To appropriately accomplish this, all lower extremity garments, including shoes and socks, should be removed. Lower extremity pulses (femoral, popliteal, dorsalis pedis, and posterior tibial arteries) are evaluated with palpation and rated as follows: 0, absent; 1, diminished; 2, normal; or 3, bounding (Table 6). Reproducibility of pulse assessment is more accurate for detection of normal versus absent pulse than for normal versus diminished pulse.5,11 Presence of all 4 (right and left) posterior tibial and dorsalis pedis pulses on palpation is associated with low likelihood of PAD.12 Evaluating for both abdominal and femoral bruits may also be useful to identify signs of PAD. Last, other findings, such as elevation pallor/dependent rubor, asymmetric hair growth, and calf muscle atrophy, may be suggestive of PAD.5,8,11 Additional evaluation for peripheral neuropathy should be considered among patients with diabetes.

Table 5.  Patients at Increased Risk for PAD Age ≥65 y Age 50-64 y, with risk factors for atherosclerosis (eg, diabetes, history of smoking, dyslipidemia, hypertension), chronic kidney disease, or family history of PAD13 Age <50 y, with diabetes and 1 additional risk factor for atherosclerosis Individuals with known atherosclerotic disease in another vascular bed (eg, coronary, carotid, subclavian, renal, mesenteric artery stenosis, or AAA) Modified with permission from Gerhard-Herman et al.14 Copyright 2017 American Heart Association, Inc., and American College of Cardiology Foundation.

AAA indicates abdominal aortic aneurysm; and PAD, peripheral artery disease. Table 6.  History and Physical Examination Findings Suggestive of PAD

History Claudication Pain type: Aching, burning, cramping, discomfort, or fatigue Location: Buttock, thigh, calf, or ankle Onset/offset: Distance, exercise, uphill, how long for relief after rest

(typically <10 min for typical claudication) Other nonjoint-related exertional lower extremity symptoms (not typical of claudication) or symptoms of impaired walking function Lower extremity muscular discomfort associated with walking that

requires >10 min rest to resolve Leg weakness, numbness, or fatigue during walking without pain Ischemic rest pain History of nonhealing or slow-healing lower extremity wound Erectile dysfunction Physical Examination Abnormal lower extremity pulse palpation (femoral, popliteal, dorsalis pedis, or posterior tibial arteries) Vascular bruit (eg, epigastric, periumbilical, groin) Nonhealing lower extremity wound Lower extremity gangrene Other physical findings suggestive of ischemia (eg, asymmetric hair growth, nail bed changes, calf muscle atrophy, or elevation pallor/dependent rubor) Modified with permission from Gerhard-Herman et al.14 Copyright 2017 American Heart Association, Inc., and American College of Cardiology Foundation.

PAD indicates peripheral artery disease.

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