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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 June 11, 2024 e1321

1.6 Abbreviations

Abbreviation Meaning/Phrase 6MWT 6-minute walk test ABI ankle-brachial index ACE angiotensin-converting enzyme ALI acute limb ischemia CAD coronary artery disease CKD chronic kidney disease CLTI chronic limb-threatening ischemia COVID-19 coronavirus disease 2019 CTA computed tomography angiography CVD cardiovascular disease ESKD end-stage kidney disease GDMT guideline-directed management and therapy LDL-C low-density lipoprotein cholesterol MACE major adverse cardiovascular events MALE major adverse limb events MI myocardial infarction MRA magnetic resonance angiography NPWT negative pressure wound therapy PAD peripheral artery disease PTA percutaneous transluminal angioplasty PVR pulse volume recordings QOL quality of life RCT randomized controlled trial SARS-CoV-2 severe acute respiratory syndrome-coronavirus-2 SBP systolic blood pressure SET supervised exercise therapy SPP skin perfusion pressure TBI toe-brachial index TcPO2 transcutaneous oxygen pressure WIfI wound, ischemia, and foot infection

2 CLINICAL ASSESSMENT FOR PAD

Clinical assessment is a central component of evaluation for PAD. Recognition of patterns (clinical subsets) of clinical presentation of PAD will direct clinical evaluation, diagnostic testing, and treatment, as well as determine the urgency of care. The clinical assessment for PAD includes the history and physical examination, consideration of differential diagnoses, and is performed before diagnostic testing for PAD (see Section 3, “Diagnostic Testing for PAD”).

2.1 Recognizing Clinical Subsets of PAD

The clinical presentation of patients with objectively confirmed PAD can be categorized into 4 clinical subsets: asymptomatic PAD, chronic symptomatic PAD, chronic limb-threatening ischemia (CLTI), and acute limb ischemia (ALI) (Figure 1). Patients with PAD may develop different symptoms over time and may move into and out of different subsets during their disease process, such as deterioration of chronic symptomatic PAD to CLTI or ALI or improvement of symptoms after treatment. The characteristics of each clinical subset of PAD are described in Table 4.

2.2 History and Physical Examination to Assess

for PAD Recommendations for History and Physical Examination to Assess for PAD Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 B-NR 1 In patients at increased risk of PAD (Table 5), a

comprehensive medical history and review of symptoms to assess for exertional leg symptoms, lower extremity rest pain, and lower extremity wounds or other ischemic skin changes should be performed.1–4

1 B-NR 2 In patients at increased risk of PAD (Table 5), a

comprehensive vascular examination and inspection of the legs and feet should be performed regularly (Table 6).2,5–8

Synopsis Clinical assessment for PAD begins with recognition of risk factors for PAD to assist in identification of patients at risk. Risk factors for atherosclerosis as well as presence of atherosclerotic disease in other vascular areas are important risk features. The history and physical examination are important to identify patients

Figure 1. Clinical Subsets of PAD. ALI indicates acute limb ischemia; CLTI, chronic limb-threatening ischemia; and PAD, peripheral artery disease.

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