Diagnosis and treatment of peripheral arterial disease.

Peripheral arterial disease (PAD) is atherosclerosis leading to narrowing of the major arteries distal to the aortic arch. The most common presenting symptom is claudication; however, only 10% of patients have classic claudication. Approximately 8 to 12 million Americans have PAD, including 15% to 20% of adults older than 70 years. The ankle-brachial index (ABI) can be used to screen for and diagnose PAD in the primary care setting. An ABI of less than 0.9 is associated with a two- to fourfold increase in relative risk for cardiovascular events and all-cause mortality. To improve cardiovascular risk stratification and risk factor modification, the American Diabetes Association recommends ABI screening for patients older than 50 years who have diabetes mellitus, and the American Heart Association recommends screening all patients 65 years and older and those 50 years and older who have a history of diabetes or smoking. Because there is no evidence that screening leads to fewer cardiovascular events or lower all-cause mortality, the U.S. Preventive Services Task Force recommends against screening for PAD. Management of claudication includes exercise, smoking cessation, statin therapy, and antiplatelet therapy with aspirin or clopidogrel, and possibly cilostazol in patients with no history of heart failure. Surgical revascularization may be considered in patients with lifestyle-limiting claudication symptoms that do not respond to medical therapy.