What You Should Know About Screening For PAD
- Volume 21 - Issue 5 - May 2008
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Essential Questions To Cover In The Patient History
In addition to claudication, there are a variety of other possible risk factors that can contribute to the development of PAD. Accordingly, physicians should ask the following questions of patients when they have a high index of suspicion. Does the patient use or have a history of tobacco use? A common mistake is to ask the question: “Do you smoke?” The truthful answer may be no. However, bear in mind that the patient in question may have quit smoking a few years ago and previously had a 10-30 pack year history.
The current state of tobacco use is irrelevant if there is a history of use. Previously, researchers found that current smoking status had a greater effect on the development of PAD than a lifetime of smoking because of the decrease in cardiovascular complications.4 More recent evidence shows that a history of lifetime smoking is related to asymptomatic PAD.4
Does the patient have diabetes mellitus? If so, is it diabetes type 1 or type 2, and how long has the patient had the disease? Many of the associated metabolic issues that accompany diabetes mellitus can lead to the development of PAD. For patients with diabetes who meet the indications for non-invasive testing, we recommend both ankle-brachial index (ABI) and digital pressures/photoplethysmography to screen for the macro- and microvascular complications associated with the disease. We recommend screening people with diabetes over the age of 40.
Does the patient have any history of heart disease? Is there stable or unstable angina? Has the patient had a baseline stress test? Is there a history of coronary artery bypass or coronary angioplasty? Does the patient’s medication history tip you off to the presence of underlying coronary artery disease? Is there a first-degree relative with heart disease?
Does the patient have a history of stroke or transient ischemic attack involving the carotid arteries? Is the patient taking aspirin or clopidogrel bisulfate (Plavix, Bristol-Myers-Squibb)? If the patient does take the latter medication, is it to address a history of circulation problems relating to cardiac, carotid or peripheral circulation?
If you have a high index of suspicion for PAD, the most common metabolic conditions to screen for are hyperlipidemia and hypertension. Do patients know their most recent total cholesterol levels? Do they check their blood pressure regularly? Are they currently taking antihypertensive therapies or medications specific for lipid reduction?
Has the patient had any prior vascular intervention? Ask if patients have a history of carotid endarterectomy, coronary angioplasty or coronary artery bypass. Also question the history of renal artery or lower extremity artery angioplasty, or another invasive intervention.
Generally speaking, the recommendation is to screen individuals over the age of 50. However, one should screen the diabetic population over the age of 40.
Obesity is the final risk factor for the development of PAD. Of note, clinical obesity relates to a body mass index (BMI) > 30 whereas moribund obesity is a BMI > 40.