When Do You Refer A Patient For Vascular Intervention?
Despite devastating five-year mortality rates that rival those of several forms of cancer, peripheral arterial disease (PAD) remains somewhat under-recognized, even by healthcare providers. This author emphasizes the importance of appropriate screening of high-risk patients and timely referrals for vascular interventionalists.
When the words “pink ribbon” are juxtaposed, what do you think of? Without hesitation, you make the connection to breast cancer awareness.
I have often asked this very question when lecturing, whether to colleagues, other professionals or laypeople. The first follow-up question is usually, “Why?” To which the response is usually, “due to the marketing” that has surrounded breast cancer awareness for many years now.
The next follow-up question I pose is, “When is Peripheral Arterial Disease (PAD) Awareness Month?” While October has become synonymous with breast cancer awareness, it is on the rarest occasion that I have received the correct reply, September, when it comes to the disease that is far more deadly and far less known than breast cancer.
This general lack of awareness underscores an even greater concern that healthcare providers equally misunderstand PAD. How can we expect providers who are lacking in fundamental appreciation of PAD to know when to refer patients who have any significant degree of the disease to an appropriate vascular specialist or for vascular intervention?
Let’s get back to basics before we recommend a solution to the problem that grows alongside the ever increasing diabetic population both here and abroad.
What You Should Know About Screening For PAD
A recent poll on Podiatry Today’s Web site asked readers, “Which non-invasive test do you rely on (in your office or hospital) for PAD diagnosis?” (see http://tinyurl.com/8eyn92w ). I will discuss the results of this poll a bit later.
The wording of the question may be a bit misleading as there is a difference between screening and diagnosing. Screening refers to identifying those who may be at risk for a particular condition or disease state. Diagnostics help confirm a diagnosis.
The American College of Cardiology/American Heart Association recommends PAD screening for anyone over the age of 50 who has diabetes and/or smokes, and those over 70 years of age.1 Additionally, an expert panel brought together by the American Diabetes Association recommends that people with diabetes over the age of 50 have an ankle-brachial index (ABI) to test for PAD.2 While the ABI has a fairly high reliability for PAD recognition, it is not intended to be the test that confirms the diagnosis.
The same holds true for methods such as palpation of pulses or the use of a handheld Doppler. These tests provide some information but each has inherent flaws that may result in either misdiagnosed or false negatives if one uses them as the definitive criteria for diagnosing PAD. For example, when a patient has calcified arteries, an ABI may yield falsely elevated values that can place a patient with diabetes and significant PAD into a perceived normal category.
Palpation of pulses is another screening test with variable results. Not only is the test dependent on the proficiency of the provider, there is also the potential to perceive one’s own finger pulses to be those of the patient’s pedal pulses.