Clinical Assessment for PAD

Clinical Assessment for PAD

History and Physical Examination

 Faktor Resiko PAD

o Usia ≥65 tahun

o Usia 50-64 tahun, dengan faktor risiko aterosklerosis (misalnya,
diabetes mellitus, riwayat merokok, hiperlipidemia, hipertensi) atau
riwayat keluarga dengan PAD
o Usia <50 tahun, dengan diabetes mellitus dan 1 faktor risiko
aterosklerosis
o Individu dengan penyakit aterosklerotik yang diketahui di vaskular lain
(mis. Koroner, karotis, subklavia, renal , stenosis arteri mesenterika, atau
AAA)
History and/or Physical Examination Findings Suggestive of PAD

History
• Claudication
• Other non–joint-related exertional lower extremity symptoms (not
typical of claudication)
• Impaired walking function
• Ischemic rest pain
Physical Examination
• Abnormal lower extremity pulse examination
• Vascular bruit
• Nonhealing lower extremity wound
• Lower extremity gangrene
• Other suggestive lower extremity physical findings (e.g., elevation
pallor/dependent rubor)
2016 AHA/ACC Lower Extremity PAD Guideline

Diagnostic Testing for the Patient With

Suspected Lower Extremity PAD
(Claudication or CLI)
Diagnostic Testing for the Patient With Suspected
Lower Extremity PAD (Claudication or CLI)

Resting ABI for Diagnosing PAD

 RESTING ABI

Pemeriksaan ankle brachial index (ABI) adalah uji noninvasif

yang cukup akurat untuk mendeteksi adanya PAD dan untuk
menentukan derajat penyakit ini. ABI merupakan
pengukuran non-invasif ABI didefinisikan sebagai rasio antara
tekanan darah sistolik pada kaki dengan tekanan darah
sitolik pada lengan.
RESTING ABI FOR DIAGNOSING PAD

COR LOE Recommendations

In patients with history or physical examination
findings suggestive of PAD (Table 4), the resting ABI,
I B-NR
with or without segmental pressures and waveforms,
is recommended to establish the diagnosis.
Resting ABI results should be reported as abnormal
I C-LD (ABI ≤0.90), borderline (ABI 0.91–0.99), normal
(1.00–1.40), or noncompressible (ABI >1.40).
In patients at increased risk of PAD (Table 3) but
without history or physical examination findings
IIa B-NR
suggestive of PAD (Table 4), measurement of the
resting ABI is reasonable.
In patients not at increased risk of PAD (Table 3) and
III: No
without history or physical examination findings
Benefi B-NR
suggestive of PAD (Table 4), the ABI is not
t
recommended.
Diagnostic Testing for the Patient With Suspected
Lower Extremity PAD (Claudication or CLI)

Physiological Testing
PHYSIOLOGICAL TESTING

COR LOE Recommendations

TBI should be measured to diagnose patients with
I B-NR suspected PAD when the ABI is greater than 1.40.

Patients with exertional non–joint-related leg

symptoms and normal or borderline resting ABI
I B-NR (>0.90 and ≤1.40) should undergo exercise
treadmill ABI testing to evaluate for PAD.
In patients with PAD and an abnormal resting ABI
IIa B-NR (≤0.90), exercise treadmill ABI testing can be
useful to objectively assess functional status.
PHYSIOLOGICAL TESTING (CONT’D)

COR LOE Recommendations

In patients with normal (1.00–1.40) or borderline
(0.91–0.99) ABI in the setting of nonhealing wounds
IIa B-NR or gangrene, it is reasonable to diagnose CLI by
using TBI with waveforms, TcPO2, or SPP.
In patients with PAD with an abnormal ABI (≤0.90)
or with noncompressible arteries (ABI >1.40 and
IIa B-NR TBI ≤0.70) in the setting of nonhealing wounds or
gangrene, TBI with waveforms, TcPO2, or SPP can
be useful to evaluate local perfusion.
 Diagnostic Testing for Suspected PAD
Diagnostic Testing for
Suspected PAD

History and physical examination

suggestive of PAD without rest pain, Suspect CLI
nonhealing wound, or gangrene (Figure 2)
Colors correspond to Class of
(Table 4)
Recommendation in Table 1.

ABI with or without ABI indicates ankle-brachial index; CLI,

segmental limb pressures critical limb ischemia; CTA, computed
and waveforms tomography angiography; GDMT, guideline-
(Class I)
directed management and therapy; MRA,
magnetic resonance angiography; PAD,
Noncompressible
Noncompressible arteries
arteries Normal
Normal ABI:
ABI: 1.00–1.40
1.00–1.40 Abnormal
Abnormal ABI:
ABI: peripheral artery disease; and TBI, toe-
ABI:
ABI: >1.40
>1.40 Borderline
Borderline ABI:
ABI: 0.91–0.99
0.91–0.99 ≤0.90
≤0.90 brachial index.

TBI Exertional
Exertional non–joint
non–joint
(Class I) related
related leg
leg symptoms
symptoms
Exercise ABI
Normal Abnormal (Class IIa)
Yes No
(>0.70) (≤0.70)
Exercise ABI
(Class I) Search for
alternative
Abnormal Normal
diagnosis
Search for (Table 5)
Lifestyle-limiting claudication
alternative
despite GDMT,
diagnosis
revascularization considered
(Table 5)

Continue GDMT Do not perform invasive

Yes No
(Class I) or noninvasive anatomic
Options assessments for
asymptomatic patients
Anatomic assessment: (Class III: Harm)
Anatomic assessment:
· Duplex ultrasound
· Invasive angiography
· CTA or MRA
(Class IIa)
(Class I)
 Diagnostic Testing for Suspected CLI
Diagnostic Testing for
Suspected CLI

History and physical examination Colors correspond to Class of

suggestive of PAD with rest pain, Recommendation in Table 1.
nonhealing wound, or gangrene
(Table 4) *Order based on expert consensus.
†TBI with waveforms, if not already
Search for alternative diagnosis performed.
Yes No
(Tables 5 and 6)

ABI ABI indicates ankle-brachial index; CLI,

(Class I) critical limb ischemia; CTA, computed
tomography angiography; MRA, magnetic
resonance angiography; TcPO2,
transcutaneous oxygen pressure; and TBI,
Non-compressible
Non-compressible arteries
arteries Normal
Normal ABI:
ABI: 1.00–1.40
1.00–1.40
ABI:
Abnormal ABI: ≤0.90
Abnormal ABI: ≤0.90 toe-brachial index.
ABI: >1.40
>1.40 Borderline
Borderline ABI:
ABI: 0.91–0.99
0.91–0.99

TBI Nonhealing
Nonhealing wound
wound Additional perfusion
(Class I) or
or gangrene
gangrene assessment, particularly
if ABI >0.70:
Normal Abnormal
Yes No · TBI with waveforms
(>0.70) (≤0.70)
· TcPO2*
· Skin perfusion pressure*
Perfusion assessment: (Class IIa)
Search for
· TBI with waveforms†
alternative
· TcPO2* Normal Abnormal
diagnosis
· Skin perfusion pressure*
(Table 5)
(Class IIa)
Anatomic assessment:
Search for · Duplex ultrasound
alternative Normal Abnormal · CTA or MRA
diagnosis (Table 6) · Invasive angiography
(Class I)
Diagnostic Testing for the Patient With Suspected
Lower Extremity PAD (Claudication or CLI)

Imaging for Anatomic Assessment

IMAGING FOR ANATOMIC ASSESSMENT

COR LOE Recommendations

Duplex ultrasound, CTA, or MRA of the lower
extremities is useful to diagnose anatomic location and
I B-NR
severity of stenosis for patients with symptomatic PAD
in whom revascularization is considered.
Invasive angiography is useful for patients with CLI in
I C-EO
whom revascularization is considered.
Invasive angiography is reasonable for patients with
lifestyle-limiting claudication with an inadequate
IIa C-EO
response to GDMT for whom revascularization is
considered.
Invasive and noninvasive angiography (i.e., CTA, MRA)
III:
B-R should not be performed for the anatomic assessment
Harm
of patients with asymptomatic PAD.
2016 AHA/ACC Lower Extremity PAD Guideline

Screening for Atherosclerotic Disease in Other

Vascular Beds for the Patient With PAD
Screening for Atherosclerotic Disease in Other Vascular Beds
for the Patient With PAD

Abdominal Aortic Aneurysm

COR LOE Recommendation

A screening duplex ultrasound for AAA is reasonable
IIa B-NR in patients with symptomatic PAD.
Screening for Atherosclerotic Disease in Other Vascular Beds
for the Patient With PAD

Screening for Asymptomatic Atherosclerosis in

Other Arterial Beds
(Coronary, Carotid, and Renal Arteries)
SCREENING FOR ASYMPTOMATIC ATHEROSCLEROSIS IN OTHER
ARTERIAL BEDS (CORONARY, CAROTID, AND RENAL ARTERIES)

• Prevalensi aterosklerosis pada arteri koroner, karotis, dan renal

lebih tinggi pada pasien dengan PAD dibandingkan pada
mereka yang tidak PAD
• Namun, modifikasi faktor risiko aterosklerosis intensif pada pasien
dengan PAD direkomendasikan jika memang tidak memiliki
kelainan di arteri lainnya
• skrining yang digunakan untuk penyakit di arterial adalah
dengan revaskularisasi yang dapat mengurangi risiko infark
miokard (MI), stroke, atau kematian => namun belum pernah
dilakukan
• Perawatan intensif faktor-faktor risiko melalui GDMT adalah
metode prinsip untuk mencegah kejadian iskemik kardiovaskular