The AHA Guidelines and Scientifi c Statements Handbook
endorsed by the American Association of Cardio-
vascular and Pulmonary Rehabilitation (AACVPR);
National Heart, Lung, and Blood Institute (NHLBI);
Society for Vascular Nursing (SVN); TransAtlantic
Inter-Society Consensus (TASC); and Vascular
Disease Foundation (VDF). Thus, this guideline
accurately refl ects the national evidence base that
should guide lower extremity PAD care.
Data standards and performance
measures
Individuals with lower extremity peripheral artery
disease are encumbered by illness that has high mor-
bidity and mortality and whose contemporary out-
comes remain suboptimal. Improvement in clinical
outcomes cannot be achieved by an evidence-based
guideline alone, and improved care standards are
more likely to be achieved when the “process of
care” aligns clinician intent within a supportive
health system, so that prescribed actions can achieve
measurable outcomes [2]. Thus, the ACC and col-
laborating societies will imminently publish a series
of PAD “data standards” that will defi ne the data
defi nitions and measurable outcomes that can be
encompassed within either electronic medical
records or other data management systems [3]. As
well, a set of PAD “performance measures” will be
soon published that will defi ne those key recom-
mendations that should serve as defi nable guide-
posts of lower extremity PAD care excellence.
Readers should seek these two publications when
they are in press in 2009.
Vascular history and physical
examination
Prior to the publication of this guideline, there was
no evidence-based, consensus-driven, and common
interdisciplinary approach to the collection of a vas-
cular history or to the performance of a clinical
examination. All clinicians, spanning primary care
to specialty practices, should utilize a proactive col-
lection of key vascular historical details. A common
measurement of pulse intensity is now established.
Class I
1 Individuals at risk for lower extremity PAD should
undergo a vascular review of symptoms to assess
walking impairment, claudication, ischemic rest
pain, and/or the presence of nonhealing wounds.
(Level of Evidence: C)
2 Individuals at risk for lower extremity PAD should
undergo comprehensive pulse examination and
inspection of the feet. (Level of Evidence: C)
Key components of the vascular review of systems
(not usually included in the review of systems of
the extremities) and family history include the
following:- Any exertional limitation of the lower extremity
muscles or any history of walking impairment. The
characteristics of this limitation may be described as
fatigue, aching, numbness, or pain. The primary
site(s) of discomfort in the buttock, thigh, calf, or
foot should be recorded, along with the relation of
such discomfort to rest or exertion. - Any poorly healing or nonhealing wounds of the
legs or feet. - Any pain at rest localized to the lower leg or foot
and its association with the upright or recumbent
positions. - Postprandial abdominal pain that reproducibly is
provoked by eating and is associated with weight
loss. - Family history of a fi rst-degree relative with an
abdominal aortic aneurysm.
Care should also be guided by performance of a
focused vascular physical examination, which is
detailed in Table 9.1.
Epidemiology, prognosis, and natural
history of PAD
The major cause of lower extremity PAD is athero-
sclerosis. Risk factors for atherosclerosis such as
cigarette smoking, diabetes, dyslipidemia, hyperten-
sion, and hyperhomocysteinemia increase the likeli-
hood of developing lower extremity PAD (Fig. 9.1).
Lower extremity PAD is a common syndrome that
affects a large proportion of most adult populations
worldwide. Peripheral arterial disease is most often
asymptomatic, but these individuals remain at high
cardiovascular risk, and such individuals can be
effectively detected by use of the ankle-brachial
index measurement. Claudication, representing the
primary symptom of lower extremity PAD, defi nes
a signifi cantly smaller subset of the total population