The AHA Guidelines and Scientifi c Statements Handbook
Class IIa
1 An exercise ABI measurement can be useful to
diagnose lower extremity PAD in individuals who
are at risk for lower extremity PAD (Table 9.1) who
have a normal ABI (0.91 to 1.30), are without classic
claudication symptoms, and have no other clinical
evidence of atherosclerosis. (Level of Evidence: C)
2 A toe-brachial index or pulse volume recording
measurement can be useful to diagnose lower
extremity PAD in individuals who are at risk for
lower extremity PAD who have an ABI greater than
1.30 and no other clinical evidence of atherosclero-
sis. (Level of Evidence: C)
Class IIb
Angiotensin-converting enzyme (ACE) inhibition
may be considered for individuals with asymptom-
atic lower extremity PAD for cardiovascular risk
reduction. (Level of Evidence: C)
Claudication
See Table 9.3.
Class I
1 Patients with symptoms of intermittent claudica-
tion should undergo a vascular physical examina-
tion, including measurement of the ABI. (Level of
Evidence: B)
2 In patients with symptoms of intermittent claudi-
cation, the ABI should be measured after exercise if
the resting index is normal. (Level of Evidence: B)
3 Patients with intermittent claudication should
have signifi cant functional impairment with a rea-
sonable likelihood of symptomatic improvement
and absence of other disease that would comparably
limit exercise even if the claudication was improved
(e.g., angina, heart failure, chronic respiratory
disease, or orthopedic limitations) before undergo-
ing an evaluation for revascularization. (Level of
Evidence: C)
4 Individuals with intermittent claudication who
are offered the option of endovascular or surgical
therapies should (a) be provided information
regarding supervised claudication exercise therapy
and pharmacotherapy; (b) receive comprehensive
risk factor modifi cation and antiplatelet therapy; (c)
have a signifi cant disability, either being unable to
perform normal work or having serious impairment
of other activities important to the patient; and (d)
have lower extremity PAD lesion anatomy such that
the revascularization procedure would have low risk
and a high probability of initial and long-term
success. (Level of Evidence: C)Class III
Arterial imaging is not indicated for patients with a
normal post-exercise ABI. This does not apply if
other causes (e.g., entrapment syndromes or iso-
lated internal iliac artery occlusive disease) are sus-
pected. (Level of Evidence: C)Critical limb ischemia
See Tables 9.4 and 9.5.Table 9.3 Indications for revascularization in intermittent
claudication
Before offering a patient with intermittent claudication the option of
any invasive revascularization therapy, whether endovascular or
surgical, the following considerations must be taken into account:
- A predicted or observed lack of adequate response to exercise
therapy and claudication pharmacotherapies - Presence of a severe disability, either being unable to perform
normal work or having very serious impairment of other activities
important to the patient - Absence of other disease that would limit exercise even if the
claudication was improved (e.g., angina or chronic respiratory
disease) - The individual’s anticipated natural history and prognosis
- The morphology of the lesion (must be such that the appropriate
intervention would have low risk and a high probability of initial
and long-term success)
Table 9.4 Objectives for diagnostic evaluation of patients with
critical limb ischemiaThe diagnostic evaluation of patients with critical limb ischemia
should be directed toward the following objectives:- Objective confi rmation of the diagnosis
- Localization of the responsible lesion(s) and a gauge of relative
severity - Assessment of the hemodynamic requirements for successful
revascularization (vis-à-vis proximal versus combined
revascularization of multilevel disease) - Assessment of individual patient endovascular or operative risk