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Peripheral Artery Disease and Intermittent Claudication

Description

An in-depth report on the causes, diagnosis, and treatment of peripheral artery disease

Alternative Names

Intermittent Claudication

Diagnosis

Evidence suggests that PAD is an important risk factor for heart disease and stroke but is greatly underdiagnosed. Many patients do not report symptoms or may not even have symptoms. People should be evaluated for peripheral artery disease if they have risk factors for heart disease, leg pain during walking, or ulcers on their legs.

Physical Examination

The physician should evaluate the patient with a number of physical examinations for high blood pressure, heart abnormalities, blockage in the artery in the neck, and abdominal aneurysms. The physician will also examine the skin of the legs and feet for color changes, ulcers, infection, or injuries. The physician will also check the pulse of the arteries in the leg.

Doppler Ultrasound and Ankle-Brachial Index

Intermittent claudication caused by peripheral artery disease is typically diagnosed using a procedure called Doppler ultrasound and a calculation called the ankle-brachial index. This procedure is also proving to be important for diagnosing PAD even in patients without symptoms of intermittent claudication.

The procedure involves the following:

  • The physician first takes a measurement of the systolic blood pressure of both arms while the patient is lying down. (The systolic pressure is the higher and first number in a blood pressure measurement. It is the force that blood exerts on the artery walls as the heart contracts to pump out the blood.)
  • The physician then applies cuffs to four different locations on each leg. An ultrasound probe is passed over arteries in the foot. The signal emitted from the strongest artery is recorded as the cuffs are inflated and deflated.

The physician divides the systolic pressure in the ankle by that in the arm. The result is called the ankle-brachial index (ABI), also called ankle-arm pressure index (API). The results suggest the following:

  • An ABI over .90. This result often rules out PAD, but if the patient has specific risk factors for artery disease, the physician may still suspect PAD. In such cases, the patient takes a treadmill test and another ABI measurement. If the API index drops, then the physicians makes a diagnosis of peripheral artery disease.
  • An ABI below .90. This is usually sufficient information to diagnose peripheral artery disease. The lower the index the greater the risk for heart attack, stroke, or other serious circulatory or heart events. (In patients with diabetes, the physician may perform additional tests, which may include ultrasound, pressure measurement in the first toe, or others that might confirm or refute a diagnosis of peripheral artery disease.)
  • Measurements of less than .50 are highly associated with impaired leg function.
  • Measurements of less than .40 indicate very severe blockage in the arteries in the leg and a risk for gangrene.

Computed Tomography Angiography

A new technology called computed tomography angiography (CTA) uses x-rays to visualize blood flow in arterial vessels throughout the body. This technique is highly effective in diagnosing PAD.

Treadmill Test

A patient is often given a treadmill test if the ankle-brachial index is questionable. Patients with claudication have a 50% to 60% reduction in peak performance, which is comparable to that in patients with congestive heart failure. The treadmill test is also useful for determining the severity of the pain while walking and for assessing the effectiveness of treatments.

Waveform Analysis

A test called a wave form analysis may be used to confirm an abnormal API or pressure reading. The patient lies on his or her back for at least 10 minutes in a warm room (so that the blood vessels will not narrow). The leg is turned out and the knee is bent slightly. A probe is passed over the leg, which picks up sound waves coming from the arteries. These signals are recorded and the wave forms traced to detect abnormal blood flow.

Tests for Detecting Heart Disease

Patients with suspect PAD should have an electrocardiogram (ECG) and possibly other tests that would detect heart problems. Evidence suggests that heart disease may be underdiagnosed in these patients. In one study, for example, a third of patients had silent ischemia, which is heart disease without angina, the chest pain that indicates blockage of blood flow to the heart.

ECG
The electrocardiogram (ECG, EKG) is used extensively in the diagnosis of heart disease, from congenital heart disease in infants to myocardial infarction and myocarditis in adults. Several different types of electrocardiogram exist.

Ruling out Other Disorders with Similar Symptoms

A number of other tests can rule out disorders with similar symptoms, which include the following:

  • Arthritis.
  • Anemia.
  • Spinal stenosis (narrowing of the spinal canal causing leg and/or lower back pain).
Spinal stenosis Click the icon to see an image of spinal stenosis.
  • Thrombophlebitis (blood clots in the deep veins of the legs).
Deep venous thrombosis, ileofemoral Click the icon to see an image of thrombophlebitis.
  • Peripheral neuropathy (nerve damage in the legs and feet, usually in people with diabetes).
  • Night cramps in older people not due to problems in blood vessels.
  • Muscle entrapment of the arteries or kinks in the arteries in the leg. These events typically occur in young athletes.
  • Adventitial cystic disease. This is a rare disorder that produces cysts that block the popliteal and other arteries and typically occurs in young people.
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