Cardiovascular diseases (CVDs) are quite insidious types of medical conditions as they rarely exhibit symptoms until they are already in a more advanced stage. Peripheral artery disease (PAD) is no exception and can be difficult to accurately diagnose without the proper diagnostic tools, even if the patient exhibits symptoms that could be attributed to the disease.
Timely and proper treatment of PAD is, of course, reliant on accurate diagnosis of the disease and its severity, whether with the use of modern diagnostic tools or through a classical physical examination, supplemented with a comprehensive questionnaire (for the patient). The best option would be diagnosing using modern tools (devices), followed by both physical examination (sans procedures involving diagnostic tools) and a questionnaire in the second place.
The presented list of 17 questions was prepared on the basis of generally recognised risk factors for PAD and symptomatology, and includes both patient-centric and physician-centric questions. Those that only a patient knows (physical sensations in his body, other symptoms), but hasn’t yet conveyed to his personal physician, and those that have answers in the patient’s medical record on the physician’s desk or computer (or are otherwise self-evident).
List of questions for assessing the relative risk of PAD:
1. AGE. How old is the patient?
Older patients (over 50 years of age) are at an increased risk of PAD, which might be asymptomatic.
2. ETHNICITY. Self-evident.
There are statistically significant discrepancies in PAD prevalence and morbidity in individuals of different ethnic groups. Studies have shown that black people (specifically African Americans) are at higher risk of developing PAD than white people.
3. GENDER. Self-evident.
Some studies have indicated greater prevalence of PAD (particularly more severe forms) in women than in men.
4. TOBACCO SMOKING. Does the patient smoke (current smoker) or did he ever smoke (former smoker)?
Current smokers have a far greater risk of developing PAD. Association between tobacco smoking and PAD is especially strong in female smokers, who are at up to 20 times greater risk for the disease than females who have never smoked. Information about past smoking (former smokers) is also important: health benefits of smoking cessation don’t translate well to PAD as even past smokers are at an increased risk with up to 2.6 times greater prevalence of PAD (in comparison with non-smokers).
5. DIABETES. Does the patient have diabetes (type 1 or 2)?
Diabetes-induced hyperglycaemia greatly increases the incidence and prevalence of PAD. Some studies estimate prevalence rates at 20%, but this number is generally recognised as being an underestimation since PAD is frequently entirely asymptomatic or is masked by other symptoms/complications of diabetes.
6. DIAGNOSED CORONARY ARTERY DISEASE (CAD). Does the patient have CAD?
Already present (diagnosed) CAD is indicative of possible atherosclerosis in other vascular beds – prevalence rates of PAD in CAD patients range from 22% to 42%.
7. HISTORY OF MYOCARDIAL INFARCTION (MI), STROKE OR TRANSIENT ISCHAEMIC ATTACKS (TIA). Has the patient at any time in their life experienced MI, stroke or TIA?
History of MI and cerebrovascular events is associated with higher prevalence rates of PAD, often in its asymptomatic form (diagnosis on basis of the ABI score).
8. DIAGNOSIS OF CHRONIC KIDNEY DISEASE (CKD). Has the patient been diagnosed with CKD or renal insufficiency in general?
Individuals with renal insufficiency are 9 times more likely to have an abnormal (defined as ABI <0.9) ABI score (indication of PAD).
9. DIAGNOSIS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD). Has the patient been diagnosed with COPD?
Patients with COPD are at double the risk of developing PAD.
10. HYPERLIPIDAEMIA. Does the patient suffer from abnormally elevated levels of lipids (lipoproteins)?
Abnormal levels of blood lipids and lipoproteins is associated with mild risk for development of large-vessel disease.
11. HYPERTENSION. Is the patient hypertensive?
Hypertension is a known risk factor for PAD (and other CVDs).
12. WEIGHT. Is the patient over- or underweight?
Weight is a risk factor for PAD (and many other medical conditions) as studies have shown that older individuals with greater BMI (body mass index) have higher incidence of PAD.
13. INTERMITTENT CLAUDICATION. Does the patient report pain during any sort of physical exercise, even walking? Does the pain subside when he/she takes a rest? Where (body part) is the pain located?
Accurately diagnosing intermittent claudication on the basis of physical sensations the patient feels during physical exertion and when still/resting is best done using the Edinburgh Claudication Questionnaire.
14. COLD FEET/LEGS. Does the patient report a cold feeling in his leg(s) or feet despite feeling otherwise (in other parts of the body) warm or otherwise comfortable at the current ambient temperature?
Reduced blood flow leads to disruption of normal thermoregulation.
15. SCALY SKIN/OF PALE OR BLUEISH HUE/DEFORMED TOENAILS. Does the patient report abnormal skin texture and colour and toenail deformation?
Occlusion in the arteries of lower extremities reduces flow of nutrients to skin and toenails, leading to stunted growth and deformations. Possible pallor in the affected leg when it is in an elevated position.
16. OPEN WOUNDS AND SORES. Does the patient have any types of wounds or other tissue damage on his legs/feet that heals very slowly or doesn’t appear to heal at all?
Another tell-tale sign of PAD, but one that is typical for advanced form of the disease are open sores/wounds – arterial insufficiency ulcers (ischaemic ulcers), usually on the patient’s feet. They can be similar to venous ulcers, which have a significantly different underlying pathophysiology and treatment regime, necessitating the use of modern diagnostic methods to differentiate between them (e.g. measuring ABI).
17. ERECTILE DYSFUNCTION (MEN). Does the patient have erectile dysfunction?
Diagnosis of erectile dysfunction carries a twofold increase in the likelihood of PAD.
18. FAMILY HISTORY. Does the patient know whether any of his relatives had or currently have PAD?
Patients with a family history of PAD are at twice the risk of the disease than those without such familial medical history.
In the absence of other diagnostic means, a comprehensive questionnaire is a valuable tool for identifying patients at risk for PAD and any suspicion should be followed by a thorough examination, preferably using modern diagnostic devices.