Clinical Examination in the Diagnosis of Peripheral Artery Disease of the Lower Extremity

A systematic review 1 including 11 studies on accuracy with a total of 6,272 subjects and 6 studies on precision with a total of 248 subjects was abstracted in DARE. In asymptomatic patients, the most useful clinical findings to diagnose PAD were the presence of symptoms of intermittent claudication (4 studies; LR 3.30, 95% CI: 2.30 to 4.80), femoral bruit (1 study; LR 4.80, 95% CI: 2.40 to 9.50) or any pulse abnormality (3 studies; LR 3.10, 95% CI: 1.40 to 6.60). The absence of these clinical examination features were not found to lower the likelihood of PAD, but the absence of symptoms of intermittent claudication (1 study; LR 0.57, 95% CI: 0.43 to 0.76) or the presence of normal pulses (1 study; LR 0.44, 95% CI: 0.30 to 0.66) were found to lower the likelihood of moderate to severe PAD. In patients who were symptomatic with leg complaints, the most useful clinical findings to diagnose PAD were the presence of cool skin in the affected leg (1 study; LR 5.90, 95% CI: 4.10 to 8.60), discoloured skin (1 study; LR 2.80, 95% CI: 2.40 to 3.30), or wounds or sores (1 study; LR 5.90, 95% CI: 2.60 to 13.40), the presence of at least one bruit at rest (iliac femoral or popliteal) (3 studies; LR 5.60, 95% CI: 4.70 to 6.70), or any palpable pulse abnormality (6 studies; LR 4.70, 95% CI: 2.20 to 9.90). The absence of any bruits (iliac, femoral or popliteal) (LR 0.39, 95% CI: 0.34 to 0.45) or pulse abnormality (LR 0.38, 95% CI: 0.23 to 0.64) reduced the likelihood of PAD. A PAD scoring system, assessed by one study, used hand-held Doppler to derive a score based on the number of auscultated arterial components, grade of the peripheral pulse and history of myocardial infarction. This system provided the greatest diagnostic accuracy: patients scoring less than 6 had an increased likelihood of PAD (LR 7.80, 95% CI: 4.80 to 12.70), whilst those scoring 6 or more had a decreased likelihood of PAD (LR 0.20, 95% CI: 0.10 to 0.40).

Comment: The quality of evidence is downgraded by limitations in study quality.

References

• Khan NA, Rahim SA, Anand SS, Simel DL, Panju A. Does the clinical examination predict lower extremity peripheral arterial disease? JAMA 2006 Feb 1;295(5):536-46. [PubMed][DARE]