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SA JOURNAL OF DIABETES & VASCULAR DISEASE
VOLUME 9 NUMBER 2 • JUNE 2012
89
Diabetes Educator’s Focus
SCREENING FOR PERIPHERAL ARTERIAL
DISEASE IN PEOPLE WITH DIABETES
S Afr J Diabetes Vasc Dis
2012;
9
:
89–91.
P
eripheral arterial disease (PAD) in people
with diabetes is due to the artheroscle-
rotic process affecting the medium-sized
arteries of the legs. The arteries that are commonly
involved in patients with diabetes are the peroneal,
tibial and profunda femoris arteries.
The diagnosis of PAD remains somewhat prob-
lematic at the primary-care level but is essential, as
PAD in people with diabetes is associated with high
morbidity and mortality rates from cardiovascular
disease. Early detection of PAD, risk modification and
referral for foot care, and surgical intervention when
appropriate, may improve outcome.
Diabetic foot disease is a multi-factorial condition
with sensori-motorneuropathy being the principle
factor involved in the development of ulceration of
the foot. PAD is one factor leading to the most dev-
astating outcome of diabetic foot disease – amputa-
tion.
1
PAD was found to be more common in patients
with diabetes who had had a major amputation and
among those undergoing re-amputation. In people
with a major amputation and critical leg ischaemia,
Bodily and Burgess found the re-amputation rate to
their contralateral leg to be 36% after two years.
2
People with diabetes are at high risk for PAD but the
true incidence and prevalence is not certain in this pop-
ulation because of different methods used to diagnose
PAD. Diagnostic criteria used in several studies vary
from using one or more of the following: deficit of pedal
pulses, symptoms of intermittent claudication, ankle–
brachial pressure index (ABPI) of < 0.9, presence of foot
ulcer, and history of lower extremity amputation.
Two studies reporting on the prevalence of PAD
among people with type 1 and 2 diabetes mellitus
had different results. Welborn
et al
.
3
showed an iden-
tical prevalence of 38% in patients with type 1 and
2 diabetes, using intermittent claudication and pulse
Gerda van Rensburg
Podiatrist, Centre for Diabetes, Houghton,
Johannesburg
e-mail: Gerda@cdecentr.co.za
deficit as diagnostic criteria.Walters
et al
.
4
found that
patients with type 2 diabetes had a higher prevalence
(23.5%) than those with type 1 diabetes (8.7%), us-
ing ABPI < 0.9 as diagnostic criterion.
PAD AND CARDIOVASCULAR DISEASE
The presence of PAD is an independent risk factor for
increased mortality, due to associated cardiovascular
disease (CVD).
5
Patients with PAD have the same rela-
tive risk of death from cardiovascular events as pa-
tients with a history of coronary and cerebrovascular
disease. Mortality is higher among those with critical
leg ischaemia (annual mortality of 25%). The lower the
ABPI, the greater the risk of cardiovascular events.
6
Early detection of PAD is important for risk modifi-
cation, which reduces the progression and improves
the outcome. Guidelines recommend that all patients
diagnosed with PAD should have a full cardiovas-
cular risk assessment.
7
The PARTNERS progam
8
demonstrated that patients with PAD were less in-
tensively treated than patients with CVD. This survey
showed that patients with PAD received lower rates
of antiplatelet and hypertension therapy compared to
patients with documented CVD.
PRESENTATION OF PAD AND DIABETES
PAD in diabetes can be asymptomatic, influencing
the diagnosis thereof. Jude
et al
. found that many
patients with PAD and diabetes did not experience
symptoms of intermittent claudication of the calf
muscles because of the presence of peripheral neu-
ropathy.
9
The high level of inactivity of many of these
patients may also affect diagnosis. PAD may there-
fore be asymptomatic until an advanced stage, when
patients present with critical ischaemic changes in
the feet. Poorer functional ability among people with
diabetes and PAD compared to those with only PAD
has been reported by Dolan.
10