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VOLUME 9 NUMBER 2 • JUNE 2012
91
SA JOURNAL OF DIABETES & VASCULAR DISEASE
EDUCATOR’S FOCUS
of PAD but with varying levels of sensitivity.
16
A planned verbal inquiry will
yield critical information. The differential diagnosis is tabled in the TASC2
guidelines.
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PEDAL PULSES
The presence of foot pulses does not exclude PAD and patients present-
ing with the classic history of intermittent claudication should be inves-
tigated further. Various recording systems are used to record the pulse
intensity. For screening purposes, the least confusing system should be
used and pulse intensity should be recorded as absent or present.
ANKLE-BRACHIAL PRESSURE INDEX
The ABPI is a reliable test in the absence of vascular calcification. A
resting cut-off point of 0.9 (95% sensitivity) is used in detecting angio-
gram-positive disease, with 99% specificity in identifying healthy sub-
jects. Symptoms of intermittent claudication are usually experienced at
a level between 0.6 and 0.9 and critical ischaemia is associated with an
ABPI of less than 0.5.
A high ABPI above 1.5 may be misleadingly in patients with vascular
calcification, as found in diabetes and advanced renal failure. For this
reason the toe pressure can be measured, as much less calcification is
found in the toe arteries. The toe pressure test is not recommended for
screening or at the primary-care level.
ABPI > 1.3 indicates medial calcification resulting in incompressible
•
arteries.
ABPI is normally > 1.0.
•
ABPI < 0.9 indicates some arterial disease.
•
ABPI > 0.5 and < 0.9 can be associated with claudication and
•
if symptoms warrant it, a patient should be referred for further
assessment.
ABPI < 0.5 indicates severe arterial disease and may be associated
•
with gangrene, ischaemic ulceration or rest pain and warrants urgent
referral for a vascular opinion.
Other modalities used to diagnose PAD are post-exercise ABPI, tread-
mill testing, pulse oximetry and near-infrared spectroscopy.
CLASSIFICATION OF PAD
The Rutherford classification is similar to the Fountaine classification and
can be used as a clinical means to describe peripheral arterial disease
(Table 2). They are useful for standardised communication among prac-
titioners.
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CONCLUSION
Because of the effect of PAD on the lower extremities and its associa-
tion with elevated risk of cardiovascular and cerebrovascular events
in people with diabetes, its early detection is essential. Initiation
of a screening protocol in patients at high risk, such as those with
diabetes, by taking a thorough history, recording deficit pulses and
performing an ankle–brachial pressure index test may improve the
diagnosis, enable early risk intervention and improve the outcome in
patients with PAD.
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Table 2.
Comparison of two systems of classification of PAD.
Rutherford’s categories of PAD
Fountaine stage classification
of PAD
Grade Category
Clinical
description
Stage Clinical findings
0
0
Asymptomatic
I
Asymptomatic,
decreased pulses,
ABPI < 0.9
I
1
Mild claudi-
cation
II
Intermittent clau-
dication
I
2
Moderate
claudication
III
Daily rest pain
I
3
Severe claudi-
cation
IV
Focal tissue
necrosis
II
4
Ischaemic rest pain
II
5
Minor tissue loss
III
6
Major tissue loss