Introduction

An estimated 8–10 million adults in the United States (US) over 40 years-old are diagnosed with PAD.1–5 Lower extremity peripheral artery disease (PAD) is a common atherosclerotic cardiovascular disease (ASCVD) involving the aortoiliac, femoropopliteal, and infrapopliteal arterial segments. While several non-atherosclerotic etiologies of PAD exist (eg, vasculitis, entrapment syndrome, cystic adventitial disease), overwhelmingly atherosclerotic PAD is most common. Multi-disciplinary care is a hallmark of PAD management, including both medical and surgical specialties along with the cardiovascular (CV) team (Central Figure). Unfortunately, PAD remains an underdiagnosed and undertreated condition associated with significant morbidity and mortality that could be prevented with early detection and initiation of medical therapies. The aim of this work is to outline and leverage the role of the CV team in the diagnosis of PAD.

Peripheral Artery Disease Awareness

The ankle-brachial index (ABI) is a simple, noninvasive measure of systolic blood pressures at different levels of the arms and legs in the supine position using a Doppler device and is a key detection tool in the diagnosis of PAD.6 In a meta-analysis of ~48,000 individuals in the US, an ABI ≤ 0.9 was associated with triple the risk of all-cause death compared with ABIs of 1.11–1.40.7,8

The relative morbidity, mortality, and quality of life impact associated with PAD present a significant burden of disease and associated strain on the healthcare system. Unfortunately, population- and clinician-level awareness of PAD, associated complications, and optimal medical therapy (eg, antiplatelet, statin) remain historically low.1,9–12 Surveys of primary care practices have demonstrated low identification of PAD despite low ABI results.9,12 This results in less use of optimal medical therapy and involvement of the CV team, despite guidelines demonstrating improved outcomes with early medical optimization.6 As a result, patients often adjust their lifestyle to avoid or manage symptoms, in comparison to coronary artery disease.11

PAD Amongst High-Risk Populations

Guidelines recommend ABI testing to establish the diagnosis of PAD in patients with history of physical exam findings suggestive of PAD. This includes patients with claudication, nonjoint-related exertional lower extremity symptoms, ischemic rest pain, history of lower extremity ulcers, or erectile dysfunction.

PAD prevalence is similar between sexes. However, an aging population whose life expectancy is longer in women as compared to men, the burden of disease disproportionately impacts women in the US aged ≥40. When women experience PAD, they are more likely to have atypical symptoms and less likely to have ideal cardiovascular health. As a result, they experience worse outcomes even after revascularization, likely because of delayed diagnosis and undertreatment of medical risk factors.13

Health disparities or preventable differences are also noted by one’s race and ethnicity. Non-Hispanic Black adults have the greatest risk of PAD while Hispanic adults have the same, if not slightly lower, rate of PAD compared with their non-Hispanic White counterparts. This similar-to-lower rate of PAD among Hispanic adults is somewhat counterintuitive given the higher prevalence of risk factors that lead to PAD, particularly diabetes.1 First and foremost, it is important to highlight that the concept of race and ethnicity is a social construct, not rooted in biology, and but governed by inequities in society as a factor of the social determinants of health (SDOH).14 Therefore, excess PAD prevalence among Black people cannot be explained by traditional risk factors alone. As Black Americans, they are not only more likely to have PAD than other racial and ethnic groups, but tend to present with more severe disease, have more atypical symptoms, and are more likely to suffer worse outcomes. Specifically, they less often undergo limb salvage therapy and more often are referred for limb amputation and thus are more likely to die from major CV events.14,15

Detection and Diagnosis

PAD is often asymptomatic in mild cases, becoming more symptomatic with progression to moderate or severe. Through a careful history and physical (H&P) examination, signs and symptoms of PAD can be detected as well as risk factors outlined in the guidelines (Table 1).6

Table 1 Pertinent Questions When Detecting for Peripheral Artery Disease

After the H&P exam, diagnostic studies can be ordered to provide quantifiable evidence of PAD. Arterial physiologic testing is a great tool to aid the diagnosis, providing a clear objective evaluation. Testing is also useful in the determination of the extent of arterial disease (Table 2).16

Table 2 Peripheral Artery Disease Testing Modalities6,16–22

Cardiovascular Team in Disease State Management

A key strategy in addressing health inequity related to PAD detection is engagement of the CV team (Table 3).23,24 Within the realm of PAD, multiple members of the team are capable to assist in PAD diagnosis.6,19,23–31 Specifically, the American Heart Association (AHA) states that ABI testing should be performed by qualified individuals through the following principles.1) Measurement and interpretation of the ABI should be within standard curriculum for medical and nursing students, and 2) all allied health professionals, beyond nursing and physicians, who perform the ABI should have didactic and experiential learning under a qualified healthcare professional to perform the ABI.32 In the team-based model, having multiple members of the team who can perform or recommend an ABI, throughout the care continuum, expands accessibility for PAD detection with potential to increase diagnosis and management.

Table 3 The Various Roles of the Cardiovascular Team in the Detection & Diagnosis of Peripheral Artery Disease

The role of the CV team in PAD diagnosis, with a focus on recommending, ordering, and interpreting ABI testing, can occur in three settings: 1) inpatient 2) outpatient 3) community (Figure 1). In terms of inpatient, all members of the CV team should assess patients for PAD risk to determine the need for diagnostic testing and/or follow-up as outlined in the ACC/AHA guideline on the management of lower extremity of PAD.6,17 Patients admitted to the hospital are seen by various members of the CV team who have the capability of performing an assessment and coordinating follow-up including allied professionals with a specialized training to assist with assessment, diagnosis, and transition of care management. Advanced practice clinicians bring a high-level, advanced CV skills in accordance with the minimum competencies set by CV organizations.29 Pharmacists within these CV specialties obtain post-graduate specialty residency accreditation, board certification, and provide direct care through comprehensive medication management.31

Figure 1 The Collaboration of Cardiovascular Team Members for Peripheral Artery Disease Management at Each Phase of Care.

In the outpatient setting, there are a multitude of clinicians in various locations that should be engaged in PAD assessment and ABI testing. A policy for CV team involvement in PAD diagnosis should include outlining the assurance of competency, outlining roles and expectations, and process for ordering specific testing or collaborative management protocols (recommending supervised exercise therapy, initiating pharmacotherapy, tobacco cessation).29,31 Beyond the traditional clinic space, there are numerous other sites with CV team members that should be engaged in PAD detection and diagnosis. Often patients who are referred to wound care clinics may have foot-related ulcer and undiagnosed PAD.19 Exercise physiologists are engaged with patients enrolled in workout programs.19 In these programs and clinics, signs and symptoms of PAD are noticed and ABI testing ordered. Lastly, an even more underutilized resource are pharmacists who exist both in clinics and community-based pharmacies. Pharmacists, one of the most accessible healthcare clinicians, are in a unique position to increase detection and implement treatment for PAD.33 The training of these accessible professionals to identify PAD symptoms and risk factors, and then mitigate ABI referrals has been proven to be effective and should be expanded upon.33 CV team members offer an effective and cost-conscious approach to improving PAD diagnosis and treatment for this highly morbid and under-treated condition.

Lastly, all members of the CVT should be engaged in community outreach. When healthcare access is improved for patients within their own communities, diagnosis and management improves.34,35 Having trained, competent-based healthcare clinics working with trusted members of varying communities to provide detection should be best practice. CV team members should be instrumental in increasing access to ABI testing in a wide range of clinical settings.

While the importance of having a diverse array of clinicians who are competent in detection and/or diagnosis, the additional benefit of CV team engagement in the management of PAD should be acknowledged. Within the cardiovascular realm, there are exhaustive examples of how team-based care improves outcomes, patient satisfaction, and reduces clinician burnout.25 The utility of the various CV team members’ knowledge base may allow for better navigation through resources for patients to obtain treatment, address barriers, and provide detailed education. As such, the detection, identification, and management of PAD patients should be incorporated early into the various healthcare curricular programs.

Conclusion

CV team members could improve the diagnosis and medical management of PAD patients. Given the heterogeneous nature of CV team roles, specific opportunities to improve PAD diagnosis and treatment will differ between clinician and within each system. Nonetheless, we should empower CV team members to 1) recognize patients with risk factors, signs, and symptoms of PAD; 2) facilitate early diagnostic testing for PAD; and 3) discuss appropriate medical management with their clinical colleagues. PAD awareness, detection and management should be an emphasis in the training of all CV team members. For vulnerable populations to underdiagnosis and undertreatment, leveraging each CV team member to assist with diagnosis and medical management of PAD is paramount.

Society Endorsements

The following organizations have reviewed and endorsed this document, recognizing the critical role of the cardiovascular team in peripheral artery disease detection and diagnosis. Furthermore, they believe that the involvement of multidisciplinary CV team members including nurses, pharmacists, and advanced practice providers will lead to improved outcomes and reduced disparities for patients with PAD:

American Association of Colleges of Pharmacy

American College of Cardiology Cardiovascular Team Section

American College of Clinical Pharmacy Cardiology Practice and Research Network

Anticoagulation Forum

Society for Vascular Medicine

Society for Vascular Nursing.

Acknowledgments

The Anticoagulation Forum supported the development of this manuscript.

Funding

Funding was provided to the Anticoagulation Forum through an unrestricted educational grant from Janssen Pharmaceuticals, Inc. The content was developed independently by the authors. Janssen was not involved in the development, revision, or decision to publish this manuscript.

Disclosure

Dr Barnes provides consulting for Pfizer, Bristol-Meyers Squibb, Janssen, Bayer, Boston Scientific, AstraZeneca, Sanofi, Anthos, Abbot Vascular and serves on the Board of Directors of the Anticoagulation Forum. The remaining authors report no conflicts of interest in this work.

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