1. Amjad AlMahameed, MD, MPH Division of Cardiology Beth Israel Deaconess Medical Center Boston Differentiating Lower Extremity Pain: Arteries, Veins, and Nerves! The Value of the ABI

2. Objectives Review the differential diagnosis of lower extremity dysfunction Beyond intermittent claudication: Recognize the different clinical presentations of PAD PAD as the cause of symptoms: Reflect on clinical evaluation

3. HTN 50 million Stroke 4.4 million CHF 4.6 mill Heart 16.8 million AMI 7.2 mill Angina 6.3 mill 68 Million Americans with CVD PAD 8.4 million PAD incidence expected to rise by 40% (M) and 15% (W) till 2030

4. Musculoskeletal Causes: - Arthritis (lumbar disk, hip, knee) - Bursitis - Tendonitis - Tight hamstring/quadriceps Neurogenic Causes - Lumbar canal stenosis - Peripheral neuropathy Podiatric Causes: - Planter fasciitis - Tarsal Tunnel Syndrome Other Vascular: - Venous claudication - Takayasu’s, giant cell vasculitis - Thromboangiitis obliterans - Chronic Pernio D Dx of Leg Pain

5. PADVenous Claudication Neurogenic Claudication Locationmuscle groupwhole legPoorly localize Quality of painCramping“Bursting”Electric shock-like OnsetGradual, predictable Variable ExacerbationWalking, biking, leg elevation Dependency (sitting, standing), walking, biking Standing, walking, lying prone, exten- ding lumbar spine ReliefStopping or standing Leg elevation, compression Rx Sitting, flexing lumbar spine Legs affectedUsually one Often both Are the Limb Symptoms Related to PAD?

6. Intermittent Claudication Predictable Leg pain induced by walking Relief with resting (stopping/standing) Recurs when walking is resumed Classic triad of symptoms in patients with IC is seen in (11-33%) of all PAD pts

7. Normal Fatigue, heaviness MildModerateSevere Rest pain Poor wound healing Impending or overt gangrene ClaudicationLimb-Threatening Ischemia Worsening Flow Limitation Spectrum of Peripheral Arterial Disease Presentation Pain Soreness Ache Weakness Tiredness Numbness Tightness Discomfort

8. Indications for the ABI Non palpable pulses Unexplained leg pain Rest pain Non healing sores or ulcers Claudication Risk stratification

9. ABI is 95% sensitive and 99% specific for PAD A/B IndexSEVERITY OF DISEASE 0.9 – 1.0Normal 0.70 – 0.89Mild disease 0.40 – 0.69Moderate disease < 0.40Severe disease Lower extremity systolic pressure ____________________________________________ Brachial artery systolic pressure ABI =

10. 180 mmHg 170 mmHg 130 mmHg180 mmHg 170 mmHg R DP 130 mmHg R PT 110 mmHg ABI 0.72 R DP 180 mmHg R PT 180 mmHg ABI 1.0 R transmit R Toe L transmit L Toe Post Exercise R AnkleL Ankle Higher R-Ankle SBP Higher Arm SBP Right ABI Higher R-Ankle SBP Higher Arm SBP Left ABI

11. Usefulness of the ABI Diagnosis, localization, and monitoring PAD progression Assess functional capacity (even asymptomatic pts) Predictor of cardiovascular morbidity and mortality

12. PAD Survival as a Factor of the ABI Year 100 80 60 40 20 0 10 8 6 4 2 Patients Survival (%) ABI >0.85 ABI 0.40–0.85 ABI <0.40 McKenna M, et al. Atherosclerosis. 1991;87:119-128.

13. PAD and Functional Impairment Peripheral arterial disease (PAD) is associated with –Poorer walking endurance –Slower walking speed –Poorer balance Compared to individuals without PAD Limited leisure and Work activities Olin JW. AM J Med 10-17,1998. Scherer SA. Arch phys Med Rehab 79:529-531,1998 Regensteiner JG. J Vasc Med Biol2:142-152,1990

14. McDermott M et al. JAMA 2004; 292:453-461. OutcomeAsymptomatic PAD Without PAD p Mean annual decline in 6- minute walk performance (ft) (95% CI) - 76.8 (- 135 to - 18.6) - 8.67 (-36.9 to -19.5) 0.04 Walking Performance in Asymptomatic Peripheral Arterial Disease

15. Clinical Tips The DP pulse is congenitally absent in up to 32% of normal individual but the absence of PT pulse is always abnormal Lack of hair on the shins is not always a sign of PAD Patients with rest pain may present with pitting edema Persistence of pallor > 40 second after 1 minute elevation is indicative of severe disease

16. PAD is NOT the Cause of Leg Symptoms if: History and physical exam not suggestive Normal rest ABI and treadmill exercise testing Presence of alternative diagnosis In this process, you may also obtain spine MRI, X-rays of the hips and knees, and even EMG/NCS