The Correlation between Symptoms and Non-Invasive Test Results in Patients Referred for Peripheral Arterial Disease Testing

Abstract

The WHO/Rose questionnaire has served as the epidemiologic and clinical standard in the assessment of leg pain in patients with peripheral arterial disease (PAD) for over three decades. However, the structure of this questionnaire does not allow assessment of leg-specific (i.e. right versus left) symptoms. We studied 508 patients aged 39-95 years (mean 68 years), initially referred for PAD non-invasive testing. A revised questionnaire, the San Diego Claudication Questionnaire, was administered which allowed determination of leg-specific symptoms and evaluated thigh and buttock as well as calf pain. Leg-specific symptoms were categorized into no pain, pain at rest, non-calf claudication, non-Rose calf claudication, and Rose claudication. At the same visit, the ankle brachial index, the toe brachial index, and peak posterior tibial flow velocity were measured by Doppler ultrasound and five categories of non-invasive results by type and severity of PAD were defined. Legs with previous intervention (Rx), surgery or angioplasty, were evaluated separately. Claudication was reported in 42% of no Rx legs and 50% of Rx legs; 40% of claudication was atypical (not Rose); 64% of no Rx and 81% of Rx legs had PAD by non-invasive testing, and 27% of affected legs had severe PAD. The correlation between the severity of symptoms and the severity of ipsilateral PAD in no Rx legs was r = -0.40, p < 0.001. In Rx legs, this correlation was somewhat less (r = 0.27, p < 0.001) due to more symptomatology at lesser degrees of PAD, suggesting reporting bias and/or more residual disease than evident from non-invasive testing. To our knowledge, these results provide the first comparison between a standardized assessment of leg pain and the severity of ipsilateral PAD by non-invasive testing.

Automated oscillometric determination of the ankle-brachial index: a systematic review and meta-analysis

“…Notably, in two studies, the diagnostic ability of the oscillometric method was improved when the erroneous oscillometric measurements were considered to be indicative of an abnormal ABI. 19,43 Oscillometric vs. Doppler method The diagnostic ability of the oscillometric method in assessing the ABI was investigated by applying the following criteria: (i) oscillometricDoppler ABI differences, (ii) oscillometric-Doppler ABI correlations and (iii) sensitivity and specificity in diagnosing PAD using Doppler as the reference method. An interesting finding in these analyses is that the oscillometric ABI values were slightly higher than the Doppler ABI values.…”

“…However, this method is likely to be more cost-effective than the Doppler method because, as mentioned above, it is faster to perform 14,19,21 and requires less training. 19,48 Although the Doppler measurement of ABI is considered to be the reference method, 43 its outcome cannot always be trusted because it is often not well performed, leading to an unreliable diagnosis. 48,49 As ABI measurement is usually not performed on a routine basis, there is a lack of experience in the general practitioner setting.…”

Leg symptoms, the ankle-brachial index, and walking ability in patients with peripheral arterial disease

“…At the study visit participants were administered a medical history questionnaire and the San Diego intermittent claudication questionnaire. 9 All participants underwent ABI measurement.…”

“…9 Patients were classified into the following four symptom categories 9 : absence of exertional leg symptoms; classic Rose intermittent claudication (Rose claudication); exertional leg symptoms, which also occur at rest (pain at rest); and exertional leg symptoms not consistent with either Rose claudication or pain at rest (atypical exertional leg pain). Classic Rose intermittent claudication is exertional calf pain that resolves within 10 minutes of rest and does not begin at rest.…”

Oscillometric measurement of the ankle-brachial index

“…By convention, the ABI is the ratio of the highest systolic pressure at the ankle to the highest systolic pressure measured in the arms (3). A ratio of 0.9 or lower by Doppler ultrasound confirms 50% or greater stenosis in one or more major vessels with 95% sensitivity and 100% specificity (4,5). However, this relatively simple calculation is rarely performed in the office because of a lack of equipment, the time required to do the procedure and the technical difficulties involved in making the measurements.…”