0
The Rational Clinical Examination | Clinician's Corner

Does the Clinical Examination Predict Lower Extremity Peripheral Arterial Disease?

Nadia A. Khan, MD, MSc; Sherali A. Rahim, MD; Sonia S. Anand, MD, PhD; David L. Simel, MD, MHS; Akbar Panju, MB, ChB
JAMA. 2006;295(5):536-546. doi:10.1001/jama.295.5.536.
Text Size: A A A
Published online

Context Lower extremity peripheral arterial disease (PAD) is common and associated with significant increases in morbidity and mortality. Physicians typically depend on the clinical examination to identify patients who need further diagnostic testing.

Objective To systematically review the accuracy and precision of the clinical examination for PAD.

Data Sources, Study Selection, and Data Extraction MEDLINE (January 1966 to March 2005) and Cochrane databases were searched for articles on the diagnosis of PAD based on physical examination published in the English language. Included studies compared an element of the history or physical examination with a reference standard of ankle-brachial index, duplex sonography, or angiogram. Seventeen of the 51 potential articles identified met inclusion criteria. Two of the authors independently extracted data, performed quality review, and used consensus to resolve any discrepancies.

Data Synthesis For asymptomatic patients, the most useful clinical findings to diagnose PAD are the presence of claudication (likelihood ratio [LR], 3.30; 95% confidence interval [CI], 2.30-4.80), femoral bruit (LR, 4.80; 95% CI, 2.40-9.50), or any pulse abnormality (LR, 3.10; 95% CI, 1.40-6.60). While none of the clinical examination features help to lower the likelihood of any degree of PAD, the absence of claudication or the presence of normal pulses decreases the likelihood of moderate to severe disease. When considering patients who are symptomatic with leg complaints, the most useful clinical findings are the presence of cool skin (LR, 5.90; 95% CI, 4.10-8.60), the presence of at least 1 bruit (LR, 5.60; 95% CI, 4.70-6.70), or any palpable pulse abnormality (LR, 4.70; 95% CI, 2.20-9.90). The absence of any bruits (iliac, femoral, or popliteal) (LR, 0.39; 95% CI, 0.34-0.45) or pulse abnormality (LR, 0.38; 95% CI, 0.23-0.64) reduces the likelihood of PAD. Combinations of physical examination findings do not increase the likelihood of PAD beyond that of individual clinical findings. However, when combinations of clinical findings are all normal, the likelihood of disease is lower than when individual symptoms or signs are normal. A PAD scoring system, which includes auscultation of arterial components by handheld Doppler, provides greater diagnostic accuracy.

Conclusions Clinical examination findings must be used in the context of the pretest probability because they are not independently sufficient to include or exclude a diagnosis of PAD with certainty. The PAD screening score using the hand-held Doppler has the greatest diagnostic accuracy.

Figures in this Article

Sign In to Access Full Content

Don't have Access?

Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more

Subscribe for full-text access to content from 1998 forward and a host of useful features

Activate your current subscription (AMA members and current subscribers)

Purchase Online Access to this article for 24 hours

Figures

Figure. Normal Arterial Anatomy of the Lower Limb and Positioning for Measurement of Ankle Systolic Pressure Used for Determining the Ankle-Branchial Index (ABI)
Graphic Jump Location

A, Normal arterial anatomy of the right lower limb in anterior view and palpation of the popliteal pulse with the examiner's hands tucked into the popliteal fossa (inset, posteromedial view). B, To obtain ankle systolic pressure for calculating the ABI using the posterior tibial artery (B, top) or the dorsalis pedis artery (B, bottom), the blood pressure cuff is placed above the pulse. The Doppler probe is positioned over the area of the arterial pulse.

Tables

References

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 94

Sign In to Access Full Content

Related Content

Customize your page view by dragging & repositioning the boxes below.

Multimedia Related by Topic
Articles Related By Topic
Related Topics
PubMed Articles
Jobs
JAMAevidence.com

Users' Guides to the Medical Literature
Peripheral Arterial Disease or Peripheral Vascular Insufficiency

The Rational Clinical Examination
Make the Diagnosis: Peripheral Arterial Disease

brightcove.createExperiences();