Peripheral arterial disease and the hospitalist: The rationale for early detection and optimal therapy

Peripheral arterial disease (PAD) is defined by the presence of stenosis or occlusion in peripheral arterial beds. Based on large population-based screening surveys, the prevalence of this disease ranges between 5.5% and 26.7% and is dependent on age, atherothrombotic risk factors, and the coexistence of other atherothrombotic diseases. Symptoms of PAD include mild to intermittent claudication, ischemic rest pain, and tissue loss. Disease severity is classified according to either Fontaine’s stages or Rutherford categories. These categorization schema have value in improving communication between physicians, which is important in ensuring continuity of care between the inpatient and outpatient settings (Table 1). Patients with PAD are at increased risk of dying from or experiencing a cardiovascular event. – 8 Among patients diagnosed with PAD, coronary artery disease (CAD), or cerebrovascular disease (CVD), those with PAD have the highest 1-year rate of cardiovascular death, MI, stroke, or vascular-related hospitalization (Fig. 1). This risk is attributable in part to the high rate of association of PAD with other atherothrombotic diseases. The Reduction of Atherothrombosis for Continued Health (REACH) Registry found that approximately 60% of participants with documented PAD have polyvascular disease, defined by the coexistence of CAD and/or CVD. In comparison, 25% of participants with CAD and 40% of participants with CVD have polyvascular disease. Thus, PAD can be considered a powerful indicator of systemic atherothrombotic disease and a predictor of cardiovascular and cerebrovascular morbidity and mortality. Unfortunately, asymptomatic PAD is more common than its symptomatic counterpart. In addition, symptomatic patients often fail to notify their physicians about PAD-associated symptoms because they attribute them to aging. 4 As a result, this disease is underdiagnosed and undertreated. Accordingly, several medical associations and physician task forces have called for an increase in screening for PAD in at-risk populations that include: patients older than 70, patients older than 50 who have concomitant atherothrombotic risk factors, and patients with atherothrombotic disease of single or multiple vascular beds. In many cases hospitalists encounter patients at high-risk for PAD whose DRG for admission might be unrelated to this disease. Nonetheless, hospitalists have the opportunity to improve patient outcomes by being capable of screening for undiagnosed PAD and initiating B R I E F R E P O R T