Response to Letter Regarding Article, “The United States Preventive Services Task Force Recommendation Statement on Screening for Peripheral Arterial Disease: More Harm Than Benefit?”
We thank Drs Calonge and Petitti for their letter regarding our article.1 However, we remain concerned about the lack of precision in the task force’s position. The recommendation statement on screening for peripheral arterial disease (PAD)2 suggests that:
The USPSTF found fair evidence that screening with ankle brachial index can detect adults with asymptomatic PAD. The evidence is also fair that screening for PAD among asymptomatic adults in the general population would have few or no benefits because the prevalence of PAD in this group is low and because there is little evidence that treatment of PAD at this asymptomatic stage of disease, beyond treatment based on standard cardiovascular risk assessment, improves health outcomes [emphasis added] [p 1].
The letter by Drs Calonge and Petitti reiterates the same point by reporting that the “intention of the USPSTF recommendation was clear: It was intended only to address PAD screening to improve the health outcomes for PAD.” We would agree that a screening ankle brachial index measurement in asymptomatic patients would not reduce adverse leg outcomes for PAD. However, we would include myocardial infarction, stroke, and death as health outcomes for PAD. This single word substitution, “health” rather than “leg,” forms the basis for misunderstanding by practitioners.
PAD affects more than 15% of the population >70 years of age and a substantial proportion of those who have smoked or have diabetes.3 Cardiovascular event rates are higher in people with abnormal ankle brachial index, independently of risk factors such as high cholesterol, diabetes, and smoking.4 PAD is atherosclerosis, not a risk factor for atherosclerosis. Therefore, detecting atherosclerosis in an asymptomatic patient may prompt physicians to intensify their treatment strategies, such as lowering low-density lipoprotein cholesterol to <100 mg/dL or prescribing aspirin independently of extant risk factors.5,6
We wish to be specific: Screening asymptomatic adults will not lower the rates of intermittent claudication, critical-limb ischemia, or amputation. Targeted screening of adults, as made clear in our editorial, is likely to reduce heart attack, stroke, and death in patients with asymptomatic PAD, and these are important health outcomes.
Beckman JA, Jaff MR, Creager MA. The United States preventive services task force recommendation statement on screening for peripheral arterial disease: more harm than benefit? Circulation. 2006; 114: 861–866.
United States Preventive Services Task Force. Recommendation Statement: Screening for Peripheral Arterial Disease. Washington, DC: Agency for Healthcare Research and Quality; August 9, 2005.
Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999–2000. Circulation. 2004; 110: 738–743.
Wild SH, Byrne CD, Smith FB, Lee AJ, Fowkes FG. Low ankle-brachial pressure index predicts increased risk of cardiovascular disease independent of the metabolic syndrome and conventional cardiovascular risk factors in the Edinburgh Artery Study. Diabetes Care. 2006; 29: 637–642.
National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002; 106: 3143–3421.
Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM Jr, White CJ, White J, White RA, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. 2006; 113: e463–e654.