The Unnatural History of Peripheral Artery Disease
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Peripheral artery disease (PAD) is widely viewed as either a risk factor for cardiovascular events or a coronary artery disease (CAD) risk equivalent. Both constructs represent a failure to understand atherosclerosis as a unified disease, which has worked to the detriment of patients with PAD by denying them diagnostic and treatment options available to patients who present with atherosclerosis in other vascular beds.
Pad as a Risk Factor
From a pathophysiologic perspective, PAD has long been coupled with the development of lower extremity symptoms resulting from arterial occlusive disease; through this prism, the rationale for diagnosing PAD has been to determine the cause underlying a patient’s symptoms. This pioneer linking of leg symptoms to occlusive disease predates the recognition that atherosclerosis is systemic. As evidence, in 1996, when the US Preventive Services Task Force, a government agency tasked with determining appropriateness of screening tests, evaluated the utility of the ankle brachial index (ABI) in patients asymptomatic for leg complaints, it did so as a means to avoid leg events. Later, once the atherosclerotic link between PAD and CAD became solidified, the Task Force redefined PAD as a risk factor for CAD akin to other cardiovascular risk factors. Ultimately, in its 2013 report, the Task Force evaluated the ABI as a “predictor for other cardiovascular disease (eg, CAD and cerebrovascular disease) and atherothrombotic events such as myocardial infarction (MI), stroke, and death.”1
Although well intentioned, and well within their mandate, US Preventive Services Task Force recommendations on screening for PAD diminished the perceived importance of PAD. Currently, the use of the ABI in screening asymptomatic patients is conflated with its diagnostic use …