Management of peripheral arterial disease in primary care

doi:10.1136/bmj.326.7389.584

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Paul Burns, research fellowa,
Stephen Gough, readerb,
Andrew W Bradbury, professora

^a Department of Vascular Surgery, University of Birmingham, Birmingham B9 5SS
^b Department of Medicine, University of Birmingham

Correspondence to A W Bradbury, University Department of Vascular Surgery, Lincoln House (Research Institute), Heartlands Hospital, Bordesley Green East, Birmingham B9 5SS

Best medical treatment for peripheral arterial disease, including managing hypertension and diabetes, reduces morbidity and mortality and can obviate the need for invasive intervention

One in five of the middle aged (65-75 years) population of the United Kingdom have evidence of peripheral arterial disease on clinical examination, although only a quarter of them have symptoms. The most common symptom is muscle pain in the lower limbs on exercise—intermittent claudication.1 Invasive interventions (angioplasty, stenting, surgery) undoubtedly have a role in the management of peripheral arterial disease. However, in common with coronary artery disease, the morbidity and mortality associated with peripheral arterial disease can be greatly reduced, and the results of intervention significantly improved, by the institution of so called “best medical treatment,” much of which can be implemented in primary care.

Summary points

Diagnosis of peripheral arterial disease is based mainly on the history, with examination and ankle brachial pressure index being used to confirm and localise the disease

Peripheral arterial disease is a marker for systemic atherosclerosis; the risk to the limb in claudication is low, but the risk to life is high

Patients with intermittent claudication should initially be treated with “best medical treatment”; some patients may be candidates for percutaneous angioplasty, but this treatment is not based on evidence

Patients should be referred to a vascular surgeon if there is doubt about the diagnosis or evidence of aortoiliac disease or if the patient has not responded to best medical treatment or has severe disease

Sources and selection criteria

We used Medline to identify recent reviews and articles on the epidemiology, assessment, and treatment of peripheral arterial disease and intermittent claudication, by using the terms “intermittent claudication,” “peripheral arterial disease,” and “peripheral vascular disease.” We also consulted standard textbooks, national and local guidelines, and service frameworks.

Fig 1.

Angiogram showing bilateral femoral artery occlusions in a …