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Ask the expert: assessment of peripheral vascular disease in primary care

BMJ 2023; 381 doi: https://doi.org/10.1136/bmj.p605 (Published 09 May 2023) Cite this as: BMJ 2023;381:p605
  1. Kosmas I Paraskevas, consultant vascular surgeon1,
  2. Clifford P Shearman, emeritus professor of vascular surgery2
  1. 1Department of Vascular Surgery, Central Clinic of Athens, Athens, Greece
  2. 2University of Southampton, UK
  1. Correspondence to K Paraskevas paraskevask{at}hotmail.com

What you need to know

  • Diagnosis of peripheral arterial disease is based on a history of symptoms of claudication or rest pain, absent peripheral pulses, and a reduced ankle brachial pressure index (ABPI)

  • Around 70% to 80% of patients with leg ulcers have venous disease, which can be diagnosed clinically

  • Patients with vascular claudication often have a reduction in ABPI, whereas ABPI may be normal (above 1.0) in patients with spinal claudication

  • Refer patients who have rest pain along with clinical evidence of peripheral arterial disease with absent pulses and a reduced ABPI urgently to a vascular unit.

Vascular specialists Clifford Shearman and Kosmas Paraskevas provide expert answers to questions from users of BMJ Learning on how to diagnose and assess peripheral vascular disease, both arterial and venous, in primary care.

Test yourself

You see a 54 year old man in your GP clinic. He is obese (BMI 32 kg/m2) and smokes. Three days ago, he noticed pain in his right calf on walking. The pain is now worse and constant, and kept him awake last night. On initial inspection his right leg is slightly swollen to the knee. It looks a normal colour but the forefoot is slightly cool. On the left leg you can palpate all the pulses. On the right side the femoral pulse is present but the popliteal pulse and pedal pulses are absent. An attempt at measuring an ankle brachial pressure index (ABPI) is unsuccessful as you cannot pick up a Doppler ultrasound signal at the ankle.

What do you do next?

  1. Refer the patient urgently to the vascular unit

  2. Ask the patient to return the next day to repeat the ABPI

  3. Review the patient’s medication and see if he is taking a statin

  4. Advise the patient to take some painkillers at home

  5. (answer at end of article).

What is the usefulness of ABPI measurement in primary care?

Venous ulcers respond to compression and elevation, but …

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