Physical examination to screen for peripheral artery disease in a defined Primary Care population: A diagnostic...

Peripheral arterial disease (PAD) is an underdiagnosed prevalent disease which implies high cardiovascular risk. Professionals usually depend on physical examination to screen for PAD.

To assess the diagnostic accuracy of physical examination to screen for PAD in a rural Primary Care population and to evaluate the nurse-physician level of agreement in pedal pulse palpation.

Diagnostic accuracy study in which two experienced professionals (physician-nurse) prospectively performed pedal pulse palpation (grading as absent, reduced, normal, or bounding), femoral bruit auscultation and calf circumference (index tests) comparing with Doppler ABI (reference test, positive cut-off: 0.9 ≥ ABI ≥ 1.4) in 158 consecutive subjects.

presence of diabetes, dyslipidaemia, hypertension, smoking habit (current or former), or age ≥ 65.

Of 315 legs included, PAD was confirmed in 38 (12.1%) legs. Absent dorsalis pedis (DP) and posterior tibial (PT) pulses were found in 37 (11.7%) and 67 (21.3%) legs, respectively. Regarding nurse evaluation, when a positive test was set if DP or PT were absent (more sensitive cut-off), sensitivity was = 86.8 (95% CI: 74.8-98.9), specificity = 82.7 (95% CI: 78.0-87.3), likelihood ratio+ = 5.01 (95% CI: 3.77-6.67), likelihood ratio- = 0.16 (95% CI: 0.07-0.36), and diagnostic odds ratio (dOR) = 31.5 (95% CI: 11.7-84.8). Age, diabetes, and calcification (ABI ≥ 1.4) influenced the rate of a false negative finding in pedal palpation. Physician-nurse weighted kappa coefficient was = 0.649 (95% CI: 0.599-0.699). The presence of a femoral bruit auscultation had a dOR = 3.8 (95% CI: 1.1-13.1), and a calf circumference <34.55 cm had a dOR = 3.2 (95% CI: 1.6-6.4).

In a mainly asymptomatic Primary Care population, pedal pulse palpation was by far the best diagnostic test, with good diagnostic accuracy and inter-rater agreement. In view of a high sensitivity and capacity to rule out the disease, pedal pulse palpation could be performed as a screening test for PAD and individuals at high cardiovascular risk.