Peripheral vascular disease in patients with symptomatic cerebrovascular ischemic events. Is there a need for routine screening?

Atherosclerosis is a systemic disease affecting cardiac, cerebral and peripheral arteries. Patients with known PAD have a 15–35% increased risk of having significant (>50%) concurrent internal carotid artery stenosis. The opposite correlation has not been established, but would be of clinical benefit, since the presence of known PAD increases the risk of death from stroke to 2–5 times that of the general population. Patients with concurrent symptomatic ischemic cerebrovascular disease and PAD may represent a particularly high-risk group, and the presence of PAD may directly influence management decisions such as the choice of antiplatelet therapy.

The objective of this preliminary pilot study was to assess patients with ischemic cerebrovascular events for the presence of PAD using a standardized questionnaire and ankle brachial index (ABI) measurements. Demographic information, traditional stroke and vascular disease risk factors and current medical therapy were obtained. Results of routine stroke evaluation (neuroimaging, echocardiography, carotid and transcranial Doppler and laboratory evaluations) were documented. Individuals were interviewed for presence of PAD symptoms using the WHO/Rose questionnaire. Standard criteria for interpretation of ABI measurements were applied.

Sixty-nine inpatients, ages 33 to 97,were included. Fifty-six patients had TIA or stroke, 6 had an intracranial hemorrhage and 7 had other medical conditions. 44.6% of those with cerebrovascular ischemic events had PAD based on ABI measurements. Only 20% of those had a previously known or documented history of PAD. An additional 24% had symptoms suggesting PAD per WHO/Rose questionnaire. Thus, 56% of patients with cerebrovascular disease and abnormal ABIs were asymptomatic regarding their PAD. All of those fulfilled criteria for mild or moderate arterial obstruction by ABI criteria. Patients with severe obstructive PAD were all symptomatic.

Although this is a limited pilot study with a small study population, the data suggest that PAD in patients with symptomatic ischemic cerebrovascular events is present with a much higher rate than expected. PAD in these patients is often asymptomatic and is frequently overlooked. The results suggest that patients with stroke or TIA should routinely be screened for PAD, the presence of which may indicate that these patients are at increased risk for recurrent stroke.