Focused History Components for Peripheral Vascular Disease
A comprehensive focused history for peripheral vascular disease (PVD) must include assessment of symptoms, risk factors, comorbidities, and functional impact to guide appropriate management and reduce morbidity and mortality. 1
Symptom Assessment
Pain Characteristics
- Location: Lower extremities (calf, thigh, buttock, foot)
- Quality: Aching, burning, cramping, discomfort, or fatigue
- Timing: Onset/offset pattern, particularly with activity and rest
- Aggravating factors: Walking, standing, specific positions
- Relieving factors: Rest, position changes (e.g., dangling legs)
- Classic claudication pattern: Pain with exertion that resolves with rest 1
Atypical Presentations
- Leg weakness, numbness, or fatigue during walking without pain
- Particularly important in patients with diabetes and neuropathy
- Rest pain (especially at night) localized to lower leg or foot
- Poorly healing or non-healing wounds of legs or feet 1
Risk Factor Assessment
- Smoking history: Current use, pack-years, quit attempts
- Diabetes: Duration, control, complications
- Dyslipidemia: Previous lipid panels, treatment
- Hypertension: Duration, control, medications
- Family history: PVD, abdominal aortic aneurysm, early cardiovascular disease
- Age: ≥65 years or 50-64 years with risk factors 1
Comorbidity Assessment
- Cardiovascular disease: History of MI, angina, heart failure
- Cerebrovascular disease: Stroke, TIA
- Renal disease: CKD, dialysis
- Erectile dysfunction: Often an early marker of vascular disease
- Previous vascular interventions: Bypass, stenting, angioplasty 1
Functional Impact Assessment
- Walking limitations: Distance before pain onset, total walking distance
- Impact on daily activities and occupation
- Quality of life effects
- Need for assistive devices
- Postprandial abdominal pain (may suggest mesenteric ischemia, especially with weight loss) 1
Medication History
- Current antiplatelet or anticoagulant therapy
- Statin use
- Antihypertensive medications
- Diabetes medications
- Previous claudication treatments (e.g., cilostazol) 1, 2
Common Pitfalls to Avoid
Misdiagnosis with pseudoclaudication: Carefully distinguish vascular claudication from other causes of exertional leg pain such as:
- Severe venous obstructive disease
- Chronic compartment syndrome
- Lumbar disease and spinal stenosis
- Osteoarthritis
- Inflammatory muscle diseases 1
Overlooking asymptomatic disease: Only about 32.6% of PVD patients present with classic intermittent claudication; 20-59% with objectively proven PVD report no leg symptoms despite functional impairment 1
Focusing only on leg symptoms: Remember PVD indicates systemic atherosclerosis with increased risk of MI, stroke, and vascular death 1, 2
Missing coexisting peripheral neuropathy: Particularly in patients with diabetes, neuropathy can mask symptoms of PVD, leading to delayed diagnosis 1
Clinical Pearls
- The presence of both diabetes and PVD significantly increases the risk of progression, particularly in small vessel disease 1, 3
- Hypertension is present in 35-55% of patients with PVD and contributes to atherosclerosis progression 4
- Smoking is strongly associated with large vessel PVD progression, while diabetes more strongly affects small vessel disease 3
- PVD patients have a 3-fold increased risk of MI, stroke, and vascular death compared to patients with intermittent claudication alone 1
By systematically addressing these components in a focused history, clinicians can better identify PVD, assess its severity, and develop appropriate management strategies to reduce both limb-specific and cardiovascular morbidity and mortality.