Cardiovascular Disability Updating the Social Security Listings (2010) / Chapter Skim
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8 Peripheral Artery Disease
8 Peripheral Artery Disease
Pages 133-156
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From page 133... ...
also, for consistency with other listings, the functional limitation for Pad should be the same as that defined for the musculoskeletal system, that is, inability to ambulate effectively. DESCRIPTION Peripheral artery disease1 (PAD)
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prevalence, that included NHANES findings diseases in 2008, including the use of the term peripheral artery disease in place of peripheral arterial disease or peripheral vascular disease (Hiatt et al., 2008a)
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. Short of situations in which revascularization is being considered, the ACC/AHA guidelines indicate that "Patients with vascular disorders can usually be assured that an accurate anatomic diagnosis will be made with modern noninvasive vascular diagnostic techniques (e.g., ankle- and toe-brachial indices, segmental pressure measurements, pulse volume recordings, duplex ultrasound imaging, Doppler waveform analysis, and exercise testing)
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From page 136... ...
. Studies of the sensitivity, specificity, and accuracy of the ABI as a tool to diagnose peripheral artery blockage of 50 percent or more, using contrast angiography as the standard, have found that the ABI has a sensitivity of 72 to 95 percent, specificity of 96 to 100 percent, positive predictive value of 90 to 100 percent, negative predictive value of 96 to 99 percent, and overall accuracy of 98 percent (Hirsch et al., 2006)
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. A case-control study of 56 men with stable claudication and toe pressures less than 40 mm Hg found that 34 percent progressed to rest pain, ulceration, or gangrene over 31 months, compared with 9 percent of age-, sex-, and race-matched controls, and that those with diabetes had the highest incidence of deterioration (Bowers et al., 1993)
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. Other Diagnostic Methods Other noninvasive, inexpensive, and relatively safe diagnostic methods that provide diagnostic discrimination include segmental pressure measurements, pulse volume recordings, duplex ultrasonography, Doppler waveform analysis, and ABI after exercise testing (Hirsch et al., 2006)
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, although clinicians previously accepted the idea that they should aggressively treat PAD symptoms to reduce functional loss, increase quality of life, and decrease rates of amputation. Also well recognized was the idea that aggressive risk factor modification was needed to lower the incidence of cardiovascular events, especially heart attack and stroke, stemming from the systemic atherosclerosis that a diagnosis of PAD strongly signals (Belch et al., 2003)
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. • Many studies have shown that supervised exercise training doubles pain-free walking distance and maximal walking time on average (Hirsch et al., 2007; Watson et al., 2008)
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PAD results in reduced blood flow to the muscles and nerves of the lower extremities. In advanced cases, the reduced flow of blood can cause muscle pain, weakness, and numbness when an individual walks or even,
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. PAD and Functional Limitation In the absence of research on the predictors of employment of those with PAD, its impact on functions that are plausibly related to work, such as exercise tolerance or ability to walk a certain distance or speed, must serve as proxies for work disability.
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CURRENT LISTING The listing for PAD requires the existence of intermittent claudication plus specified test results based on ankle or toe blood pressure readings (Box 8-1)
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. The inclusion of toe pressures addressed the fact that the ankle blood pressure readings are not a valid measure of PAD in individuals with abnormally stiff ankle arteries because of medial arterial calcification or other causes.
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. • 4.00G5 ("When will we purchase exercise Doppler studies for evaluating peripheral arterial disease?
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The committee also recommends some clarifications in and medical updates of listing 4.12. Appropriate PAD Diagnostic Techniques Listing 4.12 currently requires a diagnosis of PAD based on "appropriate medically acceptable imaging," which is defined in the introductory section to the cardiovascular system listings as a technique to diagnose and evaluate PAD that is widely accepted as accurate by the medical community.5 The ACC/AHA PAD guidelines list a number of acceptable methods for diagnosis besides the ABI, including duplex ultrasound imaging, Doppler waveform analysis, CTA, MRA, and contrast angiography (Hirsch et al., 2006)
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. 6 "If you have peripheral arterial disease, you may have pain in your calf after walking a dis tance that goes away when you rest (intermittent claudication)
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An ABI less than 0.40 is the point at which critical leg ischemia becomes a danger, potentially requiring an endovascular or surgical intervention soon, if not immediately, to prevent gangrene and amputation. Virtually everyone with this ABI score has severe leg pain and substantial muscle weakness, severely limiting mobility and stamina.
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From page 149... ...
These include the TBI, Doppler waveforms, duplex ultrasonography, MRA, CTA, contrast angiography, and graded treadmill tests. The basis for this change is the relative lack of evidence that toe pressures or changes in ankle pressure during exercise are predictive of functional status.
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. For consistency within the Listings, the committee recommends that SSA apply the same standard in evaluating PAD (see Recommendation 8-1f, below)
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Current criteria B, C, and D in listing 4.12 should be replaced by a new criterion B that an appropriate test or tests be consistent with severe PAD, when the ABI is 0.50 or greater or there is evidence of medial calcification of the ankle arteries. These tests should include the toe-brachial index, Doppler wave forms, duplex ultrasonography, magnetic resonance angiography, computed tomography angiography, contrast angiography, and graded treadmill tests.
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2003. Critical issues in peripheral arterial disease detection and management: A call to action.
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2006. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic)
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1998. The ankle brachial index independently predicts walking velocity and walking endurance in peripheral arterial disease.
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2005. Atherosclerotic risk factor control in patients with peripheral arterial disease.
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