Letters to the Editor
Letters to the Editor. The Elderly and Peripheral Arterial Disease
The Elderly and Peripheral Arterial Disease
To the Editor,
When I read the article “The Elderly and Peripheral Arterial Disease” by Na and colleagues1 from the July 2011 issue of Clinical Geriatrics, I saw no reference to palpating for peripheral pulses, such as the femoral, dorsalis pedis, and posterior tibial. Whatever happened to these as part of evaluating the arterial peripheral circulation? Is this another instance where the physical examination has been taken over completely by technology? I do not, however, dispute the importance of the confirmation of clinical findings with the use of technology.
Leon Fay, MD
Dr. Fay is a family physician who recently retired from practice at a community health center in Lawrence, MA. He currently teaches by adjunct appointment at Tufts University School of Medicine, Boston, MA.
The author reports no relevant financial relationships.
1. Na CR, Wang S, Kirsner RS, Federman DG. The elderly and peripheral arterial disease. Clinical Geriatrics. 2011;19(7):41-46.
The authors respond:
We certainly agree with the underlying premise and sentiment expressed by the letter writer, since the history and physical examination—the importance of which is inculcated early in one’s medical infancy—is one of the pillars upon which the physician-patient dyad is based. While we regret not emphasizing examining peripheral pulses in patients suspected of having vascular disease, we must be cognizant of some caveats. The absence of pedal pulses tends to overdiagnose peripheral arterial disease (PAD), as 2% of the population lack dorsalis pedis pulses and 0.1% lack posterior tibial pulses as normal anatomic variants.1 Similarly, normal distal pulses at rest do not exclude the diagnosis of PAD. The addition of exercise to a noninvasive assessment increases the sensitivity of detection. Furthermore, with respect to the history, the sensitivity of “classic” claudication is low and the majority of those with PAD are either asymptomatic or have atypical symptoms.2 Those limitations aside, we do endorse full utilization of our clinical skills, and these include a thorough history and physical examination.
Daniel G. Federman, MD
Chang R. Na, MD
Steven Wang, MD
Robert S. Kirsner, MD, PhD
Drs. Federman, Na, and Wang are from the Yale University School of Medicine, New Haven, CT. Dr. Federman is also from the Department of Medicine, VA Connecticut Healthcare System, West Haven. Dr. Kirsner is from the Department of Dermatology, Miller School of Medicine, University of Miami, FL.
The authors report no relevant financial relationships.
1. McGee SR, Boyko EJ. Physical examination and chronic lower-extremity ischemia: a critical review. Arch Intern Med. 1998;158(12):1357-1364.
2. Federman DG, Kravetz JD. Peripheral arterial disease: diagnosis, treatment, and systemic implications. Clin Dermatol. 2007;25(1):93-100.