How should you evaluate an asymptomatic patient with a femoral or ...

CLINICAL INQUIRIES
How should you evaluate
an asymptomatic patient with
a femoral or iliac artery bruit?
Evidence-based answer
Perform an ankle-arm index (AAI, or
ankle-brachial index) test to evaluate for
peripheral artery disease (PAD) (strength of
recommendation [SOR]: B, cohort studies).
If the test detects PAD, recommend steps
to modify cardiovascular risk factors (SOR:
B, extrapolation from randomized clinical
trials [RCTs]).
❚ Evidence summary
PAD affects 7 million to 13 million Americans,
or 3% to 18% of the population.
Major risk factors include smoking, older
age, hyperlipidemia, diabetes mellitus,
obesity, cerebrovascular disease, coronary
artery disease, hyperhomocysteinemia,
and elevated C-reactive protein. 1 PAD
may cause claudication, ulcers, impotence,
or leg or thigh pain, although 20%
to 50% of patients are asymptomatic. 2
Femoral artery bruit
is better predictor of PAD
Further evaluation of an incidental iliac
or femoral artery bruit helps assess the
patient’s risk of arterial disease. Auscultation
of the femoral arteries for a bruit
in asymptomatic patients is a moderately
good predictor of PAD (likelihood
ratio [LR]=4.80; 95% confi dence interval
[CI], 2.40-9.50). The absence of a
bruit doesn’t exclude disease, however
(LR=0.83; 95% CI, 0.73-0.95). 3 Auscultation
of an iliac artery bruit is a more
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Additional vascular diagnostic
evaluation is not indicated, because no
evidence suggests that proceeding with
limb revascularization will improve outcomes
in limb pain or function (SOR: C, expert
opinion). Not enough evidence exists to
recommend routine screening for iliac and
femoral arterial bruits.
modest predictor of disease (LR=2.2, no
CI provided). 4
One study of 78 patients showed
that a femoral or iliac artery bruit accompanied
by either thigh claudication
or an abnormal femoral pulse predicted
PAD. Patients with 2 out of 3 of these
clinical fi ndings had an 83% incidence
of aortoiliac disease; the incidence was
100% in patients with all 3 fi ndings. 5
Another study showed that bruits
between the epigastrium and popliteal
fossa were found in 63% of 309 patients
with arterial disease, but only 7% of 149
patients without PAD diagnosed by AAI
or angiogram. 6
Follow up a bruit with AAI testing
Patients with femoral or iliac artery bruits
should undergo AAI testing to assess the
severity of disease. The AAI has 95% sensitivity
and almost 100% specifi city in
identifying PAD, compared with angiography.
3 An AAI >0.90 is considered normal.
An AAI of 0.71 to 0.90 indicates mild dis-
Evidence Based Answers
from the Family Physicians
Inquiries Network
Katherine M. Walker, MD,
CAQSM
Brent H. Messick, MD, MS
UNC Chapel Hill School
of Medicine, Department
of Family Medicine, and
Cabarrus Family Medicine
Residency Program,
Concord, NC
Leonora Kaufman, MLIS
UNC Chapel Hill,
Department of Family Medicine,
Carolinas Medical Center,
Charlotte, NC
FAST TRACK
A femoral or iliac
artery bruit in an
asymptomatic
patient warrants
evaluation for
peripheral artery
disease with the
ankle-arm index
test.
VOL 58, NO 4 / APRIL 2009 217
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CLINICAL INQUIRIES
ease, 0.41 to 0.70 indicates moderate disease,
and ≤0.40 indicates severe disease.
Manage risk factors aggressively
Although no studies show specifi cally that
modifying risk factors in a patient with
asymptomatic PAD affects long-term
outcomes, aggressive risk factor management
is recommended because PAD is
highly associated with cerebrovascular
and coronary artery disease. 1 No data
suggest that treating asymptomatic PAD
improves future limb pain or function.
Recommendations
The American College of Cardiology/
American Heart Association 2005 Guidelines
for the Management of Patients With
Peripheral Arterial Disease 2 make the following
recommendations for patients with
asymptomatic lower extremity PAD:
• Identify patients with asymptomatic
lower extremity PAD by examination
or by measuring the ankle-brachial index
so therapeutic interventions known to
reduce the risk of myocardial infarction,
stroke, and death can be offered (level of
evidence [LOE]: B).
• Address smoking cessation, lipid
lowering, and diabetes and hypertension
treatment according to national guidelines
(LOE: B).
• Consider antiplatelet therapy to
reduce the risk of adverse cardiovascular
ischemic events (LOE: C).
The United States Preventive Services
Task Force recommends against
routine screening for PAD (D recommendation).
7 ■
Acknowledgments
Special thanks to Felipe Navarro, MD.
References
1. Peripheral Arterial Occlusive Disease. Fpnotebook
[database online]. Available at: http://fpnotebook.
com/SUR3.htm. Accessed January 8, 2008.
2. Hirsch AT, Hazkal ZJ, Hertzer NR, et al. American
College of Cardiology/American Heart Association
2005 practice guidelines for the management
of patients with peripheral arterial disease (lower
extremity, renal, mesenteric, and abdominal aortic):
a collaborative report. J Am Coll Cardiol.
2006;47:1239-1312.
3. Khan N, Rahim SA, Anand SS, et al. Does the clinical
examination predict lower extremity peripheral
arterial disease? JAMA. 2006;295:536-546.
4. McGee SR, Boyko EJ. Physical examination and
chronic lower-extremity ischemia: a critical review.
Arch Intern Med. 1998;158:1357-1364.
5. Johnston, KW, Demorais D, Colapinto RF. Diffi culty
in assessing the severity of aorto-iliac disease by
clinical and arteriographic methods. Angiology.
1981;32:609-614.
6. Carter SA. Arterial auscultation in peripheral vascular
disease. JAMA. 1981;246:1682-1686.
7. US Preventive Services Task Force. Screening for
peripheral arterial disease. August 2005. Available
at: www.ahrq.gov/clinic/uspstf/uspspard.htm. Accessed
February 27, 2009.
READ ABOUT BIPOLAR SPECTRUM DISORDERS
AND EARN 2.5 FREE CME CREDITS
HENRY A. NASRALLAH, MD, PROGRAM CHAIR
Professor of Psychiatry, Neurology, and Neuroscience
University of Cincinnati College of Medicine
Cincinnati, Ohio
DONALD W. BLACK, MD
Professor of Psychiatry
University of Iowa Carver College of Medicine
Iowa City, Iowa
JOSEPH F. GOLDBERG, MD
Associate Clinical Professor of Psychiatry
Mt Sinai School of Medicine, New York, New York
Silver Hill Hospital, New Canaan, Connecticut
DAVID J. MUZINA, MD
Vice Chair for Research & Education
Associate Professor of Medicine
Cleveland Clinic Department of Psychiatry & Psychology
Cleveland, Ohio
STEPHEN F. PARISER, MD
Professor of Psychiatry, Obstetrics and Gynecology
Medical Director, Psychiatry Clinics
Medical Director, Neuropsychiatry
Ohio State University College of Medicine
Columbus, Ohio
FACULTY
RELEASE DATE: DECEMBER 1, 2008
EXPIRATION DATE: DECEMBER 1, 2009
LEARNING OBJECTIVES
After reviewing this material, clinicians should be better able to:
• Achieve early and accurate diagnosis of patients with mood disorders
• Utilize available screening tools eff ectively
• Understand the mechanisms of action, hepatic eff ects, and other
metabolic eff ects of available agents and their potential impact on
treatment
• Develop an eff ective treatment plan that includes monotherapy or
combination therapy
• Select the most appropriate agent(s) for short- and long-term treatment
to meet individual patient needs
TARGET AUDIENCE
Psychiatrists, primary care physicians, and other health care professionals
who treat patients with psychotic and mood disorders
CME ACCREDITATION STATEMENT
The University of Cincinnati designates this educational activity for a
maximum of 2.5 AMA PRA Category 1 credits. Physicians should only
claim credit commensurate with the extent of their participation in the
activity. This CME activity has been planned and implemented in accordance
with the Essential Areas and Policies of the Accreditation Council
for Continuing Medical Education (ACCME) through the sponsorship of
the University of Cincinnati College of Medicine. The University of Cincinnati
College of Medicine is accredited by the ACCME to provide continuing
medical education for physicians.
FINANCIAL DISCLOSURES AND CONFLICTS OF INTEREST
According to the disclosure policy of the University of Cincinnati, faculty,
editors, managers, and other individuals who are in a position to control
content are required to disclose any relevant fi nancial relationships with
the commercial companies related to this activity. All relevant relationships
that are identifi ed are reviewed for potential confl icts of interest. If
a confl ict of interest is identifi ed, it is the responsibility of the University
of Cincinnati to initiate a mechanism to resolve the confl ict(s). The existence
of these interests or relationships is not viewed as implying bias or
decreasing the value of the presentation. All educational materials are
reviewed for fair balance, scientifi c objectivity of studies reported, and
levels of evidence.
THE FACULTY HAS REPORTED THE FOLLOWING:
DR NASRALLAH reports that he is on the advisory board of Abbott, AstraZeneca,
Cephalon, Janssen, Pfi zer, and Vanda Pharmaceuticals; is a
consultant for AstraZeneca, Janssen, Pfi zer, and Vanda Pharmaceuticals;
receives grants from AstraZeneca, Forest Laboratories, Janssen, Otsuka
America Pharmaceutical Inc., Pfi zer, Roche, and sanofi -aventis; and is on
the speakers bureau of AstraZeneca, Janssen, and Pfi zer.
DR BLACK reports that he is a consultant for Forest Laboratories and Jazz
Pharmaceuticals and receives grant(s) from Forest Laboratories.
DR GOLDBERG reports that he is on the advisory board, speakers bureau,
and serves as a consultant for AstraZeneca, Eli Lilly & Co, and Glaxo
SmithKline.
DR PARISER reports that he receives grants from Pfi zer and is on the
speakers bureau for AstraZeneca, GlaxoSmithKline, and Pfi zer.
DR MUZINA reports that he is on the advisory board of AstraZeneca and
Bristol-Myers Squibb; and is on the speakers bureau of AstraZeneca, Bristol-Myers
Squibb, Pfi zer, Sepracor, and Wyeth.
PLANNING COMMITTEE: Kay Weigand, University of Cincinnati; and Kristen
Georgi, Charles Williams, and Katherine Wandersee for Dowden Health
Media have disclosed no relevant fi nancial relationship(s) with any commercial
interests.
No off -label use of drugs or devices are discussed in this supplement.
SUPPORT
Supported by an educational grant from AstraZeneca.
ACKNOWLEDGEMENT
This CME activity was developed through
the joint sponsorship of the University
of Cincinnati and Dowden Health Media.
It was edited and peer reviewed by The
Journal of Family Practice.
© 2008 AMERICAN ACADEMY OF CLINICAL PSYCHIATRISTS
AND DOWDEN HEALTH MEDIA
jfponline.com and currentclinicalpractice.com
FREE
2.5 CME
CREDITS
Recognizing and managing
psychotic and mood disorders
in primary care
INTRODUCTION › HENRY A. NASRALLAH, MD
he diagnosis and management of psychotic and mood disorders is an evolv-
T ing process and an important clinical topic for primary care clinicians (PCPs).
Although many reports exist on the prevalence and treatment of depression in primary
care, far less information is available about patients in this setting with depression
accompanied by symptoms of mania or hypomania. 1
To facilitate a dialogue on the identifi cation and treatment of psychotic and
mood disorders, we invited 4 expert faculty members to present actual patient cases
followed by a panel discussion in which the collective experience of all the faculty
lends further practical insights into the nuances of management of such patients
in both inpatient and outpatient settings. In particular, these cases underscore the
importance of being alert to critical clues in a patient’s history or the family’s history.
A larger version of this panel discussion appears in a supplement to the December
2008 issue of CURRENT PSYCHIATRY. We’ve extracted the portion that we felt would be
of most interest to primary care providers.
The case selected for presentation here is by David Muzina, MD, and concerns
a 20-year-old man who was referred for psychiatric evaluation by his PCP and psychologist
for treatment of mood swings, anxiety, and confusion. He had been given
sertraline and then venlafaxine, but discontinued both medications on his own. His
symptoms began rather abruptly 14 months earlier, coinciding with an intense program
of weight lifting and supplement use to change his self-described smallness.
Profound, persistent sadness and feeling “dead inside” were his chief complaints,
and they had led to a break-up with his girlfriend, which distressed him greatly and
preoccupied his thinking. He also believed his parents were hiding from him the
truth of a signifi cant birth defect.
Following the case presentation is a faculty discussion of several pivotal issues
in the management of mood disorders:
• Pitfalls to avoid during the diagnostic evaluation
• Pros and cons of monotherapy and combination therapy
• Mechanisms of action of available medications and implications for an eff ective
treatment plan
• Suggestions for enabling patient compliance with prescribed regimens
We hope the insights you glean from this exchange of practical clinical issues
will enhance and confi rm your own approach to diagnosing and treating patients
with psychotic and mood disorders.
REFERENCE
1. Das AK, Olfson M, Gameroff MJ, et al. Screening for bipolar disorder in a primary care practice. JAMA.
2005;293:956-963.
Supplement to The Journal of Family Practice ❙ Vol 57, No 12s ❙ December 2008 S5
DON’T MISS THIS 12-PAGE CME SUPPLEMENT
AVAILABLE ONLINE AT JFPONLINE.COM
Recognizing and managing psychotic
and mood disorders in primary care
Read a case referred to psychiatry
by primary care and fi nd out
how experts manage the care
of patients with psychotic
and mood disorders.
FACULTY
} HENRY A. NASRALLAH, MD, PROGRAM CHAIR
} DONALD W. BLACK, MD
} JOSEPH F. GOLDBERG, MD
} DAVID J. MUZINA, MD
} STEPHEN F. PARISER, MD
THIS CME ACTIVITY IS SUPPORTED BY AN EDUCATIONAL GRANT FROM ASTRAZENECA AND DEVELOPED
218 VOL 58, NO THROUGH 4 / APRIL 2009 THE JOINT THE JOURNAL SPONSORSHIP OF FAMILY OF THE PRACTICE UNIVERSITY OF CINCINNATI AND DOWDEN HEALTH MEDIA.
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