Key result
Continuous wave Doppler reliably excludes PAD in patients prone to medial arterial calcification while ABI fails.
Why the study?
Medial arterial calcification impedes the accuracy of bedside tests to diagnose peripheral arterial disease in patients prone to MAC, such as those with diabetes and chronic kidney disease.
Are bedside tests reliable for diagnosing peripheral arterial disease in patients prone to medial arterial calcification?
Systematic Review (n=23)
Are bedside tests reliable for diagnosing peripheral arterial disease in patients prone to medial arterial calcification?
Single bedside tests like ABI, TBI, and TP have poor reliability for ruling out peripheral arterial disease in patients prone to medial arterial calcification, suggesting a need for comprehensive diagnostic approaches.
ABI unreliable to exclude PAD in medial calcification; challenges ABI-centric diagnostics and supports Doppler-inclusive protocols in updated guidelines.
Background: Medial arterial calcification (MAC), frequently associated with diabetes mellitus (DM) and chronic kidney disease (CKD), is a systemic vascular disorder leading to stiffness and incompressible arteries. These changes impede the accuracy of bedside tests to diagnose peripheral arterial disease (PAD). This review aimed to evaluate the reliability of bedside tests for the detection of PAD in patients prone to MAC. Methods: A systematic search (Pubmed, Embase, Web of Science, Cochrane, and Emcare) was performed according to the PRISMA guidelines to identify relevant studies providing data on the performance of bedside tests for the detection of PAD in patients prone to MAC. Studies were included when bedside test were compared to a reference standard. Primary endpoints were the positive and negative likelihood ratios (PLR, NLR). Methodological quality and risk of bias were evaluated using the QUADAS-2 tool. Findings: In total, 23 studies were included in this review. The most commonly evaluated test was the ankle-brachial index (ABI), followed by toe-brachial index (TBI), toe pressure (TP) measurements, and continuous wave Doppler (CWD). The majority of patients were older, male, and had DM. We found that ABI <0·9 was helpful to diagnose PAD, but failed to rule out PAD (NLR >0·2). The same applied for TP (NLR >0·3) and TBI (5 out of 6 studies revealed an NLR >0·2). CWD (loss of triphasic pattern) is reliable to exclude PAD (NLR 0-0·09), but was only validated in two studies. Overall, methodological quality was poor which led to risk of bias in 20 studies. Interpretation: The diagnosis of PAD in patients prone to MAC remains challenging. The ABI performed reasonably in the diagnosis of PAD, while the CWD (loss of triphasic signal) can be used to rule out PAD. This systematic review showed that test performances were generally poor with serious concerns in methodological quality of the included studies. We therefore counsel against the use of a single bedside test. Funding: None to declare.
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Brouwers et al. (2022) conducted a systematic review in Peripheral arterial disease in patients prone to medial arterial calcification (n=23). Bedside tests (ABI, TBI, TP, CWD) vs. Reference standard was evaluated on Positive and negative likelihood ratios (PLR, NLR). In patients prone to medial arterial calcification, ankle-brachial index failed to rule out peripheral arterial disease (NLR >0.2), while continuous wave Doppler reliably excluded it (NLR 0-0.09).
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