DIAGNOSTIC-VALUE OF SIGNS AND SYMPTOMS ASSOCIATED WITH PERIPHERAL ARTERIAL OCCLUSIVE DISEASE SEEN IN GENERAL-PRACTICE - A MULTIVARIABLE APPROACH

Objectives. To assess the diagnostic values of single and combined dat a from the history, physical examination, and medical record with rega rd to peripheral arterial occlusive disease (PAOD) in patients with le g complaints; to construct a multivariable model for the clinical diag nosis of PAOD by primary care physicians. Setting. 18 general practice centers in The Netherlands. Design. Cross-sectional comparison of sig ns, symptoms, and data from the medical record with the independently assessed ankle-brachial systolic pressure index (ABPI; cutoff point < 0.90); analysis: bivariate, multiple logistic regression (MLR). Popula tion. 2,455 individuals with leg complaints, aged 40.7-78.4 years; ABP I < 0.90 present in 9.2% of legs (11.7% of individuals). Outcome measu res. Clinical variables: sensitivity, specificity, positive and negati ve predictive values (PV+, PV-), diagnostic odds ratio (OR); models: l ikelihood ratio test, area under the receiver operating characteristic curve (AUG). Results. Bivariate analysis: highest sensitivity: age mo re than 60 years (77.3%); highest specificity: wounds or sores on toes and foot (99.7%); highest PV+: typical intermittent claudication (IC) (45.0%) (abnormal foot pulses 41.3%); highest PV-: strong pulses of b oth foot arteries (97.7%). MLR: the best-performing model (AUG 0.89) c onsisted of ten clinical variables: gender (OR 1.5), age more than 60 (OR 2.2); IC (OR 3.5); palpation of the skin temperature of the feet ( OR 2.5), palpation of both foot pulses [OR 16.4 (abnormal) and 7.0 (do ubtful)], auscultation of the femoral artery (OR 3.5); previous diagno sis of IHD (OR 1.7) or diabetes (OR 1.6), history of smoking (OR 2.1), and elevated blood pressure (OR 1.5). The range of predicted probabil ities was 0.4-98%. The Hosmer-Lerneshow goodness-of-fit test indicated good overall fit (p = 0.52). Conclusions. Palpation of both foot puls es is the key procedure for the clinical diagnosis of PAOD. Traditiona l clinical evaluation enables the general practitioner to exclude the diagnosis of PAOD in many individuals with a high degree of certainty, to establish the diagnosis in a small group of patients, and to defin e a limited group of patients where supplementary noninvasive testing is appropriate. The MLR model can be used as a diagnostic checklist an d as a reference for the physician's clinical hypothesis.