Atherosclerotic disease often occurs in the vasculature beyond the heart; however, cardiologists do not always take a head-to-foot approach to identify related circulatory conditions. Khusrow Niazi, MD, Emory University, Atlanta, Georgia, USA, described the importance of a head-to-foot evaluation for vascular disease.

In patients who present with symptoms such as leg weakness, it is important to ask specific questions to learn about all associated symptoms that the patient has experienced. For example, in transient ischemic attack (TIA), many patients ignore multiple symptoms of TIA because the symptoms last for only a few seconds or minutes. For patients with suspected TIA, retinal ischemic events, or ipsilateral ischemic stroke, auscultation for carotid bruit was found in a landmark 1994 NASCET trial to detect > 70% stenosis in symptomatic patients, with a sensitivity of 63% and a specificity of 61% during the clinical examination. A much more sensitive technique, however, that is easily performed by cardiologists is Duplex ultrasound with a vascular probe, which can diagnose stenosis anywhere in the vasculature.

Patients' leg pain can be broadly categorized as being due to arterial insufficiency, venous insufficiency, or other causes. Peripheral artery disease (PAD) is a common disease that affects up to 12 million individuals in the United States and is most typically a result of atherosclerosis. Hallmark symptoms of PAD include claudication with resulting decreased function and exercise capacity, with symptoms ranging from Rutherford–Becker Classification 0 (no symptoms) to 6 (gangrene). In addition, PAD is associated with a heightened risk of all-cause mortality. Therefore, it is important that clinicians do not miss a diagnosis of PAD. To diagnose PAD, an ankle-brachial index (ABI) should be performed. In patients with a compelling story but a normal rest ABI, an exercise ABI should be considered (Figure 1).

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Figure 1.

Algorithm for Ankle-Brachial Index Assessment of Arterial Insufficiency

ABI, ankle-brachial index; CTA, computed tomography angiography; MRA, magnetic resonance angiography.Reproduced with permission from K Niazi, MD.

Venous issues are a substantial problem in the United States, because, according to Dr Niazi, almost 5% (about 25 million) of individuals in the United States suffer from leg vein abnormalities, and venous stasis ulcer is the most common leg ulcer that presents in wound centers. Despite this large number, only 1.7 million patients seek treatment for their vein issues. Multiple risk factors for vein problems exist, including age, female sex, genetic predisposition, an occupation that requires a lot of standing, pregnancy, and taller height. Vein problems encompass a variety of conditions such as varicose or spider veins, leg cramps, restless legs, itching, ulcers, aching or heaviness, and swelling.

Dr Niazi recommends that all cardiologists have new patients remove their socks and shoes to examine the legs and feet; abnormal pigmentation of the lower legs is very common in patients with venous insufficiency. A common cause of venous insufficiency is malfunction of the venous valves, which do not close completely and allow the blood to travel back; the resulting increased venous pressure can cause distention of the veins and result in bleeding. The diagnosis of venous insufficiency can be made easily with venous ultrasound, which is performed while the patient is standing. The calf region should be compressed, causing blood to surge upward; in patients with venous insufficiency, the blood will fall downward again.

In conclusion, it is important that cardiologists are aware of vasculature issues that occur beyond the heart. Many potentially serious issues are a result of atherosclerotic disease, which often exists in multiple vascular beds.