The American Heart Association and American College of Cardiology (AHA/ACC) have released an updated guideline regarding the diagnosis and management of patients with lower extremity peripheral artery disease (PAD).
The previous recommendations on lower extremity in PAD were published by the AHA/ACC in 2005. The researchers reviewed evidence from January through September 2015 from randomized controlled trials, registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinion.
The guideline includes recommendations for the clinical assessment of PAD, which should begin with a review of clinical history, review of symptoms, and a physical examination. In patients with symptoms of PAD, the resting ankle-brachial index (ABI) should confirm the diagnosis. The ABI should be obtained by measuring systolic blood pressure at the arms and ankles in a supine position. Patients with an ABI ≤0.90 should be diagnosed with PAD.
Patients who are diagnosed with PAD should receive a program of guideline-directed management and therapy, which should include structured exercise and lifestyle modification to reduce cardiovascular events. Smoking cessation is critical to PAD management, and patients should also receive a program of pharmacology customized to individual risk factors, such as diabetes, to reduce cardiovascular ischemic events and limb-related events.
The AHA/ACC recommends statin treatment for all patients with PAD, and recommends antiplatelet therapy with aspirin or clopidogrel for patients with symptomatic PAD to reduce myocardial infarction, stroke, and vascular death.
A supervised exercise program is recommended for patients with claudication to improve functional status and quality of life and to reduce leg symptoms. This should be considered as a treatment option before possible revascularization. In addition, a community or home-based exercise program with behavioral change techniques can help patients with PAD improve walking ability and functional status.
Patients with PAD who have claudication, critical limb ischemia, or acute limb ischemia may require endovascular or surgical revascularization to establish in-line blood flow or minimize tissue loss.
The researchers note that PAD is a lifelong, chronic condition, and patients with PAD should have periodic evaluations, including an assessment of cardiovascular risk factors, limb symptoms, and functional status. Patients who have undergone lower extremity revascularization should have a periodic follow-up for clinical evaluation and ABI measurement.
The investigators support the availability of ABI as the initial diagnostic test for patients with a history or physical examination findings that suggest PAD. They also note the importance of ensuring access to supervised exercise programs for PAD patients and recognize that there is a need to incorporate patient-centered outcomes into the regulatory approval process for new medical therapies and revascularization technologies.
- Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2016. doi:10.1161/CIR.0000000000000471.