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New guidelines emphasize medical therapy, structured exercise for patients with PAD
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NEW ORLEANS — An estimated 202 million people worldwide have lower-extremity peripheral artery disease. A new guideline from the American Heart Association and the American College of Cardiology provides updated recommendations for the diagnosis and management of patients with the condition.
In the United States alone, “lower-extremity peripheral artery disease (PAD) is a common [CVD] that is estimated to affect approximately 8.5 million Americans above the age of 40 years and is associated with significant morbidity, mortality and quality of life impairment,” Heather Gornik, MD, vice chair of the writing committee and cardiologist and vascular medicine specialist at the Cleveland Clinic, and colleagues wrote. The guidelines document published in Circulation and the Journal of the American College of Cardiology.
The new guidance replacement a previous guideline last updated in 2011.
Health care providers evaluating patients with increased risk for PAD should focus on clinical history, symptoms and physical examination; however, PAD often presents with variable symptoms and signs, according to the authors.
Specifically, it is recommended that patients with increased PAD risk undergo a comprehensive medical history and review of symptoms to assess for exertional leg symptoms, ischemic rest pain and non-healing wounds; vascular examination, including assessment of the legs and feet, auscultation for femoral bruits and palpation of lower-extremity pulses; and noninvasive BP measurement in both arms at least once during the initial assessment, according to the document.
In general, individuals with increased risk for PAD include:
- those aged 65 years and older;
- those aged 50 to 64 years with atherosclerotic risk factors such as diabetes, smoking, hyperlipidemia and hypertension, and/or a family history of PAD;
- those aged younger than 50 years with diabetes and one additional atherosclerotic risk factor; and
- those with known atherosclerotic disease in another vascular bed, such as the coronary, carotid or subclavian.
“History or physical examination findings suggestive of PAD need to be confirmed with diagnostic testing. The resting ankle-brachial index (ABI) is the initial diagnostic test for PAD and may be the only test required to establish the diagnosis and institute guideline-directed medical therapy,” the authors wrote.
ABI continues to be recommended for patients with symptoms and signs of PAD. For patients without symptoms of PAD but who are at increased risk for PAD, it is reasonable for health care providers to use ABI to determine whether PAD is present, according to a press release. Other physiological tests may be indicated depending on the clinical presentation, such as exercise treadmill ABI testing, toe-brachial index, additional perfusion assessment measures or skin perfusion pressure, according to the guidelines.
The guidelines continue to recommend use of statin therapy for patients with PAD. In addition, health care providers should prescribe antiplatelet therapy consisting of aspirin or clopidogrel, and the guidelines discuss situations in which dual antiplatelet therapy may be considered, such as after endovascular revascularization procedures.
Carried over from previous guidelines, physical activity is a mainstay of PAD management. All patients with PAD are encouraged to participate in a structured exercise program that provides individualized recommendations for the type, duration, frequency and intensity of activity. According to the authors, the most effective form of structured exercise is a supervised exercise program in a hospital or outpatient exercise facility; for example, recommended training may consist of 30- to 45-minute exercise sessions at least three times per week for a minimum of 12 weeks. Other options include home- or community-based walking exercise or alternative forms of activity such as upper-body exercises, according to the release.
While previous guidelines emphasized the importance of smoking cessation for this patient population, the new guidelines go one step further and strongly advise patients with PAD to avoid exposure to secondhand smoke, according to the release.
Another new recommendation is an annual flu shot for all patients with PAD to avoid CV-related complications of the flu, such as MI, according to the release.
Moreover, the authors note that revascularization is “a reasonable treatment option” for patients who present with lifestyle-limiting claudication and who have an inadequate response to guideline-directed medical therapy. Available endovascular techniques for treatment of claudication in patients with PAD include angioplasty with or without stent placement and other techniques such as atherectomy.
“These techniques continue to evolve and now include covered stents, [DES], cutting balloons and drug-coated balloons,” the authors wrote.
Surgical revascularization for claudication may also be necessary, but “treatment selection should therefore be individualized on the basis of the patient’s goals, perioperative risk and anticipated benefit” compared with endovascular revascularization, according to the guideline.
“[PAD] is a common disease with devastating consequences, and clinical practice guidelines are an important tool to improve the quality of care for patients with this disease,” Heather Gornik, MD, vice chair of the PAD writing committee and cardiologist and vascular medicine specialist at Cleveland Clinic, said in a press release.
The authors recommend a comprehensive care plan for all patients with PAD, with regular follow-up.
“Periodically reassessing how we manage and treat complex diseases by incorporating the latest evidence is critical to ensure that clinicians are equipped to provide optimal care for their patients,” Marie Gerhard-Herman, MD, writing group chair and cardiologist at Brigham and Women’s Hospital, said in the release.
References:
Gornik H, et al. Introducing the 2016 PAD Guidelines and State of the Science in 2016. Presented at: American Heart Association Scientific Sessions; Nov. 12-16, 2016; New Orleans.
Gerhard-Herman MD, et al. Circulation. 2016;doi:10.1161/CIR.0000000000000471.
Gerhard-Herman MD, et al. J Am Coll Cardiol. 2016; 10.1016/j.jacc.2016.11.007.
Disclosure: Please see the guideline for a full list of the authors’ relevant financial disclosures.
*Source: Tom Merce © Cleveland Clinic.
Perspective
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Carl J. Pepine, MD, MACC
The prevalence of PAD is estimated to be approximately 10% in Americans aged older than 60 years and increases progressively with aging. These estimates are largely for those who have intermittent claudication, the symptom that prompts most patients with PAD to seek care. However, there is a much larger cohort of patients with PAD who remain asymptomatic, and the disease is detected by a simple outpatient test: the ABI and/or by an imaging study.
Unfortunately, both the symptomatic and asymptomatic PAD phenotypes are associated with a high risk for adverse outcomes that include death, MI, stroke, revascularization or even limb loss. In part, this heightened risk is related to the fact that PAD is a result of a high atherosclerosis risk factor burden (smoking, hypertension, diabetes, dyslipidemia, obesity, etc.), more diffuse atherosclerosis, enhanced platelet activation, inflammation and other disorders that promote vascular disease such as genetic polymorphisms, homocysteinemia, etc. Unfortunately, secondary prevention measures are currently very limited and include risk factor modification, exercise, statins and antiplatelet agents.
Clearly, we need new information to fill the many knowledge gaps related to PAD.
These new data will advance our understanding of this important problem and hopefully lead to improved management of a large group of patients.
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