New PAD guideline endorses multispecialty care team, structured exercise programs
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Key takeaways:
- The new guideline on peripheral artery disease encourages care through a multispecialty team.
- The guideline endorses supervised exercise training and high-intensity statin therapy, among other interventions.
A new guideline on lower-extremity peripheral artery disease encouraged managing care with a multispecialty team and having patients undergo structured exercise programs.
The guideline, developed by the American Heart Association and the American College of Cardiology along with the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Podiatric Medical Association, the Association of Black Cardiologists, the Society for Cardiovascular Angiography and Interventions, the Society for Vascular Medicine, the Society for Vascular Nursing, the Society for Vascular Surgery, the Society of Interventional Radiology and the Vascular and Endovascular Surgery Society, is the first for PAD since 2016 and was published in Circulation and the Journal of the American College of Cardiology.
Comprehensive risk factor management
“Because of the complexities of PAD, to improve outcomes and reduce the risk of limb loss for these patients, a multispecialty care team approach that is focused on comprehensively addressing risk factor management, foot care and revascularization is needed to promote collaboration, avoid duplication of care and optimize patient outcomes,” Heather L. Gornik, MD, FAHA, co-director of the Vascular Center at the University Hospitals Harrington Heart & Vascular Institute and a professor of medicine at Case Western Reserve University School of Medicine, both in Cleveland, and chair of the committee that wrote the guideline, said in a press release.
“PAD is a serious and important cardiovascular disease that is a major cause of cardiovascular morbidity, mortality, impaired function and quality of life, and a major cause of lower-extremity amputation,” Gornik told Healio. “There are significant health disparities in the diagnosis and care of patients with PAD that must be addressed. PAD is classified into four clinical subsets; all patients with PAD need medical therapy, which can be highly effective to prevent cardiovascular events, death and limb events. Patients with more severe forms of PAD need to undergo revascularization.”
As soon as PAD is diagnosed, the multispecialty care team should implement an action plan including guideline-directed medical therapy and management of PAD-related risk amplifiers, including smoking, lack of exercise, high BP, high cholesterol and poor diet, according to the guideline.
High-intensity statin therapy is recommended for all patients with PAD, and low-dose rivaroxaban (Xarelto, Janssen/Bayer) is recommended for patients with PAD who are not at high risk for bleeding, the authors wrote.
Exercise therapy
Structured exercise, including supervised exercise therapy and community-based (including structured home-based) programs, is crucial to improve quality of life and outcomes for patients with PAD, Gornik and colleagues wrote.
“Supervised exercise therapy, the gold standard exercise therapy for patients with PAD, is woefully underutilized despite its known health benefits and the fact that it is covered by Medicare and most health insurance plans,” Gornik said in the release. “Rates of referral for supervised exercise therapy among PAD patients are incredibly low. It has been estimated that less than 5% of patients with PAD in the U.S. are prescribed to participate in a supervised exercise program.”
Endovascular, surgical or hybrid revascularization is recommended to prevent limb loss for patients with chronic limb-threatening ischemia and to improve quality of life and functional status for patients with claudication who remain symptomatic despite medical therapy and structured exercise, according to the guideline.
The authors wrote that foot care is crucial for all four subsets of the PAD population — asymptomatic PAD, chronic symptomatic PAD, chronic limb-threatening ischemia and acute limb ischemia — and should include patient education, preventive foot care, more intensive wound care when needed and, in patients with severe PAD, pressure offloading to minimize risk for amputation.
Disparities in care across the PAD population, which lead to poor limb and CV outcomes in certain populations, must be addressed, the authors wrote.
“Racial and ethnic disparities in the detection, management and health outcomes of PAD have long been present in the U.S. and are an important public health issue to be addressed,” Gornik said in the release. “These disparities highlight opportunities for initiatives focused on early disease detection and improving access to effective PAD treatments for people in under-resourced, at-risk communities.”
The authors also stated that achieving the six goals of the PAD National Action Plan released by the AHA in 2022 is a priority. Those goals are:
- Reach people with PAD and those at risk for PAD by improving public awareness of PAD symptoms and diagnosis.
- Enhance professional education for multidisciplinary health care professionals who care for people with PAD.
- Activate health care systems to provide enhanced programs for the detection and treatment of patients with PAD, with a focus on understanding and addressing patient-centered outcomes.
- Reduce the rates of nontraumatic lower-extremity amputations related to PAD through public outcome reporting and public health interventions.
- Increase and sustain research to better understand prevention, diagnosis and treatment of PAD.
- Coordinate PAD advocacy efforts to shape national policy and improve health outcomes.
“These updated, evidence-based guidelines will hopefully serve as the foundation of collaborative efforts nationwide through AHA, ACC and the other societies to implement the guidelines to professionals and thus improve care for patients with PAD, save lives and save limbs,” Gornik told Healio.
References:
- Early diagnosis & treatment of peripheral artery disease essential to improve outcomes, reduce amputation risk. https://newsroom.heart.org/news/early-diagnosis-treatment-of-peripheral-artery-disease-essential-to-improve-outcomes-reduce-amputation-risk. Published May 14, 2024. Accessed May 14, 2024.
- Gornik HL, et al. J Am Coll Cardiol. 2024;doi:10.1016/j.jacc.2024.02.013.
- PAD National Action Plan. https://www.heart.org/en/health-topics/peripheral-artery-disease/pad-resources/pad-action-plan. Published May 2022. Accessed May 13, 2024.
For more information:
Heather L. Gornik, MD, FAHA, can be reached at heather.gornik@uhhospitals.org; X (Twitter): @heatherlgornik.
Perspective
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Marc P. Bonaca, MD, MPH
A key recommendation in the guideline is the recognition of the heterogeneity with which patients with PAD present. There are patients who have disease and functional limitation that they don’t recognize as vascular disease, there are patients who have typical claudication and there are patients who have critical limb ischemia. The risks and management of patients across this spectrum must be personalized. A corollary is that there are risk enhancers: factors independent of their PAD but associated with it, and that enhance or modify risk. Most patients with PAD have multiple comorbidities such as diabetes, HF, advanced age and/or kidney disease. We have to think holistically about these patients when we consider goals of care, how to manage polypharmacy and how to enter into shared decision-making.
A second key point of emphasis is the message around health equity. Treating, diagnosing and screening for PAD is a health equity emergency, where we have some groups of patients who have more than twofold the risk for amputation than others in the same country. That is a problem that is urgent and it is complex and it will require attention and engagement from all to adequate address the disparities in outcomes.
A third key point is around medical therapy. For the first time, we have a drug, low-dose rivaroxaban, that has a class I indication for the prevention of major adverse limb events, and it is a game changer for the guidelines. It is also the first-ever FDA-approved drug for the prevention of amputation and major adverse limb events. This is an inflection point for PAD guidelines. It differentiates medications that are used to reduce MACE, which are common across manifestations of atherosclerosis such as coronary disease from therapies that have specific benefits for patients with PAD. Although patients with PAD are at high risk for MACE, and prevention of MI and stroke is important, their dominant morbidity is functional limitations and major adverse limb events, and the development of medical therapies specifically to address these risks is a major evolution for the field.
The class I recommendation for low-dose rivaroxaban is a recognition that the evidence is strong including data from two large, randomized trials. Prior to this guideline statement, the field has struggled with implementation and how to balance this novel strategy with established strategies that are not well-supported by data. The uptake of rivaroxaban for patients where there is a favorable benefit-risk ratio is improving, though not as fast as some would like, and this recommendation should help. There is now a clear indication in the guidelines that dual antiplatelet therapy and aspirin plus rivaroxaban are not equivalent choices.
As we look ahead at current and future trials, more therapies used for lipid modification and diabetes treatment are being evaluated for PAD-specific endpoints, and this will hopefully translate to novel therapies that can be prioritized in patients with PAD.
I hope a more intensive and holistic approach to treatment focused on PAD outcomes translates from this guideline, from consideration of stage of the condition a patient has, to their comorbidities, to the tailoring of their medical therapy for everything they face, to exercise therapy, to the approach to revascularization should they progress. I don’t think we have had before such a comprehensive view of what the care of a patient with PAD should look like. But implementing the old guidelines was hard enough. This iteration of the guidelines has set the bar higher. So the gap between, and making sure the patients receive the benefits of the recommendations, is going to be a challenge.
Future guidelines are going to have to weigh how to prioritize drugs that address comorbidities (eg, HbA1c in diabetes) common to patients with PAD vs. drugs that have specific benefits for PAD (eg, reducing limb events and/or improving function). As clinicians and patients are faced with the challenges of polypharmacy and competing indications based on comorbidity, future iterations of guidelines will need to help support prioritization of therapies and tools for shared decision-making.
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