On May 14, 2024, The American College of Cardiology (ACC) and American Heart Association (AHA) released a new evidence-based guideline for the management of lower extremity peripheral artery disease.ⁱ This article will address some of the top takeaways from the updated guideline for peripheral artery disease and impacts for clinical practice. 

PAD in the U.S. 

Approximately 10-12 million Americans aged 40 years and older have the peripheral artery disease (PAD). It is associated with major adverse cardiovascular events and major adverse limb events.  

Although there are effective medical treatments to prevent and treat PAD, this public health issue is often under-identified and inadequately treated, leaving patients vulnerable to myocardial infarction, stroke, amputation, impaired functional ability, decreased quality of life, and death.^ii,iii 

Impacts of Health Inequity on PAD 

Certain populations experience health disparities that may lead to poor outcomes. They are often diagnosed later, may not receive appropriate guideline-directed medical therapy, are less likely to participate in structured exercise therapy, and are less likely to be afforded limb-salvaging revascularization procedures.  

In the United States, Black, American Indian, and Hispanic populations have a higher risk of limb amputation compared with White populations.”³ 

In addition to race and ethnicity, geography, structural racism, and implicit bias, as well as social determinants of health, contribute to disparities in cardiovascular and PAD care.^1,2,3 

PAD Risk Factors and Identification 

Recognition of individuals with the following PAD risk factors guides clinical evaluation and management:  

• Age >65 years 

• Age 50-64 with risk factors for atherosclerosis (diabetes, history of smoking, dyslipidemia, hypertension), chronic kidney disease, and family history of PAD 

• Age <50 years with diabetes and one additional risk factor for atherosclerosis 

• Known atherosclerosis in other vascular beds (coronary artery disease, carotid artery disease, subclavian stenosis, renal mesenteric artery stenosis, or abdominal aortic aneurysm 

The following have been identified as PAD-related risk amplifiers for major adverse cardiovascular events and major adverse limb events: 

• Older age (>75 years) and Geriatric Syndromes (frailty, mobility impairment) 

• Diabetes 

• Ongoing smoking and other tobacco use 

• Chronic kidney disease and end-stage kidney disease 

• Polyvascular disease 

• Microvascular disease 

• Depression³ 

Components of Lower Extremity Evaluation 

Clinical inspections and evaluations to assess the presence of PAD, evaluate the effectiveness of treatment, and identify the need for additional intervention should include the following elements:³ 

• evaluation of pulses 

• auscultation for possible abdominal and femoral bruits     

• observation for non-healing wounds 

• observation for elevation pallor/dependent rubor 

• observation for asymmetric hair growth or calf atrophy 

PAD Prevention  

Prevention and treatment of PAD require that clinicians identify risk factors and obtain a history that includes functional limitations due to leg pain and difficulty walking.  

• If indicated by history or reported symptoms, a thorough lower extremity examination should be performed.  

• A resting ankle-brachial index (ABI) is indicated for history and physical examination suggestive of PAD.  

• If resting ABIs are inconclusive, toe-brachial index pressures, segmental pressures, Doppler studies, and exercise ABIs may be conducted.  

• Arterial imaging studies are generally reserved for individuals for whom revascularization is being considered.³ 

PAD Treatment  

Patients with PAD should be prescribed effective medical therapies to prevent major adverse cardiovascular events and major adverse limb events. Topline information is available below; refer to the full guideline document for further details. 

Individuals with PAD can be categorized into four clinical subsets: asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia. The updated guideline provides risk assessment, clinical assessment, diagnosis, and management strategies for each subset. In addition, the guidelines stress the importance of addressing health disparities and PAD-risk amplifiers when developing patient-centered treatment plans.^2,3 

Treatment of confirmed PAD is best accomplished by a multidisciplinary team and typically includes structured exercise therapy, management of risk factors, and medication. Revascularization may be indicated if these measures do not relieve symptoms, or if chronic limb-threatening ischemia or acute limb ischemia are present.^2,3 

Guideline-Directed Medical Therapy to Reduce Risk of Major Adverse Cardiovascular Events and Major Adverse Limb Events 

In addition to medical therapy recommendations in the 2016 guidelines, the updated guideline for medical therapy recommends the addition of rivaroxaban, a high-intensity statin to lower LDL by at least 50%, and the COVID vaccination sequence plus boosters. Also, glucagon-like peptide 1 agonists (GLP-1) and sodium-glucose cotransporter-2 inhibitors (SGLT-2) are recommended to reduce the risk of major adverse cardiovascular events in patients with type 2 diabetes. In summary, guidelines for medical therapy in PAD include:^3,iv 

• Antiplatelet and Antithrombotic Therapy: In patients who are not at increased risk of bleeding, rivaroxaban 2.5 mg BID plus ASA 81 mg   

• Lipid-lowering Therapy: High-intensity statin 

• Antihypertensive Therapy: for PAD patients with hypertension 

• Diabetes Management: GLP-1 agonists or SGLT2 inhibitors are beneficial to reduce the risk of major acute cardiovascular events for type 2 diabetics with PAD 

• Immunizations: Annual influenza vaccinations and COVID vaccination sequence, including boosters 

• Treatment of claudication: In the absence of congestive heart failure, cilostazol may be used to reduce symptoms and increase walking distance 

• Preventive Foot Care: including patient and family education, clinician inspection each visit, therapeutic footwear for high-risk individuals, annual comprehensive clinician evaluation to identify risk factors for ulcers and amputation 

Structured Exercise Therapy 

Structured Exercise Therapy has strong evidence for improving functional status, walking performance, and quality of life for patients with chronic symptomatic PAD. Patients undergoing structured exercise therapy are asked to walk on a treadmill, with intermittent rest periods when pain becomes moderate to severe. There is also growing evidence that structured, community-based programs offer similar benefits. These programs, designed and supervised by a qualified health professional, may be provided in the home, community, or patient’s neighborhood and increase access to this core component of a PAD management program.^2,3 

Revascularization Techniques 

Guideline-directed medical therapy is recommended for all patients with PAD. Revascularization techniques, however, are generally reserved for patients with more severe symptoms or if chronic limb-threatening ischemia or acute limb ischemia are present.³ 

Conclusion 

Clinicians who are aware of the risk factors of PAD, screen for the disease, and work with patients on guideline-directed medical therapy can significantly impact patients’ limb retention, risk of stroke, cardiovascular disease, or death, and help maximize individual quality of life. 

The guideline reminds readers that “Management, in accordance with guideline recommendations is effective only when followed by both practitioners and patients.”²  The complete guideline, as well as supplemental publications, are useful resources for practitioners. Utilizing shared decision-making, which allows patients to make decisions about their care, with consideration given to their personal values, preferences, and personal situation, fosters adherence to recommended therapies^2,3 and supports improved patient outcomes. 

---

Resources

[1] American College of Cardiology. New ACC/AHA Guideline Focused on Management of Lower Extremity PAD. American College of Cardiology website. May 14, 2024. Accessed July 9, 2024. 

[2] Bates K, Moore M, Cibotti-Sun M. 2024 Lower Extremity Peripheral Artery Disease Guideline-at-a-Glance. JACC. 2024 Jun, 83 (24) 2605–2609. 

[3] Gornik H, Aronow H. et al. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. JACC. 2024 Jun, 83 (24) 2497–2604.

[4] Gerhard-Herman H, Gornick H., et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(12):e686-e725.