Management of Patients With Lower Extremity Peripheral Artery Disease

Publication Date: May 14, 2024
Last Updated: May 14, 2024

Diagnosis

2.2. History and Physical Examination to Assess for PAD

  1. In patients at increased risk of PAD (Table 5), a comprehensive medical history and review of symptoms to assess for exertional leg symptoms, lower extremity rest pain, and lower extremity wounds or other ischemic skin changes should be performed.
(1, B-NR)
3594573
  1. In patients at increased risk of PAD (Table 5), a comprehensive vascular examination and inspection of the legs and feet should be performed regularly (Table 6).
(1, B-NR)
3594573

Treatment

5. Medical Therapy and Preventive Footcare for Patients With PAD

5.1.1. Antiplatelet and Antithrombotic Therapy for PAD

  1. In patients with symptomatic PAD, single antiplatelet therapy is recommended to reduce the risk of MACE.
(1, A)
3594573
  1. In patients with symptomatic PAD, single antiplatelet therapy with clopidogrel alone (75 mg daily) is recommended to reduce the risk of MACE.
(1, B-R)
3594573
  1. In patients with symptomatic PAD, single antiplatelet therapy with aspirin alone (range, 75–325 mg daily) is recommended to reduce the risk of MACE.
(1, C-LD)
3594573
  1. In patients with symptomatic PAD, low-dose rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin is effective to reduce the risk of MACE and MALE.
(1, A)
3594573
  1. After endovascular or surgical revascularization for PAD, antiplatelet therapy is recommended.
(1, B-R)
3594573
  1. After endovascular or surgical revascularization for PAD, low-dose rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin is recommended to reduce the risk of MACE and MALE.
(1, A)
3594573
  1. After endovascular revascularization for PAD, dual antiplatelet therapy with a P2Y12 antagonist and low-dose aspirin is reasonable for at least 1 to 6 months.
(2a, C-LD)
3594573
  1. After endovascular or surgical revascularization in patients with PAD who require full-intensity anticoagulation for another indication and are not at high risk of bleeding, adding single antiplatelet therapy is reasonable.
(2a, C-LD)
3594573
  1. In patients with asymptomatic PAD single antiplatelet therapy is reasonable to reduce the risk of MACE.
(2a, C-EO)
3594573
  1. In patients with symptomatic PAD without recent revascularization, the benefit of dual antiplatelet therapy is uncertain.
(2b, B-R)
3594573
  1. In patients with symptomatic PAD, the benefit of vorapaxar added to existing antiplatelet therapy is uncertain.
(2b, B-R)
3594573
  1. After surgical revascularization for PAD with a prosthetic graft, dual antiplatelet therapy with a P2Y12 antagonist and low-dose aspirin may be reasonable for at least 1 month.
(2b, B-R)
3594573
  1. In patients with PAD without another indication (eg, atrial fibrillation), full-intensity oral anticoagulation should not be used to reduce the risk of MACE and MALE.
(3 - Harm, A)
3594573

5.2. Lipid-Lowering Therapy for PAD

  1. In patients with PAD, treatment with high-intensity statin therapy is indicated, with an aim of achieving a ≥50% reduction in low-density lipoprotein cholesterol (LDL-C) level.
(1, A)
3594573
  1. In patients with PAD who are on maximally tolerated statin therapy and have an LDL-C level of ≥70 mg/dL, it is reasonable to add PCSK9 inhibitor therapy.
(2a, B-R)
3594573
  1. In patients with PAD who are on maximally tolerated statin therapy and have an LDL-C level of ≥70 mg/dL, it is reasonable to add ezetimibe therapy.
(2a, B-R)
3594573

5.3. Antihypertensive Therapy for PAD

  1. In patients with PAD and hypertension, antihypertensive therapy should be administered to reduce the risk of MACE.
(1, A)
3594573
  1. In patients with PAD and hypertension, a systolic blood pressure (SBP) goal of <130 mm Hg and a diastolic blood pressure target of <80 mm Hg is recommended.
(1, B-R)
3594573
  1. In patients with PAD and hypertension, the selective use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers is recommended to reduce the risk of MACE.
(1, B-R)
3594573

5.4. Smoking Cessation for PAD

  1. Patients with PAD who smoke cigarettes or use any other forms of tobacco should be advised at every visit to quit or encouraged to maintain cessation.
(1, A)
3594573
  1. Patients with PAD who smoke cigarettes or use any other forms of tobacco should be assisted in developing a plan for quitting that includes pharmacotherapy (ie, varenicline, bupropion, and/or nicotine replacement therapies) combined with counseling, and/or referral to a smoking cessation program.
(1, A)
3594573
  1. Patients with PAD should be advised to avoid exposure to secondhand tobacco smoke in all indoor or enclosed spaces, including work, home, transportation vehicles, and public places.
(1, B-NR)
3594573

5.5. Diabetes Management for PAD

  1. In patients with PAD and type 2 diabetes, use of glucagon-like peptide-1 agonists (liraglutide and semaglutide) and sodium-glucose cotransporter-2 (SGLT-2) inhibitors (canagliflozin, dapagliflozin, and empagliflozin) are effective to reduce the risk of MACE.
(1, A)
3594573
  1. In patients with PAD, management of diabetes should be coordinated among members of the health care team.
(1, C-EO)
3594573
  1. In patients with PAD and diabetes, glycemic control may be beneficial to improve limb outcomes.
(2b, B-NR)
3594573

5.6. Other Medical Therapies for Cardiovascular Risk Reduction in PAD

  1. Patients with PAD should receive an annual influenza vaccination.
(1, C-LD)
3594573
  1. Patients with PAD should receive the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination sequence, including the booster(s).
(1, C-EO)
3594573
  1. In patients at high cardiovascular risk, a diet emphasizing intake of vegetables, fruits, legumes, nuts, whole grains, and fish can be beneficial for reducing the risk of developing PAD and the risk of MACE.
(2a, B-R)
3594573
  1. In patients with PAD, B-complex vitamin supplementation to lower homocysteine levels is not beneficial for prevention of MACE.
(3 - No Benefit, B-R)
3594573
  1. In patients with PAD, chelation therapy (eg, EDTA) is not beneficial for prevention of MACE.
(3 - No Benefit, B-R)
3594573
  1. In patients with PAD, vitamin D supplementation is not beneficial for prevention of MACE.
(3 - No Benefit, B-R)
3594573

5.7. Medications for Leg Symptoms in Chronic Symptomatic PAD

Cilostazol
  1. In patients with claudication, cilostazol is recommended to improve leg symptoms and increase walking distance.
(1, A)
3594573
  1. In patients with PAD, cilostazol may be useful to reduce restenosis after endovascular therapy for femoropopliteal disease.
(2b, B-R)
3594573
  1. In patients with PAD and congestive heart failure of any severity, cilostazol should not be administered.
(3 - Harm, C-LD)
3594573
Pentoxifylline
  1. In patients with chronic symptomatic PAD, pentoxifylline is not recommended for treatment of claudication.
(3 - No Benefit, B-R)
3594573
Chelation Therapy
  1. In patients with chronic symptomatic PAD, chelation therapy is not recommended for treatment of claudication.
(3 - No Benefit, B-R)
3594573

5.8. Preventive Foot Care for PAD

  1. In patients with PAD, providing general preventive foot self-care education to patients and their family members and support persons is recommended.
(1, C-LD)
3594573
  1. In patients with PAD, foot inspection by a clinician at every visit is recommended.
(1, C-EO)
3594573
  1. In patients with PAD at high risk for ulcers and amputation (Table 12), therapeutic footwear is recommended.
(1, C-LD)
3594573
  1. In patients with PAD, a comprehensive foot evaluation (Table 13) should be performed at least annually to identify risk factors for ulcers and amputation.
(1, C-EO)
3594573
  1. In patients with PAD, referral to a foot care specialist, when available, is reasonable for ongoing preventive care and longitudinal surveillance.
(2a, B-NR)
3594573

Overview

Title

Management of Patients With Lower Extremity Peripheral Artery Disease

Authoring Organizations

American College of Cardiology

American Heart Association