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
- 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.
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- 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).
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Treatment
5. Medical Therapy and Preventive Footcare for Patients With PAD
5.1.1. Antiplatelet and Antithrombotic Therapy for PAD
- In patients with symptomatic PAD, single antiplatelet therapy is recommended to reduce the risk of MACE.
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- In patients with symptomatic PAD, single antiplatelet therapy with clopidogrel alone (75 mg daily) is recommended to reduce the risk of MACE.
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- In patients with symptomatic PAD, single antiplatelet therapy with aspirin alone (range, 75–325 mg daily) is recommended to reduce the risk of MACE.
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- 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.
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- After endovascular or surgical revascularization for PAD, antiplatelet therapy is recommended.
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- 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.
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- 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.
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- 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.
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- In patients with asymptomatic PAD single antiplatelet therapy is reasonable to reduce the risk of MACE.
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- In patients with symptomatic PAD without recent revascularization, the benefit of dual antiplatelet therapy is uncertain.
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- In patients with symptomatic PAD, the benefit of vorapaxar added to existing antiplatelet therapy is uncertain.
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- 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.
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- 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.
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5.2. Lipid-Lowering Therapy for PAD
- 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.
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- 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.
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- 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.
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5.3. Antihypertensive Therapy for PAD
- In patients with PAD and hypertension, antihypertensive therapy should be administered to reduce the risk of MACE.
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- 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.
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- 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.
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5.4. Smoking Cessation for PAD
- 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.
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- 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.
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- 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.
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5.5. Diabetes Management for PAD
- 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.
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- In patients with PAD, management of diabetes should be coordinated among members of the health care team.
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- In patients with PAD and diabetes, glycemic control may be beneficial to improve limb outcomes.
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5.6. Other Medical Therapies for Cardiovascular Risk Reduction in PAD
- Patients with PAD should receive an annual influenza vaccination.
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- Patients with PAD should receive the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination sequence, including the booster(s).
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- 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.
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- In patients with PAD, B-complex vitamin supplementation to lower homocysteine levels is not beneficial for prevention of MACE.
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- In patients with PAD, chelation therapy (eg, EDTA) is not beneficial for prevention of MACE.
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- In patients with PAD, vitamin D supplementation is not beneficial for prevention of MACE.
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5.7. Medications for Leg Symptoms in Chronic Symptomatic PAD
Cilostazol
- In patients with claudication, cilostazol is recommended to improve leg symptoms and increase walking distance.
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- In patients with PAD, cilostazol may be useful to reduce restenosis after endovascular therapy for femoropopliteal disease.
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- In patients with PAD and congestive heart failure of any severity, cilostazol should not be administered.
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Pentoxifylline
- In patients with chronic symptomatic PAD, pentoxifylline is not recommended for treatment of claudication.
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Chelation Therapy
- In patients with chronic symptomatic PAD, chelation therapy is not recommended for treatment of claudication.
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5.8. Preventive Foot Care for PAD
- In patients with PAD, providing general preventive foot self-care education to patients and their family members and support persons is recommended.
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- In patients with PAD, foot inspection by a clinician at every visit is recommended.
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- In patients with PAD at high risk for ulcers and amputation (Table 12), therapeutic footwear is recommended.
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- In patients with PAD, a comprehensive foot evaluation (Table 13) should be performed at least annually to identify risk factors for ulcers and amputation.
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- In patients with PAD, referral to a foot care specialist, when available, is reasonable for ongoing preventive care and longitudinal surveillance.
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Overview
Title
Management of Patients With Lower Extremity Peripheral Artery Disease
Authoring Organizations
American College of Cardiology
American Heart Association