Diabetes is a risk factor for the development of peripheral artery disease (PAD), which usually causes symptoms of leg pain or cramping with activity, numbness, or slow healing sores. For people with diabetes, PAD may not cause any symptoms and therefore, may not be diagnosed in the earlier stages. These patients are also at increased risk for major adverse cardiovascular events and major adverse limb events, including amputation, making it even more important that PAD be identified early and managed appropriately. In response to this concern, the American College of Cardiology (ACC) recently published a consensus report for the management of PAD in adults with diabetes.
In today's side-by-side comparison, we feature the latest consensus report from the ACC and a 2024 clinical practice guideline from the ACC and American Heart Association (AHA). We encourage you to review the full-text version available at the links below for the most complete look at these publications.
Read on to learn more about the consensus report, and how it compares with the 2024 guideline from the ACC/AHA endorsed by the Society for Cardiovascular Angiography and Interventions (SCAI), the Society for Vascular Medicine (SVM), and the Society for Vascular Surgery (SVS).
Guidance for Comparison
| Publication | Management of Peripheral Artery Disease in Adults With Diabetes | Management of Patients With Lower Extremity Peripheral Artery Disease |
|---|---|---|
| Authoring Organization | American College of Cardiology (ACC) | American College of Cardiology (ACC) / American Heart Association (AHA) |
| Type | Consensus | Guideline |
| Publication Date | December 2025 | May 2024 |
| Graded Recommendations | No | Yes |
| Links | Overview / Full Text | Summary / Full Text |
Key Takeaways
The ACC article presents an overview of current recommendations to create a consensus report for adults with both diabetes and PAD.
The ACC/AHA article is a comprehensive guideline for identification and management of adults with PAD. The recommendations target all adults with PAD with a few additional recommendations for adults with diabetes.
Screening
- The ACC suggests screening for asymptomatic adults with diabetes who also have additional risk for PAD, to include:
- The ACC/AHA guideline recommends screening based on history and physical exam findings potentially missing some asymptomatic patients.
Ankle-Brachial Index (ABI)
- Both articles are in agreement on screening tests for PAD. Resting ABI should be completed to establish the diagnosis of PAD.
- For patients whose ABI results showed noncompressible arteries a toe-brachial index (TBI) should be performed.
- For patients with exertional leg symptoms and borderline or normal ABI, an exertional ABI may be useful in detecting PAD.
- The recommended frequency of screening could not be determined according to the ACC article and was not addressed in the ACC/AHA guideline.
Medical Management
- Both articles recommend care be coordinated between members of a multidisciplinary team.
SGLT2 Inhibitors and GLP-1RA
- Both articles recommend the use of sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide–1 agonists (GLP-1RAs).
- The ACC article noted that of these medications semaglutide improved symptoms, function, and quality of life in people with symptomatic PAD.
- The ACC/AHA guideline did not favor a specific medication, but stated that use of these medications reduces the risk of major adverse cardiovascular events (MACE).
Lipid Lowering Therapy
- Both articles recommend that those with high LDL-C aim for a reduction of at least 50%.
- The ACC article simply states that therapy with proven benefit should be used.
- The ACC/AHA guideline recommends high intensity statin therapy. Subsequent treatment for those who continue to have elevated LDL-C on maximally tolerated statin therapy includes adding in a PCSK9 inhibitor or ezetimibe.
Blood Pressure Lowering Therapy
- Both articles recommend high blood pressure be treated to a goal of less than 130 mmHg systolic and less than 80 mmHg diastolic.
- The ACC/AHA guideline recommends selective use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers to decrease the risk of MACE.
Antiplatelet and Antithrombotic Therapy
- Both articles recommend rivaroxaban 2.5 mg twice daily in combination with low-dose aspirin daily to decrease the risk of MACE and major adverse limb events (MALE).
- Other options include monotherapy using either clopidogrel or aspirin, but this only reduces the risk of MACE, not MALE.
Side-By-Side Comparison of Recommendations for Screening
| Topic | ACC | ACC/AHA |
|---|---|---|
| Who Should Be Screened | Screening for PAD is reasonable in asymptomatic adults with diabetes and risk-enhancing factors. | In patients with history or physical examination findings suggestive of PAD, the resting ABI, with or without ankle pulse volume recordings (PVR) and/or Doppler waveforms, is recommended to establish the diagnosis. In patients not at increased risk of PAD and without history or physical examination findings suggestive of PAD, screening for PAD with the ABI is not recommended. |
| Resting ABI | The ABI is a simple, inexpensive measure to detect PAD (≤0.90), but its sensitivity is limited in individuals with vascular calcification. If the ABI is indicative of noncompressible arteries (>1.40), the TBI is the preferred alternative measure (abnormal TBI is <0.70). | In patients at increased risk of PAD, screening for PAD with the resting ABI, with or without ankle PVR and/or Doppler waveforms, is reasonable. The resting ABI should be reported as abnormal (ABI ≤0.90), borderline (ABI 0.91-0.99), normal (ABI 1.00-1.40), or noncompressible (ABI >1.40). In patients with suspected PAD, toe pressure/ toe-brachial index (TBI) with waveforms should be performed when the resting ABI is >1.40 (noncompressible). |
| Exercise ABI | Measurement of the ABI immediately after treadmill exercise may better capture the presence of PAD in people with diabetes and exertional leg symptoms with a normal or borderline resting ABI. | Patients with suspected chronic symptomatic PAD (ie, exertional nonjoint-related leg symptoms) and normal or borderline resting ABI (>0.90 and ≤1.40, respectively) should undergo exercise treadmill ABI testing to evaluate for PAD. In patients with PAD and an abnormal resting ABI (≤0.90), the exercise treadmill ABI test can be useful to objectively assess the functional status and walking performance. |
| Frequency of Screening | No data are available on an optimal frequency for serial screening. | Not addressed. |
Side-by-Side Comparison of Recommendations for Medical Management
| Topic | ACC | ACC/AHA |
|---|---|---|
| Multidisciplinary Team | Because of medical complexity, people with diabetes may benefit from multidisciplinary care teams as clinically indicated, including cardiology, endocrinology, podiatry, primary care, vascular medicine, and vascular surgery. | In patients with PAD, management of diabetes should be coordinated among members of the health care team. |
| SGLT2 Inhibitors and GLP-1RA | SGLT2 inhibitors and GLP-1RA should be prioritized because of the broad cardio-kidney-metabolic benefit. One GLP-1RA, semaglutide, has specifically been shown to improve functional capacity, symptoms, and quality of life in people with symptomatic 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. |
| LDL-C Lowering Therapy | Treatment of LDL-C to a target reduction ≥50% and goal <55 mg/dL is recommended, using therapies with proven cardiovascular benefit. | 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. 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. 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. |
| Blood Pressure Lowering Therapy | High blood pressure should be treated to a goal of <130/80 mm Hg, ideally SBP <120 mm Hg if it can be safely achieved. | In patients with PAD and hypertension, antihypertensive therapy should be administered to reduce the risk of MACE. 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. 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. |
| Antiplatelet and Antithrombotic Therapy | Rivaroxaban 2.5 mg bid and aspirin 75-100 mg daily should be used to reduce MACE and MALE, except in people who are at high risk of bleeding. The second line option is monotherapy with aspirin 75-100 mg or clopidogrel 75 mg daily, which reduces MACE but has not been shown to reduce MALE. | 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. In patients with symptomatic PAD, single antiplatelet therapy is recommended to reduce the risk of MACE. In patients with symptomatic PAD, single antiplatelet therapy with clopidogrel alone (75 mg daily) is recommended to reduce the risk of MACE. 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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