PAD performance measures set to improve diagnosis, treatment

The ankle brachial index (ABI), statins and antiplatelets, smoking cessation and supervised exercise programs form the core of new peripheral artery disease (PAD) performance measures intended to systematically improve diagnosis and treatment and thereby prevent cardiac events and premature death.

The American College of Cardiology/American Heart Association issued the performance measures for PAD. The measures are online and will be co-published in several cardiovascular journals.

Patients with peripheral artery disease have the highest rate of heart attacks, stroke and cardiovascular death, noted the report. They are up to six times more likely to die of heart disease compared to age-matched controls, and pooled results of eight randomized, prospective trials show patients with PAD and coronary disease are more than twice as likely to die one year after undergoing percutaneous coronary intervention than patients with coronary disease alone. Yet, PAD patients receive antiplatelet or statins much less frequently than patients with coronary artery disease.

The performance measures call for screening for PAD using the ankle brachial index in patients deemed at risk, defined as

• all patients with exertional leg symptoms,
• all patients ages 50 to 69 with cardiovascular risk factors, particularly diabetes or smoking,
• all patients age 70 or older regardless of risk factors, or
• all patients with a Framingham Risk Score 10% to 20%.

The measures also recommend treatments for PAD patients, including:

• statin therapy to lower the low-density lipoprotein cholesterol to less than 100 mg/dL,
• smoking cessation interventions ("the most potent modifiable risk factor for development of PAD," noted the report; continued tobacco use affects disease progression and graft patency),
• antiplatelet therapy with aspirin or clopidogrel to reduce risk of heart attack, stroke or death in people with history of symptomatic PAD, defined as claudication, critical limb ischemia (ischemic rest pain, nonhealing ischemic ulcers, gangrene), a history of vascular reconstruction, bypass surgery, percutaneous intervention to the extremities, or amputation for critical limb ischemia.
• supervised exercise programs (a minimum of 30 to 45 minutes, in sessions performed at least three times per week, for a minimum of 12 weeks. Randomized trials show that a supervised exercise program for claudication is able to increase patient walking distance by up to 200% as well as walking speed),
• lower-extremity vein bypass graft surveillance via periodic ABI and ultrasound, and
• monitoring of abdominal aortic aneurysms that are between 4.0 and 5.4 cm.

The goal of the performance measures is to increase the use of ABI and exercise programs, and thus improve patients' overall well-being, quality of life and pain-free walking distance and speed, as well as reduce their risk of heart attack, stroke and death.