Guideline updates recommendations on management of lower-limb PAD

An updated guideline provides recommendations to guide clinicians in the treatment of patients with lower-extremity peripheral artery disease (PAD) across four clinical presentations ranging from asymptomatic to acute.

The American College of Cardiology/American Heart Association joint clinical practice guideline was published May 14 in Circulation and the Journal of the American College of Cardiology.

The guideline includes the following points:

1. 1. PAD is common, especially at the end of life, and is associated with increased risk of amputation, myocardial infarction, stroke, and death, as well as impaired quality of life, walking performance, and function.
2. 2. There are four clinical subsets of PAD: asymptomatic (may have functional impairment), chronic symptomatic (including claudication), chronic limb-threatening ischemia, and acute limb ischemia.
3. 3. Detecting PAD in most patients is done through the history, physical examination, and resting ankle-brachial index.
4. 4. Health disparities in patients with PAD are associated with more limb amputations and worse cardiovascular outcomes and must be addressed at the individual patient, population, and structural level.
5. 5. Effective medical therapies should be prescribed to prevent major adverse cardiovascular events and major adverse limb events for patients with PAD, including antiplatelet and antithrombotic therapies, lipid-lowering and antihypertensive drugs, management of diabetes, and smoking cessation. Rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin (81 mg daily) is effective to prevent major adverse cardiovascular events and major adverse limb events in patients with PAD who are not at increased risk of bleeding, the guideline said.
6. 6. Exercise is a core component of care for PAD, including supervised therapy and community-based and home-based programs.
7. 7. Revascularization (endovascular, surgical, or hybrid) should be used to prevent limb loss in those with limb-threatening ischemia and can be used to improve quality of life and functional status in patients with claudication not responsive to medicine or exercise, according to the guideline.

An accompanying editorial in Circulation noted that since the societies last released a guideline on the subject in 2016, much has changed and more evidence-based management options are available.

For example, the recommendation in support of the combination of rivaroxaban and aspirin represents the first new class I recommendation of an antithrombotic regimen for PAD in approximately two decades.

"As new evidence becomes available, future iterations of the PAD Guidelines will have to consider recommendations regarding dual antiplatelet therapy after endovascular intervention despite the lack of supportive efficacy data vs the proven strategy of aspirin and low dose rivaroxaban, whether targeted diabetes therapies should be recommended based on their efficacy for PAD outcomes relative to other benefits, and whether there is a role for anti-inflammatory therapies," the editorial stated. "Ultimately ongoing research will be required as the guideline writing committee is dependent on researchers to provide rich data for it to consider and weigh when making recommendations."