Guidance issued on diagnosis, management of PAD in diabetes
A scientific statement from the American College of Cardiology covers screening, lifestyle and exercise recommendations, medications, and other topics in patients with diabetes who have or are at risk for peripheral artery disease (PAD).
Screening for peripheral artery disease (PAD) is reasonable in asymptomatic adults with diabetes and additional risk factors, according to a recent scientific statement from the American College of Cardiology.
The statement, which was published Dec. 17 by the Journal of the American College of Cardiology, covers screening, lifestyle and exercise recommendations, medications, and other topics in patients with diabetes who have or are at risk for PAD.
The sensitivity of the ankle-brachial index (ABI) is limited in individuals with vascular calcification, the statement said. If the ABI indicates noncompressible arteries, the toe-brachial index is preferred, with values below 0.70 considered abnormal. Measuring the ABI immediately after treadmill exercise may better identify PAD in people with diabetes and exertional leg symptoms whose ABI is normal or borderline at rest, according to the statement.
Regarding lifestyle, clinicians should recommend smoking cessation, physical activity, and a plant-forward, lower-fat, whole food-based diet in patients with diabetes and PAD. There is strong evidence that standardized exercise therapy improves functional status and quality of life in people with symptomatic PAD, the statement said, noting that if access to such therapy is limited, a structured home-based program is a reasonable alternative.
Patients with diabetes may benefit from multidisciplinary care teams including cardiology, endocrinology, podiatry, primary care, vascular medicine, and vascular surgery and should receive evidence-based medications that improve cardiorenal and limb outcomes, functional status, and quality of life in accordance with clinical practice guidelines, the statement said. The statement recommended prioritizing sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists because of their broad cardio-kidney-metabolic benefits, noting that semaglutide has specifically been shown to improve functional capacity, symptoms, and quality of life in people with symptomatic PAD.
Low-density lipoprotein cholesterol should be treated to a target reduction of at least 50%, with a goal of a level below 55 mg/dL, the statement said. Hypertension should be treated to a goal below 130/80 mm Hg, with an ideal systolic blood pressure less than 120 mm Hg if it can be achieved safely, according to the statement. Rivaroxaban, 2.5 mg twice daily, and aspirin, 75 to 100 mg/d, should be used to reduce risk of major adverse cardiac and limb events, except in those at high risk for bleeding, the statement said. Aspirin monotherapy, 75 to 100 mg/d, or clopidogrel, 75 mg/d, should be considered as second-line therapy.
The statement also included recommendations on additional assessments for patients with PAD and surgical and interventional management. “Key knowledge gaps persist in optimal screening cadence and mentation, standardized clinical endpoints, and cost-effectiveness needed to align incentives,” the statement authors concluded. “Implementing these evidence-based strategies through equitable ways is the best way to prevent limb loss and cardiovascular events in people with diabetes and PAD.”