You’ll get questions about managing stable peripheral artery disease (PAD)...based on new guidelines from Am Coll of Cardiology/Am Heart Assn.
Think of managing PAD as similar to coronary artery disease.
Plaque buildup puts PAD patients at high risk of complications, such as CV events or limb amputation. And they may develop symptoms...such as pain or claudication that reduces walking distance and quality of life.
Emphasize lifestyle changes. Explain that smoking may accelerate progression of PAD and shorten walking times. Strongly encourage smoking cessation if needed...it lowers risk of CV events, amputations, and death.
Recommend exercise to reduce pain and increase walking distance. A supervised program (cardiac rehab, etc) seems to help most. It may increase walking distance by about the length of a football field.
Stress proper foot care...especially in PAD patients with diabetes.
Focus on CV risks...hypertension, dyslipidemia, and diabetes. For example, recommend a high-intensity statin (atorvastatin 80 mg/day, etc).
And recommend aspirin 81 mg/day OR clopidogrel 75 mg/day to reduce CV risk in symptomatic PAD. Expect DUAL antiplatelets to be saved for after procedures, such as a few months after a peripheral artery stent.
But other antithrombotics aren’t as clear-cut.
For example, adding rivaroxaban 2.5 mg bid to low-dose aspirin for 2 years prevents a stroke, heart attack, or CV death in about 1 in 50 PAD patients...and prevents an amputation in about 1 in 150 patients.
On the other hand, the combo leads to an additional major bleed in about 1 in 100 PAD patients. Plus rivaroxaban costs about $570/month.
Help guide shared decisions. Consider adding rivaroxaban in select cases...such as the rare PAD patient who’s adherent to optimized CV meds AND has low bleeding risk.
Don’t jump to additional meds just to improve walking distance.
For example, benefit with cilostazol is modest...adverse effects (diarrhea, dizziness, etc) are common...and it’s contraindicated with heart failure. Generally save cilostazol for patients with PAD symptoms despite exercise and optimized CV risk factors.
And don’t recommend pentoxifylline to improve walking distance...it doesn’t seem more effective than placebo.
Use our resource, Optimizing Care of Patients With PAD, for guidance on managing CV risk, choosing antithrombotics, and more.
- Writing Committee Members; Gornik HL, Aronow HD, Goodney PP, et al. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2024 Jun 18;83(24):2497-2604.
- Aboyans V, Ricco JB, Bartelink MEL, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. Endorsed by: the European Stroke Organization (ESO) The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J. 2018 Mar 1;39(9):763-816.
- Medication pricing by Elsevier, accessed July 2024.