What should be done if Peripheral Artery Disease (PAD) is suspected?

Management of Suspected Peripheral Artery Disease (PAD)

When peripheral artery disease (PAD) is suspected, patients should undergo a comprehensive vascular review of symptoms, pulse examination, and inspection of the feet, followed by ankle-brachial index (ABI) measurement as the initial diagnostic test. 1

Initial Assessment

• Individuals at risk for PAD should undergo a vascular review of symptoms to assess walking impairment, claudication, ischemic rest pain, and/or the presence of nonhealing wounds 1
• A comprehensive pulse examination and inspection of the feet should be performed for all individuals at risk for PAD 1
• Individuals over 50 years of age should be asked about family history of abdominal aortic aneurysm (AAA) in first-order relatives 1
• Blood pressure should be measured in both arms at least once during initial assessment to identify potential subclavian artery stenosis (difference >15-20 mmHg) 1

Diagnostic Testing

• Ankle-brachial index (ABI) is the recommended initial diagnostic test for confirming PAD 1

  • An ABI ≤0.90 confirms PAD diagnosis 1
  • If ABI is normal (>0.90) but clinical suspicion remains high, post-exercise ABI should be considered (a post-exercise decrease >20% is diagnostic for PAD) 1
  • For ABI >1.40 (non-compressible vessels, common in diabetes and end-stage renal disease), toe-brachial index (TBI) should be used 1, 2

• Additional diagnostic tests to consider:

  • Duplex ultrasound is recommended as first-line imaging for PAD screening and diagnosis 1
  • Segmental pressure measurements and pulse volume recordings can help localize disease 1
  • For patients with suspected critical limb ischemia (CLI), assessment of tissue perfusion with transcutaneous oxygen pressure (TcPO2) is recommended 1

Medical Management

• Antiplatelet therapy:

  • Clopidogrel (75 mg daily) is preferable to aspirin alone for all PAD patients 3, 4
  • For patients with PAD and high ischemic risk but non-high bleeding risk, combination of low-dose rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg daily) should be considered 1

• Lipid management:

  • High-intensity statin therapy is recommended to achieve LDL-C ≤2.5 mmol/L (100 mg/dL) 2, 5

• Blood pressure control:

  • Target blood pressure <140/90 mmHg 5
  • All classes of antihypertensive drugs including beta-blockers are acceptable 5

• Diabetes management:

  • Target HbA1c ≤7% 5
  • Consider GLP-1 receptor agonists and SGLT-2 inhibitors (with caution regarding amputation risk with canagliflozin) 2

• Smoking cessation:

  • Pharmacotherapy with nicotine replacement, bupropion, or varenicline is recommended 4

Exercise Therapy

• Supervised exercise therapy is recommended for patients with intermittent claudication 1

  • Training frequency of at least three times per week
  • Session duration of at least 30 minutes
  • Program duration of at least 12 weeks 1

• If supervised exercise is not available, structured home-based exercise programs with step monitoring should be considered 4

Management of Critical Limb Ischemia (CLI)

• Patients with CLI should undergo expedited evaluation and treatment of factors that increase amputation risk 1
• Early recognition and referral to a vascular team is essential for limb salvage 1
• Revascularization should be performed as soon as possible in CLI patients 1
• Patients with CLI in whom open surgical repair is anticipated should undergo cardiovascular risk assessment 1

Follow-up

• Patients with PAD should be followed up at least annually to assess clinical and functional status, medication adherence, limb symptoms, and cardiovascular risk factors 1
• Patients with a history of CLI should be evaluated at least twice annually by a vascular specialist due to the high risk of recurrence 1
• Patients at risk of CLI (ABI <0.4 in diabetics or any diabetic with known PAD) should undergo regular foot inspection 1

Revascularization Considerations

• Revascularization may be considered in patients with symptomatic PAD and impaired quality of life after 3 months of optimal medical therapy and exercise 1
• Revascularization is not recommended for asymptomatic PAD or solely to prevent progression to CLI 1
• The mode and type of revascularization should be adapted to anatomical lesion location, morphology, and general patient condition 1