What is the treatment plan for Peripheral Artery Disease (PAD)?

Treatment Plan for Peripheral Artery Disease (PAD)

The treatment of PAD should include a comprehensive program of supervised exercise training, optimal medical therapy, risk factor modification, and revascularization when appropriate to reduce morbidity, mortality, and improve quality of life.

Risk Factor Modification and Lifestyle Changes

• Smoking cessation is essential for all patients with PAD who smoke, with counseling and pharmacotherapy (varenicline, bupropion, and/or nicotine replacement therapy) 1
• Structured exercise programs should be implemented with a frequency of at least three times per week, session duration of at least 30 minutes, and program duration of at least 12 weeks 1
• Patients should exercise to moderate-severe claudication pain to maximize walking performance improvements, though a flexible approach considering patient preferences may be needed 1
• A heart-healthy diet rich in legumes, fiber, nuts, fruits, and vegetables is recommended for cardiovascular risk reduction 2

Pharmacological Management

Antiplatelet/Antithrombotic Therapy

• For symptomatic PAD patients, low-dose rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin is recommended to reduce major adverse cardiovascular events (MACE) and major adverse limb events (MALE) 1
• Alternatively, single antiplatelet therapy with aspirin (75-100 mg daily) or clopidogrel (75 mg daily) is recommended for secondary prevention 1, 3
• After endovascular revascularization, dual antiplatelet therapy with a P2Y12 antagonist and low-dose aspirin is reasonable for 1-6 months 1
• Anticoagulation alone is not recommended to reduce cardiovascular events in PAD patients 1

Lipid Management

• Statin therapy is indicated for all patients with PAD 1
• Target LDL-C should be <70 mg/dL for very high-risk PAD patients 2
• For patients on maximally tolerated statin therapy with LDL-C ≥70 mg/dL, adding PCSK9 inhibitors or ezetimibe is reasonable 1

Blood Pressure Management

• Antihypertensive therapy should be administered to reduce the risk of MI, stroke, heart failure, and cardiovascular death 1
• Target blood pressure should be <140/90 mmHg for patients without diabetes and <130/80 mmHg for patients with diabetes or chronic kidney disease 1
• Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are effective to reduce cardiovascular events in PAD patients 1, 2

Glycemic Control

• Management of diabetes should be coordinated between healthcare team members 1
• Improved glycemic control can benefit patients with critical limb ischemia to reduce limb-related outcomes 1

Symptom Management

• Cilostazol (100 mg twice daily) is recommended for patients with refractory claudication despite exercise therapy and smoking cessation 1
• Pentoxifylline is not recommended due to limited efficacy 1, 4
• For patients with critical limb ischemia and rest pain who cannot undergo revascularization, prostanoids may be considered 1

Exercise Therapy

• Supervised exercise training (SET) is recommended as first-line therapy for patients with claudication to improve functional status and quality of life 1
• SET should include at least three sessions per week, 30-60 minutes per session, for at least 12 weeks 1
• When SET is unavailable, structured home-based exercise training should be offered, though it is somewhat less effective 1
• Vigorous intensity exercise (77%-95% of maximal heart rate) provides the best walking and cardiorespiratory fitness improvements, but programs should begin at lower intensity and gradually advance 1

Revascularization

• Revascularization (endovascular, surgical, or hybrid) should be considered for:
  • Patients with chronic limb-threatening ischemia to prevent limb loss 1
  • Patients with claudication not responsive to medical therapy and structured exercise to improve quality of life 1
• The approach to revascularization should be tailored to the anatomical location, lesion morphology, and patient's overall condition 2

Follow-up and Monitoring

• Patients with PAD should receive periodic clinical evaluation including assessment of cardiovascular risk factors, limb symptoms, and functional status 1
• After revascularization, patients should undergo regular follow-up with ABI measurement 1
• Duplex ultrasound surveillance is beneficial for monitoring infrainguinal autogenous vein bypass grafts 1
• Annual follow-up is recommended to assess clinical and functional status, medication adherence, limb symptoms, and cardiovascular risk factors 2

Special Considerations

• Patients with PAD should be screened for abdominal aortic aneurysm 2
• Care for patients with PAD, especially those with chronic limb-threatening ischemia, is optimized when delivered by a multispecialty care team 1
• Foot care is crucial for all PAD patients, particularly those with diabetes, including appropriate footwear, daily inspection, skin cleansing, and prompt attention to lesions 1

Common Pitfalls to Avoid

• Underutilization of optimal medical therapy in PAD compared to coronary artery disease patients 1, 5
• Delaying supervised exercise programs, which have strong evidence for improving walking performance 1
• Overreliance on opioid medications for pain management, which carries risks of dependency, addiction, depression, and death 1
• Failure to recognize the high cardiovascular risk of PAD patients, who require aggressive risk factor modification 6, 7