What is the initial management and treatment for patients with peripheral artery disease (PAD)?

Initial Management and Treatment for Peripheral Artery Disease (PAD)

The initial management of peripheral artery disease should include supervised exercise therapy, antiplatelet therapy, statin medication, risk factor modification, and smoking cessation, with revascularization considered only after a 3-month trial of optimal medical therapy in patients with persistent lifestyle-limiting symptoms. 1, 2

Risk Factor Modification

• All patients with PAD should receive aggressive cardiovascular risk factor modification to reduce morbidity and mortality 1
• Statin therapy is indicated for all PAD patients to achieve an LDL-C target of <100 mg/dL, with a more aggressive target of <70 mg/dL reasonable for very high-risk patients 1
• Antihypertensive therapy should target blood pressure <140/90 mmHg in most patients, or <130/80 mmHg in those with diabetes or chronic kidney disease 1
• Beta-blockers are effective antihypertensive agents and are not contraindicated in PAD 1
• For patients with diabetes and PAD, glucose control should target hemoglobin A1C <7% to reduce microvascular complications 1
• Proper foot care is essential for patients with diabetes and PAD, including appropriate footwear, daily foot inspection, and prompt treatment of skin lesions 1

Exercise Therapy

• A supervised exercise training program is recommended as first-line treatment for patients with intermittent claudication 1, 2
• Exercise sessions should be performed at least 3 times per week for a minimum of 30 minutes per session, for at least 12 weeks 1, 2
• Walking to moderate-severe claudication pain may improve walking performance, though improvements can also be achieved with lesser pain severities 1
• Progressive increase in exercise training load every 1-2 weeks may be considered based on patient tolerance 1

Antiplatelet Therapy

• For symptomatic PAD patients, antiplatelet therapy is recommended to reduce the risk of myocardial infarction, stroke, and vascular death 1
• Clopidogrel (75 mg daily) is recommended as the preferred antiplatelet agent for PAD patients 1, 3, 4
• Alternatively, aspirin (75-100 mg daily) is effective for reducing cardiovascular events in symptomatic PAD patients 1
• For asymptomatic PAD patients with ABI ≤0.90, antiplatelet therapy can be useful to reduce cardiovascular risk 1
• In high ischemic risk PAD patients with non-high bleeding risk, combination therapy with rivaroxaban (2.5 mg twice daily) and aspirin (100 mg daily) should be considered 1

Pharmacological Management of Claudication

• Cilostazol (100 mg twice daily) is indicated to improve symptoms and increase walking distance in patients with intermittent claudication who do not have heart failure 1
• Pentoxifylline (400 mg three times daily) may be considered as a second-line alternative to cilostazol, though its clinical effectiveness is marginal 1

Revascularization

• Revascularization should be considered only after a 3-month trial of optimal medical therapy (OMT) and exercise therapy in patients with persistent lifestyle-limiting symptoms and impaired quality of life 1
• The mode and type of revascularization should be adapted to anatomical lesion location, lesion morphology, and general patient condition 1
• Revascularization is not recommended for asymptomatic PAD or solely to prevent progression to chronic limb-threatening ischemia (CLTI) 1
• For femoro-popliteal lesions, drug-eluting treatment should be considered as the first-choice endovascular strategy 1

Follow-up

• Regular follow-up at least once a year is recommended to assess clinical and functional status, medication adherence, limb symptoms, and cardiovascular risk factors 1, 2
• Duplex ultrasound assessment should be performed as needed during follow-up 1

Special Considerations for Chronic Limb-Threatening Ischemia (CLTI)

• Early recognition of CLTI and prompt referral to a vascular team are essential for limb salvage 1
• Revascularization should be performed as soon as possible in CLTI patients 1
• In CLTI patients with ulcers, offloading mechanical tissue stress is indicated to allow wound healing 1
• Lower-limb exercise training is not recommended in CLTI patients with wounds 1