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

Treatment of Mild Peripheral Artery Disease

Supervised exercise training is the first-line treatment for mild peripheral artery disease (PAD), with a recommended frequency of at least three times per week for at least 30 minutes per session over a minimum of 12 weeks. 1

First-Line Interventions

Exercise Therapy

• Supervised exercise training (SET) is recommended as the primary treatment for patients with mild PAD 1
• When SET is not available, a structured home-based exercise training (HBET) program with monitoring (calls, logbooks, connected devices) should be considered 1
• Walking should be the first-line training modality, with high-intensity exercise (77-95% of maximal heart rate) recommended for optimal results 1
• Exercise improves walking performance through multiple mechanisms including improved mitochondrial function, arteriogenesis, endothelial function, and reduced inflammation 1

Risk Factor Modification

• Smoking cessation is essential for all patients with PAD who smoke 1, 2
• Healthy diet rich in legumes, fiber, nuts, fruits, and vegetables is recommended 3, 4
• Weight loss for overweight/obese patients should be encouraged 4

Pharmacological Management

Antiplatelet Therapy

• Antiplatelet therapy with aspirin alone (75-325 mg daily) or clopidogrel alone (75 mg daily) is recommended to reduce myocardial infarction, stroke, and vascular death in symptomatic PAD 1, 5
• In asymptomatic patients with PAD (ABI ≤0.90), antiplatelet therapy is reasonable to reduce cardiovascular events 1
• Clopidogrel may be preferred over aspirin based on the CAPRIE trial showing greater benefit in the PAD subgroup 1, 6

Lipid Management

• Statin therapy is indicated for all patients with PAD 1, 2
• Target LDL-C should be <70 mg/dL for PAD patients who are at very high cardiovascular risk 2, 3

Blood Pressure Management

• Antihypertensive therapy should be administered to reduce cardiovascular events in patients with PAD and hypertension 1, 2
• Target blood pressure should be <140/90 mmHg for patients without diabetes and <130/80 mmHg for patients with diabetes or chronic kidney disease 2

Additional Pharmacotherapy

• Cilostazol (a phosphodiesterase III inhibitor) has shown benefit in improving maximal walking distance and ankle-brachial index in patients with claudication 1
• For patients with diabetes, glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors should be considered 6

Treatment Algorithm for Mild PAD

1. Initial Management (0-3 months):

   • Begin supervised exercise training (3+ sessions/week, 30+ minutes/session) 1
   • Start antiplatelet therapy (clopidogrel 75 mg daily preferred) 1, 6
   • Initiate statin therapy 1, 2
   • Implement risk factor modification (smoking cessation, diet, weight management) 2, 4
   • Control blood pressure if hypertensive 2

2. Assessment at 3 months:

   • Evaluate PAD-related quality of life and symptoms 1
   • If improved: continue current management
   • If not improved: consider adding cilostazol 1

3. Follow-up:

   • Regular follow-up at least once a year to assess clinical and functional status, medication adherence, limb symptoms, and cardiovascular risk factors 1

Important Considerations and Pitfalls

• Revascularization is NOT recommended for asymptomatic PAD or solely to prevent progression to chronic limb-threatening ischemia 1
• Patients with PAD should be screened for abdominal aortic aneurysm 1, 2
• Women may respond less well than men to exercise therapy, though evidence is inconsistent 1
• The effectiveness of dual antiplatelet therapy (aspirin and clopidogrel) to reduce cardiovascular events in PAD is not well established 1
• Patients with PAD are often undertreated compared to those with other forms of cardiovascular disease 1

By following this evidence-based approach focusing on exercise therapy, risk factor modification, and appropriate pharmacotherapy, patients with mild PAD can experience significant improvements in walking capacity, quality of life, and reduced risk of cardiovascular events.