What is the next step in managing a patient with peripheral arterial disease (PAD) and significant atheromatous changes in the lower extremity arteries?

Management of Peripheral Arterial Disease with Atheromatous Changes

The next step in managing a patient with moderate to severe atheromatous changes in the lower extremity arteries should be initiation of antiplatelet therapy, statin medication, and a structured exercise program while addressing modifiable cardiovascular risk factors. 1

Pharmacological Management

Antiplatelet Therapy

• Single antiplatelet therapy with either aspirin (75-325 mg daily) or clopidogrel (75 mg daily) is indicated to reduce the risk of myocardial infarction, stroke, and vascular death in patients with symptomatic PAD 1
• In asymptomatic patients with PAD (ABI ≤0.90), antiplatelet therapy is reasonable to reduce cardiovascular risk 1
• Clopidogrel may be preferred over aspirin based on the CAPRIE trial, which demonstrated greater benefit in the PAD subgroup 2
• For very high-risk patients, low-dose rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin (81 mg daily) can be considered to reduce both cardiovascular and limb events 3

Lipid Management

• Statin therapy is indicated for all patients with PAD to reduce cardiovascular risk 1
• Target LDL-cholesterol should be less than 70 mg/dL for patients with PAD at very high risk of ischemic events 1, 4
• Intensive lipid lowering is particularly important as patients with PAD demonstrate greater progression of atheroma volume compared to those without PAD 4

Blood Pressure Management

• Antihypertensive therapy should be administered to patients with hypertension and PAD to reduce the risk of myocardial infarction, 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 can be effective to reduce cardiovascular events in patients with PAD 1

Exercise Therapy

• Structured exercise therapy is a core component of PAD management and should be initiated promptly 1
• Supervised exercise training is recommended 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 5, 3
• When supervised exercise is not available, a structured home-based exercise program with monitoring should be considered 2
• Walking should be the primary training modality, with exercise to moderate-severe claudication pain to maximize walking performance improvements 3, 2

Risk Factor Modification

• Smoking cessation is essential for all patients with PAD who smoke, with counseling and pharmacotherapy including varenicline, bupropion, and/or nicotine replacement therapy 1, 5
• Management of diabetes should be coordinated between healthcare team members, with glycemic control beneficial for patients with critical limb ischemia 1, 3
• A comprehensive approach addressing all modifiable risk factors simultaneously provides greater risk reduction than addressing individual factors 6

Follow-up and Monitoring

• Patients with PAD should receive periodic clinical evaluation, including assessment of cardiovascular risk factors, limb symptoms, and functional status 1
• Duplex ultrasound can be beneficial for routine surveillance after endovascular procedures in patients with PAD 1
• Follow-up should occur at least annually to evaluate clinical status, functional status, medication adherence, limb symptoms, and cardiovascular risk factors 5

Special Considerations

• The ultrasound findings indicate moderate to severe atheromatous changes with plaque formation causing mild to moderate arterial narrowing, which requires medical management before considering invasive interventions 7
• Revascularization (endovascular or surgical) should be considered only if symptoms persist despite optimal medical therapy and structured exercise for at least 3 months 5
• Patients with PAD should be screened for abdominal aortic aneurysm due to the high prevalence of concomitant vascular disease 3
• Care is optimized when delivered by a multispecialty team, especially for patients with advanced disease 1

Common Pitfalls to Avoid

• Undertreatment of PAD compared to other forms of cardiovascular disease is common and should be avoided 2
• Dual antiplatelet therapy is not well established for routine use in PAD and should be reserved for specific high-risk scenarios 1
• Focusing only on limb symptoms while neglecting the increased risk of cardiovascular events can lead to suboptimal outcomes 8, 9
• Delaying initiation of comprehensive medical therapy while waiting for symptoms to worsen can miss the opportunity for early risk reduction 1