Antihypertensive Management in Peripheral Artery Disease
In patients with peripheral artery disease (PAD) and hypertension, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) should be considered as first-line antihypertensive therapy with a target systolic blood pressure of 120-129 mmHg, if tolerated. 1
Blood Pressure Targets
- A systolic blood pressure (SBP) target of <130 mmHg and diastolic blood pressure (DBP) target of <80 mmHg is recommended for patients with PAD and hypertension to reduce the risk of major adverse cardiovascular events (MACE) 1
- The 2024 ESC guidelines recommend targeting SBP towards 120-129 mmHg in patients with peripheral arterial and aortic diseases (PAAD) and hypertension, if tolerated 1
- For patients who cannot tolerate lower targets, an individualized, more lenient BP goal (e.g., <140/90 mmHg) should be considered in specific populations:
First-Line Medication Recommendations
- ACEIs or ARBs should be considered as first-line antihypertensive therapy in patients with PAD and hypertension 1
- The selective use of ACEIs or ARBs is recommended to reduce the risk of MACE in patients with PAD and hypertension 1
- ACEIs/ARBs may be considered in all patients with PAD to reduce cardiovascular events, regardless of BP levels, in the absence of contraindications 1
Evidence for ACEI/ARB Use in PAD
- In the HOPE (Heart Outcomes Prevention Evaluation) trial, ramipril reduced the risk of MI, stroke, or vascular death by 25% in a subgroup of 4,051 patients with PAD 1
- The ONTARGET trial showed that telmisartan had similar efficacy to ramipril in reducing cardiovascular events in patients with PAD 1
- This benefit was observed in both symptomatic PAD and asymptomatic patients with low ABI 1
Other Antihypertensive Medications in PAD
- Beta-blockers are not contraindicated in PAD and can be prescribed to patients with intermittent claudication when necessary, as they do not worsen walking capacity or limb events 1
- Multiple studies have demonstrated that blood pressure treatment, including beta-blockers, does not worsen claudication symptoms or impair functional status in patients with PAD 1
- In renal artery stenosis (RAS)-related hypertension, the combination of ACEIs/ARBs with diuretics and/or calcium channel blockers should be considered 1
Comprehensive Management Approach
- Antihypertensive therapy should be administered to all patients with hypertension and PAD to reduce the risk of MI, stroke, heart failure, and cardiovascular death 1
- There is no conclusive evidence that one specific class of antihypertensive medication is superior for blood pressure lowering in PAD 1, 2
- Treatment decisions should prioritize overall cardiovascular risk reduction rather than focusing solely on the choice of individual antihypertensive drugs 3
- Combination therapy is often required to achieve target blood pressure goals 4
Common Pitfalls and Caveats
- Avoid excessive blood pressure lowering that might compromise perfusion to the affected limb 5
- Both high and relatively lower blood pressure levels have been associated with worse outcomes in PAD patients 5
- Monitor for worsening renal function when using ACEIs/ARBs, particularly in patients with bilateral renal artery stenosis 1
- In patients with bilateral RAS, antihypertensive medication including ACEIs/ARBs may be considered only if close patient monitoring (renal function) is feasible 1
- Recognize that PAD patients often require multiple antihypertensive agents to reach goal blood pressure 4
Additional Cardiovascular Risk Management
- All patients with PAD should receive antiplatelet therapy (75-100 mg aspirin daily) to reduce MACE 1
- Statin therapy is indicated for all patients with PAD to improve both cardiovascular and limb outcomes 1
- Supervised exercise therapy is recommended for patients with symptomatic PAD 1
- Smoking cessation is crucial for patients with PAD who smoke 1