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

Treatment of Peripheral Artery Disease (PAD)

The comprehensive treatment of Peripheral Artery Disease (PAD) requires a combination of supervised exercise training, optimal medical therapy including antiplatelet agents and statins, 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 recommended to improve outcomes 1, 2
• A healthy diet rich in legumbres, fiber, nuts, fruits, and vegetables is recommended for cardiovascular prevention in PAD patients 3
• Proper foot care, including appropriate footwear, daily foot inspection, skin cleansing, and addressing skin lesions urgently is crucial, especially in diabetic patients 1
• Weight loss should be encouraged for overweight/obese patients with PAD 4

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, 2
• SET should be performed at least three times per week, for 30-60 minutes per session, with a program duration of at least 12 weeks 1, 5
• Patients should exercise to moderate-severe claudication pain to maximize walking performance improvements 1, 2
• When SET is not available, structured home-based exercise training with monitoring should be offered as an alternative 1, 5

Pharmacological Management

Antiplatelet/Antithrombotic Therapy

• Antiplatelet therapy with aspirin (75-100 mg daily) or clopidogrel (75 mg daily) is recommended for all symptomatic PAD patients to reduce myocardial infarction, stroke, and vascular death 1, 6
• Clopidogrel is preferred over aspirin based on the CAPRIE trial results 5, 7
• Low-dose rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin can be considered to reduce major adverse cardiovascular events (MACE) and major adverse limb events (MALE) in symptomatic PAD patients 2
• Antiplatelet therapy is not routinely indicated in patients with isolated asymptomatic PAD 1

Lipid Management

• Statin therapy is indicated for all patients with PAD to achieve a target LDL-C level of less than 100 mg/dL 1, 2
• For PAD patients at very high risk of ischemic events, a target LDL-C of less than 70 mg/dL is reasonable 1, 5
• Fibric acid derivatives can be useful for PAD patients with low HDL cholesterol, normal LDL cholesterol, and elevated triglycerides 1

Blood Pressure Management

• Antihypertensive therapy should be administered to reduce cardiovascular events in PAD patients with 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 1, 2
• Beta-blockers are effective antihypertensive agents and are not contraindicated in PAD patients 1
• ACE inhibitors may be considered for asymptomatic PAD patients to reduce adverse cardiovascular events 1

Diabetes Management

• Strict glycemic control is recommended for diabetic patients with PAD 1
• Treatment to reduce hemoglobin A1C to less than 7% can effectively reduce microvascular complications and potentially improve cardiovascular outcomes 1

Additional Pharmacotherapy

• Cilostazol, a phosphodiesterase III inhibitor, can improve walking distance and symptoms in patients with claudication 5, 8

Revascularization

• Revascularization should be considered for patients with chronic limb-threatening ischemia to prevent limb loss 2
• Revascularization may be considered for patients with claudication who have not responded to 3 months of optimal medical therapy and structured exercise 1, 2
• The mode and type of revascularization should be adapted to the anatomical location of the lesion, lesion morphology, and the patient's general condition 3
• Revascularization is not recommended for asymptomatic PAD 5

Follow-up and Monitoring

• Regular follow-up, at least annually, is recommended for PAD patients to assess clinical and functional status, medication adherence, limb symptoms, and cardiovascular risk factors 3, 2
• After revascularization, patients should undergo regular follow-up with ABI measurement 2
• Follow-up clinical evaluation, including physical examination and renal function assessment, is recommended within 2 weeks after contrast angiography to detect delayed adverse effects 1

Common Pitfalls and Special Considerations

• PAD patients are often undertreated compared to those with other forms of cardiovascular disease 5, 9
• Patients with PAD should be screened for abdominal aortic aneurysm 5, 2
• Care for PAD patients, especially those with chronic limb-threatening ischemia, is optimized when delivered by a multidisciplinary vascular team 1, 2
• Women may respond differently than men to exercise therapy 5
• The prevalence of atherosclerosis in coronary, carotid, and renal arteries is higher in PAD patients, justifying intensive risk factor management 3