What changes are made to a patient's treatment plan if they are diagnosed with Peripheral Artery Disease (PAD)?

Treatment Changes Upon PAD Diagnosis

When PAD is diagnosed, initiate comprehensive medical therapy immediately, including high-intensity statin therapy targeting LDL-C <70 mg/dL, antithrombotic therapy (combination rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily for high ischemic risk patients with non-high bleeding risk), supervised exercise training at least 3 times weekly for minimum 12 weeks, aggressive blood pressure control, smoking cessation with pharmacotherapy, and annual follow-up with vascular specialists. 1

Lipid Management

• Start statin therapy immediately to achieve LDL-C <100 mg/dL (Class I recommendation), with a more aggressive target of <70 mg/dL reasonable for very high-risk PAD patients 1
• The 2024 ESC guidelines emphasize intensive lipid lowering as foundational therapy 1
• Consider fibric acid derivatives for patients with low HDL, normal LDL, and elevated triglycerides 1

Antithrombotic Therapy

The most significant recent advancement is dual pathway inhibition:

• Combination rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily should be considered for PAD patients with high ischemic risk and non-high bleeding risk 1
• This combination is also recommended following lower-limb revascularization in patients with non-high bleeding risk 1
• For patients not on dual therapy, clopidogrel 75 mg daily (without loading dose for chronic PAD) or aspirin 75-100 mg daily are alternatives 2, 3
• Aspirin 75-100 mg may be considered for primary prevention in asymptomatic PAD patients with diabetes 1

Important caveat: Clopidogrel effectiveness depends on CYP2C19 metabolism; consider alternative P2Y12 inhibitors in poor metabolizers 2

Blood Pressure Control

• Treat hypertension to achieve <140/90 mmHg (or <130/80 mmHg in patients with diabetes or chronic kidney disease) 1
• Beta-blockers are not contraindicated in PAD and are effective antihypertensives 1
• ACE inhibitors may be considered to reduce adverse cardiovascular events 1

Exercise Therapy

Supervised exercise training is a Class I recommendation as initial treatment:

• Walking training at high intensity (77-95% maximal heart rate or 14-17 on Borg scale) should be considered 1
• Minimum parameters: 3 times weekly, 30 minutes per session, for at least 12 weeks 1
• Alternative modes (strength training, arm cranking, cycling) should also be considered 1
• Exercise to moderate-severe claudication pain may be considered to improve walking performance 1

Critical distinction: Exercise training is not recommended in patients with chronic limb-threatening ischemia (CLTI) and wounds 1

Smoking Cessation

Mandatory intervention at every visit:

• Ask about tobacco use status at every encounter 1
• Provide counseling and develop a quit plan with pharmacotherapy 1
• Offer one or more of: varenicline, bupropion, or nicotine replacement therapy (unless contraindicated) 1, 3

Diabetes Management

• Target HbA1c <7% to reduce microvascular complications and potentially improve cardiovascular outcomes 1
• Implement proper foot care immediately: appropriate footwear, daily foot inspection, skin cleansing, topical moisturizing creams, and urgent attention to skin lesions/ulcerations 1

Revascularization Considerations

The 2024 ESC guidelines provide clear algorithmic guidance:

• After 3 months of optimal medical therapy (OMT) and exercise therapy, assess PAD-related quality of life 1
• Revascularization may be considered only if QOL remains impaired after this 3-month trial 1
• Revascularization is NOT recommended solely to prevent progression to CLTI 1
• Asymptomatic PAD should NOT be revascularized 1

Follow-Up Protocol

Establish structured longitudinal care:

• Annual follow-up minimum with vascular specialist, assessing clinical/functional status, medication adherence, limb symptoms, and cardiovascular risk factors 1
• Coordinate care among multiple clinicians to optimize management of PAD and comorbid conditions 1
• Periodic assessment of functional status and health-related QOL is recommended 1
• Long-term guideline-directed medical therapy (GDMT) to prevent major adverse cardiovascular events (MACE) and major adverse limb events (MALE) 1

Post-Revascularization Surveillance

If revascularization is performed:

• ABI and arterial duplex ultrasound at 1-3 months, 6 months, 12 months, then annually for both endovascular and autogenous vein bypass procedures 1
• Immediate ABI and duplex ultrasound if new lower extremity signs or symptoms develop 1

Special Considerations for CLTI

If PAD progresses to chronic limb-threatening ischemia:

• Immediate referral to vascular team for limb salvage 1
• Revascularization as soon as possible 1
• Offloading mechanical stress for ulcers to allow wound healing 1

Common pitfall: Many clinicians underutilize evidence-based medical therapies in PAD patients, particularly statins, optimal antihypertensives, smoking cessation interventions, and supervised exercise programs 4. The diagnosis of PAD should trigger immediate, aggressive implementation of all these therapies simultaneously, not sequentially.