What is the recommended management for a patient with peripheral arterial disease (PAD) diagnosed via US (Ultrasound) Doppler arterial legs bilateral study?

Management of Peripheral Arterial Disease Based on Bilateral Lower Extremity Doppler Findings

This patient requires immediate initiation of comprehensive medical therapy including high-intensity statin therapy (targeting LDL-C <70 mg/dL), antiplatelet therapy with aspirin 75-100 mg daily or clopidogrel 75 mg daily, supervised exercise training for at least 12 weeks, aggressive cardiovascular risk factor modification, and annual follow-up with a vascular specialist. 1, 2

Immediate Medical Management

Lipid Management

• Start high-intensity statin therapy immediately to achieve LDL-C <70 mg/dL, as this patient has established PAD placing them in the very high-risk category 1, 2, 3
• If statin-intolerant and not achieving LDL-C goals on ezetimibe, add bempedoic acid alone or combined with a PCSK9 inhibitor 1
• Fibrates are not recommended for cholesterol lowering in PAD 1

Antithrombotic Therapy

• Initiate single antiplatelet therapy with either aspirin 75-100 mg daily or clopidogrel 75 mg daily to reduce major adverse cardiovascular events 1, 2
• Long-term dual antiplatelet therapy is not recommended for stable PAD 1
• Consider rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily only if the patient has high ischemic risk and non-high bleeding risk 2
• Oral anticoagulation monotherapy is not recommended unless indicated for another condition 1

Blood Pressure Control

• Target blood pressure <140/90 mmHg (or <130/80 mmHg if diabetes or chronic kidney disease present) 2, 3
• ACE inhibitors are preferred as they may reduce adverse cardiovascular events and improve walking distance 2, 3, 4
• Beta-blockers are not contraindicated and are effective antihypertensives in PAD 2

Diabetes Management (if applicable)

• Target HbA1c <7% (53 mmol/mol) to reduce microvascular complications 1, 2
• Prioritize SGLT2 inhibitors or GLP-1 receptor agonists with proven cardiovascular benefit to reduce cardiovascular events 1
• Implement immediate proper foot care: appropriate footwear, daily foot inspection, skin cleansing, topical moisturizing creams, and urgent attention to any skin lesions 2

Supervised Exercise Training

Supervised exercise training is the cornerstone of initial treatment and must be prescribed before considering revascularization. 1, 2

• Prescribe walking training at high intensity, 3 times weekly, for at least 12 weeks 1, 2
• Exercise to moderate-severe claudication pain to improve walking performance 2
• Alternative modes (strength training, arm cranking, cycling) should also be considered 1
• If the patient undergoes future revascularization, continue supervised exercise training as adjuvant therapy 1

Smoking Cessation (if applicable)

• Ask about tobacco use at every encounter and provide counseling 2
• Offer varenicline, bupropion, or nicotine replacement therapy unless contraindicated 2, 3

Assessment for Revascularization

Revascularization should NOT be considered at this time based on the Doppler findings alone. 1, 2

The 3-Month Rule

• After 3 months of optimal medical therapy and supervised exercise training, assess PAD-related quality of life 1, 2
• Revascularization may only be considered if quality of life remains significantly impaired after this 3-month trial 1, 2

Criteria for Considering Revascularization (after 3-month trial)

The patient must meet ALL of the following 1:

• Significant disability (unable to perform normal work or serious impairment of important activities) 1
• Lesion anatomy with low procedural risk and high probability of success 1
• Failed optimal medical therapy and supervised exercise training 1, 2

Important Caveats

• Revascularization is NOT recommended solely to prevent progression to chronic limb-threatening ischemia 1, 2
• Revascularization is NOT recommended for asymptomatic PAD 1
• The abnormal toe-brachial indices and blunted PVR waveforms indicate moderate disease but do not automatically warrant revascularization 1

Follow-Up Protocol

Regular Surveillance

• Schedule annual follow-up with a vascular specialist at minimum 1, 2
• At each visit, assess: clinical/functional status, medication adherence, limb symptoms, cardiovascular risk factors 1, 2
• Perform duplex ultrasound assessment as needed 1
• Conduct comprehensive pulse examination and foot inspection at each visit 1

Monitoring for Critical Limb-Threatening Ischemia

• Watch for ischemic rest pain, non-healing wounds, or tissue loss 1
• Patients at risk (ABI <0.4 with diabetes, or any diabetes patient with known PAD) require regular foot inspection 1
• If critical limb-threatening ischemia develops, immediate referral to vascular team is required for limb salvage 1, 2

Common Pitfalls to Avoid

• Do not proceed directly to revascularization without the mandatory 3-month trial of optimal medical therapy and supervised exercise training 1, 2
• Do not use ticagrelor routinely in PAD patients 1
• Do not treat asymptomatic PAD with antiplatelet drugs unless other clinically relevant atherosclerotic disease is present 1
• Do not use long-term dual antiplatelet therapy in stable PAD 1
• Do not assume beta-blockers are contraindicated—they are safe and effective in PAD 2