What is the next step in managing a patient with peripheral arterial disease (PAD) diagnosed via US Doppler arterial legs bilateral study?

Management of Peripheral Arterial Disease in Primary Care

This patient requires immediate initiation of comprehensive medical therapy including high-intensity statin therapy, antiplatelet therapy, aggressive blood pressure control, smoking cessation support, and referral to supervised exercise training, with vascular specialist follow-up within 3 months to assess response before considering any revascularization. 1

Immediate Medical Therapy Initiation

Lipid Management

• Start high-intensity statin therapy immediately with target LDL-C <70 mg/dL given the moderate arterial occlusive disease on the right leg 1, 2
• Consider adding ezetimibe if LDL target not achieved with statin alone 3
• PCSK9 inhibitors may be considered if LDL remains elevated despite statin plus ezetimibe 3

Antithrombotic Therapy

• Initiate rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily if the patient has high ischemic risk (which this patient does with moderate right-sided disease and abnormal bilateral toe-brachial indices) and non-high bleeding risk 1
• This combination significantly reduces major adverse cardiovascular events and major adverse limb events compared to aspirin alone 1
• If bleeding risk is high, use aspirin 75-100 mg daily alone 1, 2

Blood Pressure Control

• Target blood pressure <140/90 mmHg (or <130/80 mmHg if diabetes or chronic kidney disease present) 1
• ACE inhibitors are preferred as they reduce adverse cardiovascular events and may improve walking distance 1, 2
• Beta-blockers are not contraindicated and are effective antihypertensives in PAD 1

Smoking Cessation (if applicable)

• Ask about tobacco use at this visit and every subsequent encounter 1
• Provide counseling and develop a quit plan with pharmacotherapy: varenicline, bupropion, or nicotine replacement therapy 1, 2

Supervised Exercise Training

• Refer immediately to supervised exercise training program as first-line treatment for claudication symptoms 1
• Prescribe walking training at high intensity, 3 times weekly, for at least 12 weeks 1
• Exercise should be to moderate-severe claudication pain to improve walking performance 1
• Alternative modes include strength training, arm cranking, or cycling if walking is not feasible 1

Diabetes Management (if applicable)

• Target HbA1c <7% to reduce microvascular complications 1
• Implement proper foot care immediately: appropriate footwear, daily foot inspection, skin cleansing, topical moisturizing creams, and urgent attention to any skin lesions or ulcerations 1
• This patient has abnormal toe-brachial indices bilaterally, placing them at higher risk for critical limb ischemia if diabetic 4

Vascular Specialist Referral and Follow-Up

• Schedule vascular specialist appointment within 3 months to assess response to optimal medical therapy and exercise training 1
• The specialist will assess PAD-related quality of life and functional status after this 3-month trial 1
• Revascularization should only be considered if quality of life remains significantly impaired after 3 months of optimal medical therapy and supervised exercise 1
• Revascularization is not indicated solely to prevent progression to critical limb ischemia 1

Ongoing Surveillance Protocol

• Schedule annual follow-up with vascular specialist after initial 3-month assessment 1
• At each visit, assess clinical/functional status, medication adherence, limb symptoms, and cardiovascular risk factors 1
• Perform ABI measurement at follow-up visits to monitor disease progression 4
• Educate patient on self-surveillance for potential worsening: new rest pain, non-healing wounds, or acute limb symptoms 4

Critical Warning Signs Requiring Urgent Evaluation

• Ischemic rest pain (pain in feet or legs when resting or lying down) requires expedited vascular specialist evaluation 4
• Non-healing wounds or skin ulcerations require immediate referral to wound care specialists and vascular team 4
• Acute limb symptoms (sudden worsening of pain, coldness, pallor) represent a vascular emergency requiring immediate vascular surgery evaluation 4
• This patient's ABI <0.4 would indicate critical limb ischemia risk, but the right ABI shows moderate disease (not critical) 4

Common Pitfalls to Avoid

• Do not delay medical therapy while waiting for specialist appointment—start statins, antithrombotics, and blood pressure management immediately 1, 2
• Do not refer directly for revascularization without first completing 3-month trial of optimal medical therapy and supervised exercise 1
• Do not assume beta-blockers are contraindicated in PAD—they are safe and effective 1
• Do not overlook the abnormal toe-brachial indices bilaterally, which indicate distal disease and require regular foot inspection 4
• Do not forget to coordinate care among multiple clinicians to optimize management of PAD and comorbid conditions 1