From the Guidelines
Peripheral arterial disease (PAD) management should prioritize a comprehensive approach including lifestyle modifications, medical therapies, and revascularization procedures to reduce morbidity, mortality, and improve quality of life, as outlined in the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline 1.
Key Components of PAD Management
- Lifestyle modifications: smoking cessation, regular exercise (30-45 minutes of walking daily), and a heart-healthy diet
- Medical therapies: antiplatelet therapy (aspirin 75-100mg daily or clopidogrel 75mg daily), statins (atorvastatin 40-80mg or rosuvastatin 20-40mg daily) to lower cholesterol, and blood pressure control (target <140/90 mmHg) 1
- Revascularization procedures: angioplasty, stenting, or bypass surgery for severe disease with rest pain or tissue loss
Additional Considerations
- Diabetes control: target HbA1c <7% to reduce cardiovascular risk
- Foot care: regular inspection and care, especially for diabetic patients, to prevent complications
- Health disparities: addressing individual patient and population-level disparities to improve outcomes 1
Medical Therapies
- Rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin (81 mg daily) is effective in preventing major adverse cardiovascular events and major adverse limb events for patients with PAD 1
- Cilostazol 100mg twice daily may improve walking distance for patients with claudication symptoms
Comprehensive Management
- PAD management requires a comprehensive approach to reduce systemic atherosclerosis risk, which increases the risk for heart attack and stroke
- Regular follow-up and monitoring are crucial to adjust treatment plans and prevent complications 1
From the FDA Drug Label
- 2 Recent MI, Recent Stroke, or Established Peripheral Arterial Disease
In patients with established peripheral arterial disease or with a history of recent myocardial infarction (MI) or recent stroke clopidogrel tablets are indicated to reduce the rate of MI and stroke.
Clopidogrel is indicated to reduce the rate of myocardial infarction and stroke in patients with established peripheral arterial disease.
- The recommended dose for patients with established peripheral arterial disease is 75 mg once daily orally without a loading dose 2.
- Pentoxifylline has also been used for the treatment of peripheral arterial disease, and it is recommended to monitor patients for signs of bleeding when used with other drugs that increase the risk of bleeding 3.
From the Research
Overview of Peripheral Arterial Disease
- Peripheral arterial disease (PAD) is the third leading cause of atherosclerotic morbidity after coronary heart disease and stroke 4, 5.
- It is estimated to affect more than 200 million people worldwide, with over 50% of those affected being asymptomatic 6.
- PAD accounts for 3%-4% of amputations and has a crude 5-year death rate of 82.4 deaths per 1000 patient-years when adjusted for duration of follow-up 6.
Risk Factors and Management
- Treatment of risk factors such as diabetes and cigarette smoking can benefit patients with PAD 5.
- Patients should have adequate blood pressure and lipid control to decrease clinical manifestations and symptoms of PAD 5.
- The management of PAD includes conservative therapies, pharmacological treatments, interventional and surgical revascularization of blood vessels 6.
- Statins have been shown to improve symptoms associated with PAD and reduce the risk of vascular events 4.
Antithrombotic Treatment
- In symptomatic PAD, single antiplatelet therapy (SAPT) with aspirin or clopidogrel is indicated 7.
- Dual antiplatelet therapy (DAPT) with clopidogrel and aspirin does not provide benefit over SAPT with aspirin alone and is associated with increased risk of major bleeding 7.
- Rivaroxaban (2.5 mg b. i. d.) plus aspirin (100 mg daily) has been shown to be beneficial for PAD patients in terms of reducing total mortality and cardiovascular mortality 7.
- Antithrombotic therapies, including single or dual antiplatelet agents, anticoagulation, or a combination of these treatments, have been shown to reduce cardiovascular and limb events in patients with PAD 8.