Should a patient with peripheral arterial disease (PAD) continue statin (HMG-CoA reductase inhibitor) therapy to manage their cardiovascular risk factors?

Yes, Absolutely Continue Statin Therapy in PAD

Statin therapy is a Class I, Level A recommendation for ALL patients with peripheral arterial disease, regardless of symptom status, and should be continued without question. 1

Why This Is Non-Negotiable

The evidence supporting statin use in PAD is unequivocal and comes from the highest-quality guidelines:

• The 2016 AHA/ACC guidelines explicitly state that "treatment with a statin medication is indicated for all patients with PAD" with the strongest possible recommendation (Class I, Level A evidence). 1

• The 2024 ESC guidelines reinforce this, recommending lipid-lowering therapy for all patients with atherosclerotic peripheral arterial and aortic diseases (Class I, Level A). 1

• This recommendation applies whether your patient has symptomatic claudication, asymptomatic disease detected by abnormal ABI, or a history of revascularization. 1

Target LDL-C Goals

The most recent guidelines have become more aggressive with lipid targets:

• The 2024 ESC guidelines recommend an LDL-C goal of <1.4 mmol/L (55 mg/dL) with a >50% reduction from baseline (Class I, Level A). 1, 2

• The older 2016 AHA/ACC guidelines recommended <100 mg/dL as the primary target, with <70 mg/dL reasonable for very high-risk patients. 1, 3

• Given the more recent ESC data, target the lower threshold of <55 mg/dL for optimal cardiovascular risk reduction. 1

Escalation Strategy If Target Not Met

If your patient doesn't achieve target LDL-C on maximally tolerated statin monotherapy:

1. Add ezetimibe (Class I, Level B recommendation). 1

2. If still not at goal, add a PCSK9 inhibitor (Class I, Level A recommendation). 1

3. For statin-intolerant patients, use ezetimibe plus bempedoic acid or PCSK9 inhibitor (Class I, Level B). 1

Clinical Benefits Beyond Lipid Lowering

Statins provide multiple benefits in PAD patients beyond just cardiovascular event reduction:

• Reduced risk of MI, stroke, and cardiovascular death by 24% in the Heart Protection Study of PAD patients. 1

• Improved claudication distance and walking time in prospective trials. 1

• Improved graft patency rates after surgical revascularization. 4, 5

• Reduced perioperative morbidity and mortality in patients undergoing vascular procedures. 4

• May reduce AAA growth and rupture risk (Class IIa, Level B recommendation). 1

Common Pitfall to Avoid

PAD patients are significantly undertreated with statins compared to coronary artery disease patients, despite having equivalent or higher cardiovascular risk. 1, 6, 5 Do not fall into this treatment gap—your patient with PAD deserves the same aggressive lipid management as someone with a prior MI.

Additional Cardiovascular Risk Reduction

While continuing the statin, ensure your patient is also receiving:

• Antiplatelet therapy (aspirin 75-325 mg daily OR clopidogrel 75 mg daily) to reduce MI, stroke, and vascular death (Class I, Level A). 1

• Antihypertensive therapy if hypertensive, targeting <140/90 mmHg (or <130/80 mmHg if diabetic) (Class I, Level A). 1

• ACE inhibitors or ARBs are particularly effective for reducing cardiovascular events in PAD (Class IIa, Level A). 1

• Supervised exercise therapy as first-line treatment for claudication symptoms (Class I, Level A). 1, 3