From the Guidelines
Peripheral vascular disease treatment should prioritize a comprehensive approach including lifestyle modifications, medical therapy, and revascularization procedures to improve symptoms, prevent disease progression, and reduce cardiovascular risk, as recommended by the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline 1. The treatment of peripheral vascular disease (PVD) involves a multifaceted strategy to manage symptoms, prevent disease progression, and reduce the risk of major adverse cardiovascular events.
Key Components of PVD Treatment
- Lifestyle modifications:
- Smoking cessation
- Regular exercise, such as walking for 30-45 minutes daily
- Weight management
- Medical therapy:
- Antiplatelet agents like aspirin (75-100 mg daily) or clopidogrel (75 mg daily) to prevent thrombotic events
- Statins, regardless of cholesterol levels, with atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily being preferred options, as supported by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1
- Blood pressure control targeting levels below 140/90 mmHg using ACE inhibitors, ARBs, calcium channel blockers, or diuretics as appropriate
- Tight glycemic control for patients with diabetes, aiming for HbA1c below 7%
- Revascularization procedures for severe cases with critical limb ischemia, including endovascular interventions (angioplasty, stenting) or surgical bypass
Additional Considerations
- Regular foot care and inspection are crucial, especially for diabetic patients, to prevent ulceration and infection
- Exercise therapy, such as supervised exercise therapy (SET) or home-based exercise training (HBET), is recommended for patients with symptomatic PAD, as stated in the 2024 ESC guidelines 1
- Lipid-lowering therapy is recommended for patients with atherosclerotic peripheral arterial and aortic diseases, with an ultimate LDL-C goal of <1.4 mmol/L (55 mg/dL) and a >50% reduction in LDL-C vs. baseline, as recommended by the 2024 ESC guidelines 1 The primary goal of PVD treatment is to improve peripheral circulation, reduce atherosclerotic burden, prevent thrombotic complications, and ultimately preserve limb function and quality of life while reducing the risk of major cardiovascular events, as emphasized by the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline 1.
From the FDA Drug Label
Of the predefined secondary endpoints, treatment with atorvastatin calcium 80 mg/day significantly reduced the rate of coronary revascularization, angina, and hospitalization for heart failure, but not peripheral vascular disease. The FDA-approved treatment guideline for peripheral vascular disease (PVD) using atorvastatin is not directly supported by the provided drug labels 2 and 2.
- The studies did not show a significant reduction in the rate of PVD endpoints.
- The primary and secondary endpoints focused on major cardiovascular events, such as myocardial infarction, stroke, and coronary heart disease, but did not provide specific guidance on PVD treatment.
From the Research
Peripheral Vascular Disease Treatment Guidelines
The treatment of peripheral vascular disease (PVD) is divided into lifestyle, medical, and surgical therapies 3.
- Lifestyle therapies focus on:
- Exercise
- Smoking cessation
- Dietary modification
- Medical therapy is directed at reducing platelet aggregation, and managing contributing disorders such as:
- Hypertension
- Diabetes
- Hyperlipidemia
- Surgical therapies include:
- Stents
- Arterectomies
- Angioplasty
- Bypass surgery
Antiplatelet Therapy
Antiplatelet therapy is invariably prescribed for patients with PVD and critical limb ischemia, but high-quality data in this high-risk and challenging patient population are often lacking 4.
- Aspirin or clopidogrel is indicated for symptomatic PVD 5
- Ticagrelor may be considered in PAD patients with prior myocardial infarction 5
- Rivaroxaban (2.5 mg b.i.d.) plus aspirin (100 mg daily) has shown significant benefit for PAD patients in terms of total mortality and cardiovascular mortality 5
Management of Peripheral Arterial Disease
The management of PAD includes medications such as:
- Aspirin
- Clopidogrel
- Ticagrelor
- Warfarin
- Rivaroxaban
- Statins
- Angiotensin-converting enzyme inhibitors
- Evolocumab and Ezetimibe 6
- Antithrombotic treatment, including single antiplatelet therapy (SAPT) and dual antiplatelet therapy (DAPT) 5
Revascularization
Revascularization is recommended for patients with rest limb ischemia or ulceration to minimize the chance of limb loss 7.
- Percutaneous revascularization
- Surgical therapy, including bypass surgery 3