What is the treatment for arterial insufficiency in lower extremities, also known as peripheral arterial disease (PAD), in patients with a history of cardiovascular events, diabetes, and hypertension?

Treatment of Arterial Insufficiency in Lower Extremities (PAD)

All patients with lower extremity PAD—regardless of symptom status—require comprehensive cardiovascular risk reduction therapy including antiplatelet agents, high-dose statins, blood pressure control, smoking cessation, and diabetes management, as these patients face a higher risk of myocardial infarction, stroke, and death than limb-related complications. 1

Antiplatelet Therapy

Antiplatelet therapy is mandatory for all symptomatic PAD patients and should be either aspirin 75-325 mg daily OR clopidogrel 75 mg daily to reduce MI, stroke, and vascular death. 1, 2, 3

• Clopidogrel 75 mg daily is an effective alternative to aspirin and may be preferred in patients with aspirin intolerance 1, 2, 3
• For asymptomatic patients with ABI ≤0.90, antiplatelet therapy is reasonable to reduce cardiovascular events 1
• Dual antiplatelet therapy (aspirin plus clopidogrel) is NOT routinely recommended for stable PAD, as the effectiveness is not well established and bleeding risk increases 1
• After lower extremity revascularization, dual antiplatelet therapy may be reasonable to reduce limb-related events 1

Lipid Management

All PAD patients must receive high-dose statin therapy regardless of baseline cholesterol levels, as statins reduce cardiovascular events and may improve claudication symptoms. 1, 2

• Statins have been shown to reduce nonfatal MI and cardiovascular death by 22% in PAD patients 1
• Atorvastatin specifically increased distance walked to onset of claudication in prospective trials 1

Blood Pressure Control

Antihypertensive therapy should target <140/90 mmHg (or <130/80 mmHg in diabetics) to reduce MI, stroke, heart failure, and cardiovascular death. 1

• ACE inhibitors are recommended for symptomatic PAD patients to reduce cardiovascular events by approximately 25% 1, 2
• ACE inhibitors may be considered for asymptomatic PAD patients for cardiovascular risk reduction 1
• Beta-blockers are safe and effective in PAD patients and do NOT worsen claudication or adversely affect walking capacity—this is a critical pitfall to avoid 1, 2

Smoking Cessation

Every clinical encounter must include smoking cessation counseling with comprehensive interventions including behavioral therapy, nicotine replacement, bupropion, or varenicline. 1, 2

• Coordinated programs combining counseling and pharmacotherapy increase cessation rates to 21.3% versus 6.8% with standard advice alone 2
• Observational studies demonstrate substantially greater risk of death, MI, and amputation in patients who continue smoking 1

Diabetes Management

For diabetic patients with PAD, target HbA1c <7% to reduce microvascular complications and potentially improve cardiovascular outcomes. 1, 2

• Glycemic control is particularly critical in critical limb ischemia, as optimized glucose control improves limb-related outcomes including lower amputation rates 2
• Intensive insulin therapy reduced PAD events (claudication, revascularization, amputation) by 22% in the Diabetes Control and Complications trial, though this did not reach statistical significance 1

Comprehensive Foot Care for Diabetic PAD Patients

Daily foot inspection, appropriate footwear, skin cleansing, and topical moisturizing creams are mandatory, with urgent attention to any skin lesions or ulcerations. 1, 2

• Patients must perform daily visual foot inspection using a mirror if loss of protective sensation is present 2
• Well-fitted walking shoes or athletic shoes that cushion feet and redistribute pressure are required for patients with neuropathy or increased plantar pressures 2
• Patients with bony deformities need extra wide or deep shoes 2
• Severe deformities including Charcot foot require custom-molded shoes if commercial therapeutic footwear cannot accommodate 2
• Comprehensive foot evaluation must be performed at least annually, including inspection of skin integrity, musculoskeletal deformities, neurological assessment, vascular assessment, and history of decreased walking speed, leg fatigue, and claudication 2
• Obtain ABI testing when clinical suspicion of PAD exists rather than relying solely on pedal pulse palpation 2

Exercise Therapy

Supervised treadmill exercise programs improve 6-minute walk distance by 30-35 meters, while effective home-based programs with behavioral coaching improve walking by 42-53 meters. 4

• Structured exercise is a vital component of comprehensive PAD management 1
• Home-based exercise programs require monitoring by a coach to be effective 4

Symptom Management for Claudication

Cilostazol is effective medical therapy for treatment of leg symptoms and walking impairment due to claudication, though side effects including headache, diarrhea, dizziness, and palpitations lead to 20% discontinuation within 3 months. 1

Diagnostic Approach

Measurement of ABI is the most cost-effective tool for PAD detection and should be performed in all at-risk patients. 1

At-risk populations requiring ABI screening include: 1

• Age <50 years with diabetes and one other atherosclerosis risk factor (smoking, dyslipidemia, hypertension, hyperhomocysteinemia)
• Age 50-69 years with history of smoking or diabetes
• Age ≥70 years
• Leg symptoms with exertion or ischemic rest pain
• Abnormal lower extremity pulse examination
• Known atherosclerotic coronary, carotid, or renal artery disease

For patients with normal ABI (0.91-1.30) but suspected PAD, exercise ABI testing can be useful for diagnosis. 1

For patients with ABI >1.30 (suggesting non-compressible vessels from medial arterial calcification), toe-brachial index or pulse volume recording should be obtained. 1

Critical Pitfalls to Avoid

• Do not withhold beta-blockers in PAD patients due to unfounded concerns about worsening claudication 1, 2
• Do not rely on pedal pulse palpation alone—obtain ABI testing when PAD is suspected 2
• Do not assume asymptomatic PAD patients have normal limb function—they have significant functional impairment and require full cardiovascular risk reduction 1
• Patients with visual difficulties, physical constraints, or cognitive problems need family members to assist with foot care 2