What is the recommended management for peripheral arterial disease in a middle‑aged to older adult with smoking, diabetes, hypertension and hyperlipidaemia?

Management of Peripheral Arterial Disease

Comprehensive Risk Factor Modification (Foundation of Treatment)

All patients with PAD require aggressive cardiovascular risk reduction regardless of symptom severity, as PAD represents systemic atherosclerosis with 4-5% annual risk of MI, stroke, or vascular death. 1

Lipid Management

• Initiate high-intensity statin therapy immediately in all PAD patients, targeting LDL-C <55 mg/dL (<1.4 mmol/L) with ≥50% reduction from baseline. 1
• If target not achieved on maximally tolerated statin, add ezetimibe. 1
• If still not at goal on statin plus ezetimibe, add PCSK9 inhibitor. 1
• For statin-intolerant patients not reaching LDL goal on ezetimibe, add bempedoic acid alone or combined with PCSK9 inhibitor. 1
• Fibrates are NOT recommended for cholesterol lowering. 1

Antiplatelet Therapy

• Start single antiplatelet therapy with either aspirin 75-325 mg daily or clopidogrel 75 mg daily (clopidogrel preferred) to reduce MI, stroke, and vascular death. 1
• Consider adding rivaroxaban 2.5 mg twice daily to aspirin 81 mg daily in patients without increased bleeding risk to reduce both cardiovascular events and limb-related events. 2, 3
• Dual antiplatelet therapy (aspirin plus clopidogrel) may be reasonable for 1-6 months after lower extremity revascularization to reduce limb-related events. 1

Blood Pressure Control

• Target systolic BP 120-129 mmHg if tolerated in all PAD patients with hypertension. 1
• Use ACE inhibitors or ARBs as preferred agents—they reduce cardiovascular events and may improve walking distance. 1
• Beta-blockers are NOT contraindicated in PAD and should be used, especially if coronary artery disease or heart failure coexists. 1, 3

Diabetes Management

• Target HbA1c <53 mmol/mol (7%) to reduce microvascular complications. 1
• Prescribe SGLT2 inhibitors with proven cardiovascular benefit to reduce cardiovascular events, independent of baseline HbA1c. 1
• Prescribe GLP-1 receptor agonists with proven cardiovascular benefit to reduce cardiovascular events, independent of baseline HbA1c. 1
• Prioritize glucose-lowering agents with proven cardiovascular benefits over those without. 1
• Avoid hypoglycemia and individualize HbA1c targets based on comorbidities, diabetes duration, and life expectancy. 1

Smoking Cessation

• Advise cessation at every visit—smoking is the most potent modifiable risk factor, increasing PAD risk 2-6 fold. 1
• Offer pharmacotherapy with varenicline, bupropion, and/or nicotine replacement therapy combined with behavioral counseling or referral to smoking cessation program. 1

Foot Care in Diabetic PAD Patients

• Implement daily foot inspection by patient, appropriate footwear to avoid pressure injury, and daily topical moisturizing creams (such as ammonium lactate lotion) after gentle cleansing. 1, 2
• Arrange chiropody/podiatric care with proper toenail cutting. 1, 2
• Address skin lesions and ulcerations urgently. 1, 2
• Schedule biannual foot examination by clinician. 2

Structured Exercise Therapy

Supervised exercise training is the most effective initial treatment for intermittent claudication, improving functional status, quality of life, and reducing leg symptoms. 1

• Prescribe supervised exercise program performed at least 3 times weekly for minimum 30 minutes per session over at least 12 weeks. 1, 3
• Walking should be the primary modality with low- to moderate-intensity (or high if tolerated) aerobic activity. 1, 3
• Structured community- or home-based programs with specific guidance are effective alternatives to supervised programs. 1
• Unstructured advice to "just walk more" is NOT efficacious. 1
• Long-term benefits persist from 18 months to 7 years. 1

Pharmacotherapy for Claudication Symptoms

• Prescribe cilostazol (phosphodiesterase III inhibitor) for symptomatic improvement in claudication and walking distance if exercise alone is insufficient. 3, 4
• Cilostazol is contraindicated in heart failure. 5
• Pentoxifylline is less effective than cilostazol but may be considered as alternative. 6

Diagnostic Evaluation

• Measure ankle-brachial index (ABI) as first-line screening and diagnostic test, using ABI ≤0.90 as diagnostic criterion. 1
• In non-compressible ankle arteries (ABI >1.40, common in diabetes), use toe pressure, toe-brachial index, or Doppler waveform analysis. 1
• Perform thorough vascular examination including pulse palpation at brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial sites. 2
• Inspect feet for color, temperature, skin integrity, ulcerations, distal hair loss, trophic changes, and hypertrophic nails. 2
• Auscultate femoral arteries for bruits. 2

Revascularization Indications

Consider revascularization for:

• Critical limb ischemia (ABI <0.4 or absolute ankle pressure ≤50 mmHg)—this is a vascular emergency requiring urgent specialist referral. 2
• Incapacitating claudication interfering with work or lifestyle despite optimal medical therapy and exercise. 5, 7
• Rest pain, nonhealing ulcers, infection, or gangrene. 5, 7

Critical Pitfalls to Avoid

• Never delay vascular assessment in diabetic patients with neuropathy—presentation may be subtle with absent pain despite severe ischemia. 2
• Do not assume bilateral presentation excludes vascular disease—bilateral PAD and critical limb ischemia are common. 2
• Avoid compression therapy entirely if ABI <0.6 without first checking arterial status. 2
• Never use vasodilators (ACE inhibitors, calcium channel blockers, direct vasodilators) expecting improvement in claudication—they are ineffective for PAD symptoms despite being appropriate for blood pressure control. 3
• Initiate systemic antibiotics promptly if any skin ulcerations show infection signs (pain, erythema, edema, induration, discharge, foul odor)—untreated infection with PAD confers nearly 3-fold higher amputation risk. 2
• Do not avoid beta-blockers in PAD patients—they have minimal effect on walking distance and should be used especially if coronary disease or heart failure is present. 3

Special Considerations for This Patient Population

Given the combination of smoking, diabetes, hypertension, and hyperlipidemia:

• This patient has multiple atherosclerotic risk factors placing them at very high cardiovascular risk with likely polyvascular disease. 8
• Screen for coexisting coronary and cerebrovascular disease, as cardiovascular events are more frequent than limb events in PAD patients. 8
• Diabetic patients with PAD are 7-15 times more likely to require amputation than non-diabetics with PAD. 8
• Older patients with PAD have 3-4 fold increased cardiovascular risk and are less likely to receive guideline-directed medical therapy than younger patients. 3