What are the management options for Peripheral Artery Disease (PAD)?

From the Guidelines

Peripheral artery disease (PAD) management should prioritize a comprehensive approach focusing on symptom relief, preventing disease progression, and reducing cardiovascular risk, with a combination of lifestyle modifications, medical therapy, and revascularization as needed, as recommended by the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline 1, 2, 3, 4. The management of PAD requires a multifaceted approach that includes:

• Lifestyle modifications such as smoking cessation, regular exercise (30-45 minutes of supervised walking 3-5 times weekly), and dietary improvements
• Medical therapy with antiplatelet agents like aspirin (75-100 mg daily) or clopidogrel (75 mg daily), along with aggressive risk factor management including statins (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) to achieve LDL-C below 70 mg/dL
• Blood pressure control to below 140/90 mmHg using ACE inhibitors or ARBs as first-line agents
• Tight glycemic control for diabetic patients with a target HbA1c below 7%
• Cilostazol (100 mg twice daily) to improve walking distance in patients with claudication
• Revascularization via endovascular procedures or bypass surgery for severe disease with critical limb ischemia
• Regular foot care and inspection, especially for diabetic patients This approach is supported by recent guidelines, including the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline, which emphasizes the importance of a comprehensive approach to PAD management, including lifestyle modifications, medical therapy, and revascularization as needed 1, 2, 3, 4. Key aspects of PAD management include:
• Aggressive risk factor management to slow the progression of PAD and prevent major adverse cardiovascular events (MACE) and major adverse limb events (MALE)
• Monitoring limb symptoms and functional status to assess the degree of functional status and quality of life
• A multispecialty care team approach to promote collaboration and avoid potential duplication of care
• Coordination of care to optimize outcomes for patients with PAD, including management of cardiovascular risk factors such as diabetes, hypertension, smoking, and dyslipidemia The use of rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin (81 mg daily) is effective in reducing the risk of MACE and MALE in patients with PAD, as recommended by the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline 1, 2.

From the FDA Drug Label

1. 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.

2. 2 Recent MI, Recent Stroke, or Established Peripheral Arterial Disease 75 mg once daily orally without a loading dose

Peripheral Artery Disease Management:

• Clopidogrel is indicated to reduce the rate of myocardial infarction and stroke in patients with established peripheral arterial disease.
• The recommended dose for peripheral artery disease management is 75 mg once daily orally without a loading dose 5.

From the Research

Peripheral Artery Disease Management

The management of peripheral artery disease (PAD) involves a multifaceted approach, including lifestyle modifications, medical management, and potentially, endovascular repair or surgery 6. Key components of medical therapy include:

• Smoking cessation: Cigarette smoking is a major preventable risk factor for PAD, and smoking cessation is crucial in reducing disease progression and improving outcomes 7.
• Lipid-lowering therapy: Reducing cholesterol levels can help slow the progression of atherosclerosis and reduce the risk of major adverse cardiovascular events 8, 9.
• Hypertension treatment: Controlling blood pressure is essential in managing PAD and reducing the risk of cardiovascular complications 8, 9.
• Antiplatelet and antithrombotic therapies: These medications can help reduce the risk of cardiovascular and limb events in patients with PAD 9.
• Exercise therapy: Supervised exercise therapy can improve walking capacity and reduce symptoms of PAD 8, 10.
• Peripheral vasodilators: Medications such as cilostazol can help improve walking capacity and reduce symptoms of PAD 8.

Personalized Approach to PAD Management

The heterogeneity of risk profiles in patients with PAD supports a personalized approach to management, with consideration of treatment intensification in those at high risk of adverse events 8. This may involve:

• Risk factor modification: Identifying and addressing modifiable risk factors, such as diabetes, obesity, and physical inactivity, can help reduce the risk of disease progression and improve outcomes 8.
• Optimal medical therapy: Ensuring that patients receive evidence-based medical therapies, including antiplatelet and antithrombotic agents, lipid-lowering therapy, and hypertension treatment, can help reduce the risk of major adverse cardiovascular events and limb events 8, 9, 10.
• Regular monitoring and follow-up: Regular monitoring of patients with PAD can help identify potential complications early and ensure that treatment is optimized to reduce the risk of adverse events 10.