Management of Elderly Patients with Moderate Arterial Insufficiency

Diagnostic Evaluation and Risk Stratification

The American College of Cardiology recommends measuring ankle-brachial index (ABI) immediately to confirm peripheral artery disease (PAD) diagnosis, with an ABI ≤0.90 being diagnostic regardless of symptoms 2, 3
For patients with noncompressible vessels, the European Heart Journal suggests obtaining toe-brachial index (TBI) with waveforms, transcutaneous oxygen pressure (TcPO2), or skin perfusion pressure (SPP) to evaluate local perfusion 2, 3
Duplex ultrasound of lower extremities is indicated as first-line imaging to assess anatomic location and severity of stenosis, according to the European Heart Journal and Circulation 2, 3
The WIfI (Wound, Ischemia, and foot Infection) score should be used to determine amputation risk and assess for chronic limb-threatening ischemia (CLTI), as recommended by the European Heart Journal 2

The American College of Cardiology recommends single antiplatelet therapy to reduce risk of myocardial infarction, stroke, and vascular death, with clopidogrel 75 mg daily as first-line therapy (Class I, Level B-R) 1, 6, 7
The American College of Cardiology also suggests considering dual therapy with low-dose rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily for very high-risk patients, particularly if not at high bleeding risk 1, 2
Statin therapy is mandatory for all patients with PAD, with a target LDL-C <1.4 mmol/L (<55 mg/dL) or at least 50% reduction from baseline, as recommended by the American College of Cardiology and European Heart Journal 1, 2, 6
Antihypertensive therapy is indicated to reduce risk of MI, stroke, heart failure, and cardiovascular death, with ACE inhibitors or ARBs preferred, according to Circulation 6

Cilostazol 100 mg twice daily is indicated to improve symptoms and increase walking distance (Class I, Level A), but is contraindicated in heart failure patients, as recommended by the Journal of the American College of Cardiology 7, 8, 9
Supervised exercise training is recommended as initial treatment, with 30-45 minutes per session, at least 3 times weekly for minimum 12 weeks (Class I, Level A), according to the Journal of the American College of Cardiology 7, 9, 10

Patient education about foot care is mandatory, especially with lower extremity artery disease (LEAD), even if asymptomatic (Class I, Level C), as recommended by the European Heart Journal 2
Early recognition of tissue loss and/or infection with referral to multidisciplinary team is mandatory to improve limb salvage, according to the European Heart Journal 2

Refer to vascular surgery if lifestyle-limiting claudication with inadequate response to GDMT and acceptable perioperative risk, or if any signs of CLTI (rest pain, nonhealing ulcers, gangrene), as recommended by the Journal of the American College of Cardiology 4
CT angiography or MRA is indicated when revascularization is considered (Class I, Level C), according to the European Heart Journal 2
Evaluate frailty, functional status, life expectancy, and comorbidities before revascularization decisions, as recommended by the Journal of the American College of Cardiology 1

Yearly screening with clinical assessment and/or ABI measurement is indicated for disease progression monitoring (Class I, Level C), according to the European Heart Journal 2
Monitor for development of CLTI symptoms: rest pain, nonhealing wounds, gangrene, as recommended by the Journal of the American College of Cardiology and Journal of the American College of Cardiology 1, 4
Coordinate care between primary care, vascular specialist, and diabetologist if diabetes present, as recommended by the European Heart Journal 2