2024 ACC/AHA Guideline Recommendations for Peripheral Artery Disease (PAD)

Clinical Definition and Risk Significance

PAD is a manifestation of systemic atherosclerosis affecting the lower‑extremity arteries and serves as a critical marker of cardiovascular disease, conferring a very high risk of myocardial infarction, stroke, and death. 1
The 2024 ACC/AHA guidelines classify PAD into four clinical presentations: asymptomatic disease, chronic symptomatic disease (intermittent claudication), chronic limb‑threatening ischemia, and acute limb ischemia. 1
Patients with PAD are categorized as very high cardiovascular risk, experiencing substantially increased rates of major adverse cardiovascular events (MACE) and major adverse limb events (MALE). 1

Resting ankle‑brachial index (ABI) is the primary diagnostic test; an ABI ≤ 0.9 confirms PAD, while an ABI ≥ 1.4 indicates non‑compressible arteries and warrants alternative imaging. 1

Symptomatic PAD: Low‑dose rivaroxaban 2.5 mg twice daily plus aspirin 81 mg daily reduces MACE and MALE (Class I recommendation). 2
Asymptomatic PAD: Single antiplatelet therapy is reasonable to lower MACE risk (Class IIa). 2
Post‑revascularization (any modality): Rivaroxaban 2.5 mg twice daily plus aspirin is recommended (Class I). 2
Post‑endovascular revascularization: Dual antiplatelet therapy (P2Y12 inhibitor + aspirin) for 1–6 months is reasonable (Class IIa). 2

High‑intensity statin therapy is indicated for all patients with PAD (Class I). 1
In patients on maximally tolerated statins with LDL‑C ≥ 70 mg/dL, adding a PCSK9 inhibitor or ezetimibe is reasonable (Class IIa). 2

Antihypertensive therapy to achieve guideline‑directed blood pressure control is recommended (Class I). 1
Mandatory smoking cessation is a core component of PAD care (Class I). 1

Structured exercise programs—including supervised and community‑based regimens—are essential for all PAD patients, improving functional status and quality of life (Class I). 2

Revascularization is indicated to prevent limb loss in chronic limb‑threatening ischemia (Class I). 2
It is also indicated to improve quality of life and functional status in patients with claudication who remain symptomatic despite optimal medical therapy and structured exercise (Class I). 2

Optimal management of PAD, especially chronic limb‑threatening ischemia, requires a multispecialty team—including cardiologists, vascular surgeons, podiatrists, and wound‑care specialists (Class I). 1

Clinicians and health systems must actively identify and address disparities in PAD diagnosis, treatment, and outcomes (Class I). 2
Implementing targeted interventions to reduce these disparities is a top priority to improve limb and cardiovascular outcomes (Class I). 1