Management of Peripheral Arterial Disease

Risk Assessment and Diagnosis

• The American College of Cardiology recommends that patients with peripheral arterial disease (PAD) undergo aggressive cardiovascular risk reduction, as PAD significantly increases the risk of myocardial infarction, stroke, and cardiovascular death 3
• The presence of PAD, even with mild stenosis in the aorta and popliteal arteries, warrants aggressive cardiovascular risk reduction, according to the American College of Cardiology 4, 5
• CT findings indicating atherosclerotic disease with 20-30% stenosis in the infrarenal abdominal aorta and less than 20-30% stenosis in the popliteal arteries bilaterally are consistent with PAD 1, 2

Medical Management

• The American College of Cardiology recommends antiplatelet therapy to reduce the risk of adverse cardiovascular events in patients with PAD 3
• The European Society of Cardiology suggests that a combination of low-dose rivaroxaban and aspirin should be considered for symptomatic PAD without high bleeding risk 6
• Aggressive lipid-lowering therapy is recommended with an LDL-C reduction of ≥50% from baseline and a goal of <1.4 mmol/L (<55 mg/dL), according to the European Heart Journal 6
• Statin therapy is recommended to improve symptoms of intermittent claudication and reduce cardiovascular risk, as stated by the American Heart Association 1
• Antihypertensive therapy should target blood pressure <140/90 mmHg in non-diabetics or <130/80 mmHg in diabetics and those with chronic renal disease, according to the American Heart Association 1
• Angiotensin-converting enzyme inhibitors (ACEIs) are reasonable for symptomatic PAD patients to reduce cardiovascular events, as recommended by the American Heart Association 1

Exercise Therapy and Lifestyle Modifications

• The American College of Cardiology recommends supervised exercise therapy as a cornerstone of PAD management 5
• A structured exercise program can improve claudication symptoms, walking distance, and quality of life, according to the American College of Cardiology 5, 7

Foot Care and Monitoring

• Regular foot inspection and proper foot care are critical, especially if the patient has diabetes, as recommended by the American Heart Association 1, 8
• Any skin lesions or ulcerations should be addressed urgently, according to the American Heart Association 1, 8

Follow-up and Surveillance

• Regular follow-up with a vascular specialist is recommended to monitor disease progression, as stated by the American College of Cardiology 4
• Periodic vascular examinations including pulse assessment and ABI measurements should be performed, according to the American Heart Association 9
• Patients should be educated about symptoms that warrant immediate medical attention, such as worsening pain, color changes, or new ulcerations, as recommended by the American College of Cardiology 4, 8

Indications for Revascularization

• The American Heart Association recommends considering revascularization only if there is an inadequate response to exercise and pharmacological therapy, severe disability affecting normal activities, a favorable risk-benefit ratio, and appropriate lesion morphology 10