Peripheral Artery Disease Management

Medical Therapy

• High-intensity statin therapy is recommended to achieve LDL <70 mg/dL for patients with peripheral artery disease (PAD) to reduce cardiovascular risk 1, 2
• Target blood pressure is <140/90 mmHg for patients without diabetes or chronic kidney disease, and <130/80 mmHg for patients with diabetes or chronic kidney disease, as recommended by the American College of Cardiology 1, 3, 2
• Treatment to reduce hemoglobin A1C to <7% is recommended to reduce microvascular complications in patients with PAD, as per the American College of Cardiology 1, 3
• ACE inhibitors are strongly recommended for symptomatic PAD patients (Class IIa, Level B) to reduce the risk of MI, stroke, and vascular death by approximately 25% 2
• Beta-blockers are not contraindicated in PAD patients (Class I, Level A) and are effective antihypertensive agents that do not adversely affect walking capacity, particularly beneficial for PAD patients with coexisting coronary artery disease or heart failure 1, 2, 4
• Antiplatelet therapy with single antiplatelet therapy (preferably clopidogrel) is recommended for all PAD patients to reduce cardiovascular risk 2, 4
• Telmisartan is an alternative to ACE inhibitors when not tolerated, with equivalent cardiovascular protection to ramipril 4
• Dihydropyridine CCBs, such as amlodipine, are effective for vasospastic angina, which may coexist with coronary artery disease (CAD), according to the American College of Cardiology 5
• Carvedilol can be safely used in patients with peripheral artery disease (PAD) and does not worsen walking capacity, according to the European Society of Cardiology 6

Lifestyle Modifications

• Supervised exercise programs are recommended as first-line treatment for intermittent claudication, with structured exercise as a core component of care for patients with PAD, as per the American College of Cardiology 1, 7
• Smoking cessation is critical for all patients who smoke, with assistance from counseling, pharmacotherapy, and/or referral to smoking cessation programs, as recommended by the American College of Cardiology and the European Society of Cardiology 1, 3, 6
• Proper foot care, including appropriate footwear, daily foot inspection, skin cleansing, and moisturizing creams, is recommended for patients with PAD, as per the American College of Cardiology 1, 3
• Regular physical activity with supervised exercise therapy is recommended for at least 30-45 minutes, ≥3 times/week, to improve walking capacity and reduce cardiovascular risk, as per the European Society of Cardiology 6
• Weight reduction if overweight/obese and dietary sodium restriction are essential lifestyle modifications for PAD management, as recommended by the American College of Cardiology and the European Society of Cardiology 1, 6

Multidisciplinary Care

• Care for PAD patients is optimized when delivered by a multispecialty care team, including podiatrists and specialists with expertise in foot care, wound-healing therapies, and foot surgery, as per the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline 7
• Annual follow-up is recommended to assess clinical and functional status, medication adherence, limb symptoms, and cardiovascular risk factors in patients with PAD, with a focus on optimizing diabetes management if applicable, as per the European Society of Cardiology 6
• Assessment of medication adherence at each visit is crucial for effective PAD management, with a focus on optimizing treatment and reducing cardiovascular risk, as per the European Society of Cardiology 6
• Measuring blood pressure in both arms at least once during initial assessment is recommended, with consideration for orthostatic hypotension, especially in elderly patients, as per the European Society of Cardiology 8
• Blood pressure monitoring should be regular, with consideration for renal function monitoring when using ACE inhibitors/ARBs, especially in patients with bilateral renal artery stenosis, as per the European Society of Cardiology 6

Blood Pressure Management

• The following table summarizes special considerations for blood pressure goals in different populations:

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• A systolic blood pressure (SBP) target of 120-129 mmHg and diastolic blood pressure (DBP) target of <80 mmHg is recommended to reduce cardiovascular events and mortality in patients with PAD and hypertension, as per the European Society of Cardiology 6, 7
• A more lenient blood pressure goal (<140/90 mmHg) may be considered in elderly patients (≥85 years) or those with severe frailty, as per the European Society of Cardiology 6, 7