New Guideline for Management of Lower Extremity PAD

A new collaborative, multispecialty guideline has been established for the management of lower extremity peripheral arterial disease (PAD). The guideline  published in  Circulation and the Journal of the American College of Cardiology (JACC), entitled “2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines”, provides guidance for clinicians in the treatment of patients with lower extremity PAD across the following clinical presentation subsets – asymptomatic, chronic symptomatic, chronic limb-threatening ischemia (CLTI), and acute limb ischemia (ALI).

This guideline was led by the American Heart Association (AHA) and the American College of Cardiology (ACC) Joint Committee of Clinical Practice Guidelines; and developed and recommended by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), the American Podiatric Medical Association (APMA), the Association of Black Cardiologists (ABC), the Society for Cardiovascular Angiography and Interventions (SCAI), the Society for Vascular Medicine (SVM), the Society for Vascular Nursing (SVN), the Society for Vascular Surgery (SVS), the Society of Interventional Radiology (SIR), and the Vascular & Endovascular Surgery Society (VESS).

Development of this guideline was the result of a comprehensive literature review from October 2020 to May 2023, including relevant studies, reviews and databases, and other evidence considered during the peer review process. Highlights include (for all clinical subsets) clinical assessment for PAD; diagnostic testing for PAD; special considerations, such as risk amplifiers, health disparities and older patients with PAD; medical therapy/preventative foot care; exercise therapy for PAD; revascularization techniques and registries; and follow-up of PAD.

The guideline also includes top 10 take home messages, which state:

  1. Peripheral artery disease (PAD) is a common cardiovascular disease associated with increased risk of amputation, myocardial infarction, stroke, and death, as well as impaired quality of life (QOL), walking performance, and functional status.
  2. This guideline defines 4 clinical subsets of PAD: asymptomatic PAD (may have functional impairment), chronic symptomatic PAD (including claudication), chronic limb-threatening ischemia, and acute limb ischemia.
  3. Detection of PAD in most patients is accomplished through the history, physical examination, and resting ankle-brachial index.
  4. Health disparities in PAD are associated with poor limb and cardiovascular outcomes and must be addressed at the individual patient and population levels, with interventions coordinated between multiple stakeholders across the cardiovascular community and public health infrastructure.
  5. Effective medical therapies for patients with PAD should be prescribed to prevent major adverse cardiovascular events and major adverse limb events for patients with PAD, including antiplatelet (generally single antiplatelet) and antithrombotic therapy, lipid-lowering (ie, high-intensity statin) and antihypertensive therapy, management of diabetes, and smoking cessation. Rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin (81 mg daily) is effective to prevent major adverse cardiovascular events and major adverse limb events in patients with PAD who are not at increased risk of bleeding.
  6. Structured exercise is a core component of care for patients with PAD. It includes supervised exercise therapy and community-based (including structured home-based) programs.
  7. Revascularization (endovascular, surgical, or hybrid) should be used to prevent limb loss in those with chronic limb-threatening ischemia and can be used to improve QOL and functional status in patients with claudication not responsive to medical therapy and structured exercise.
  8. Care for patients with PAD, and especially those with chronic limb-threatening ischemia, is optimized when delivered by a multispecialty care team.
  9. Foot care is crucial for patients with PAD across all clinical subsets and ranges from preventive care and patient education to advanced care in the setting of chronic limb-threatening ischemia. Podiatrists and other specialists with expertise in foot care, wound-healing therapies, and foot surgery are important members of the multispecialty care team.
  10. The PAD National Action Plan outlines 6 strategic goals to improve awareness, detection, and treatment of PAD nationwide. Implementation of this action plan is recognized as a top advocacy priority by the writing committee.