The American College of Cardiology Foundation and American Heart Association (ACCF/AHA have updated their guidelines for the management of patients with peripheral artery disease (PAD), emphasizing the expanded use of ankle-brachial index (ABI) measurements for earlier diagnosis, increased attention on getting patients to quit smoking, and better use of antiplatelet and other antithrombotic medications.

-Team@CMHF

• The guidelines are an update of the 2005 ACCF/AHA guidelines and focus on the treatment of atherosclerotic lower-extremity peripheral artery and abdominal aortic aneurysmal disease.
• The updated guidelines reflect a consensus of expert opinion after a review of recent clinical trials deemed relevant to PAD patients, as well as other important data sources that might inform improved care standards for the management of PAD
• There is evidence that the prevalence of PAD remains very high and is likely to increase, especially with an aging, more obese and more diabetic population.
• The new guidelines are intended to facilitate the identification of PAD patients so that the healthcare system might be more effective by providing earlier use of effective measures of prevention, such as smoking cessation and antiplatelet therapy.

Update of the 2005 guidelines

• Specifically, in the new guidelines the ACCF/AHA writing group modified recommendations on the use of the resting ABI to diagnose lower-extremity PAD in suspected at-risk patients, lowering the age of testing from 70 to 65 years and changing the class I recommendation level of evidence from C to B.
• Patients with suspected PAD are defined as those with exertional leg symptoms suspicious for claudication, nonhealing wounds, those aged 65 years old and older, or those aged 50 years and older who have a history of smoking or diabetes
• The updated guidelines also emphasize smoking cessation, with a new class I recommendation for clinicians to ask patients with PAD who are former or current smokers about their smoking status during every office visit (level of evidence A).
• Patients are also to be assisted with developing a plan for quitting smoking, including counseling, referral to a smoking-cessation program, and/or pharmacotherapy, if they have no other contraindications for drug therapy.
• For those without contraindications, the guidelines state that varenicline, bupropion and nicotine-replacement therapy should be recommended (class I recommendation, level of evidence A).
• At least half the population-attributable risk of PAD is tobacco-related
• Tobacco cessation is core to PAD intervention.
• And while clinicians can be cynical, such intervention is known to be feasible in real-world practice.
• Regarding antiplatelet therapy, the ACCF/AHA continues to recommend treatment to reduce the risk of MI, stroke, and vascular death in patients with atherosclerotic lower-extremity PAD.
• Aspirin in daily doses of 75 to 325 mg is a class I recommendation, but the level of evidence has been downgraded from A to B.
• Clopidogrel 75 mg also maintains a class I recommendation as a safe and effective alternative to aspirin.
• Combination therapy with aspirin and Clopidogrel is newly recommended to reduce the risk of cardiovascular events in selected high-risk patients with symptomatic PAD, while antiplatelet therapy monotherapy is suggested as useful in patients with an ABI <0.90.
• The ACCF/AHA guidelines also provide some clarity on the use of surgery and angioplasty for patients with life-threatening lower-extremity ischemia and in whom another vein conduit is not available.
• For those with a life expectancy of less than two years, angioplasty can be performed, while open surgical revascularization may have a preferential and durable benefit in patients expected to live longer than two years. Both are class IIa, level B recommendations.
• The cardiovascular practitioners and primary-care physicians might not recognize critical limb ischemia as a key cardiovascular syndrome that represents a slow-burning vascular emergency.
• For these patients with limb-threatening PAD, the appropriate use of open surgical and endovascular revascularization is emphasized, with careful patient selection critical in deciding the best approach for treatment.
• Healthcare system has done a fantastic job lowering door-to-balloon times for patients with coronary artery disease, but not as good a job lowering leg door-to-balloon times.
• ACCF/AHA also updated the 2005 recommendations for the treatment of abdominal aortic aneurysms by incorporating endovascular repair as a primary treatment option (class I recommendation, level of evidence A) for infrarenal abdominal aortic aneurysms and/or common iliac aneurysms.
• There is also a new recommendation stating that patients who can’t be monitored long term following endovascular repair should be treated with surgery.
• High-surgical-risk patients should undergo endovascular repair.

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