PAD guideline updates clinicians should know

The American College of Cardiology and the American Heart Association (ACC/AHA), in collaboration with nine other societies, have released the 2024 guideline for managing peripheral artery disease (PAD), with new recommendations to guide practice.

The guideline – an update to the 2016 ACC/AHA guidance on PAD – delves into the importance of PAD as a public health issue, assessment of PAD-risk amplifiers and evidence of health disparities, and the use of effective medical therapies and lifestyle interventions to guide treatment decisions. It recognises that PAD is associated with an increased risk of amputation, MACE*, impaired quality of life (QoL), and poor functional status. [J Am Coll Cardiol 2024;S0735-1097(24)00381-4]

Clinical assessment is a central component of PAD evaluation. The clinical presentation of PAD can be categorized into four clinical subsets – asymptomatic (may have functional impairment), chronic symptomatic (with claudication), chronic limb-threatening ischaemia (CLTI), and acute limb ischaemia (ALI).

Patients may develop different symptoms during the disease process and move into and out of different subsets. They could deteriorate to CLTI or ALI, or their symptoms could improve after treatment.

The guideline-writing committee said recognizing these clinical subsets will direct diagnostic testing and treatment and determine the urgency of care needed for each patient.

PAD-related risk amplifiers up the risk of MACE and MALE**

Unlike the 2016 ACC/AHA PAD guideline, the new guideline recommends assessing PAD-related risk amplifiers (Figure) when evaluating patients to guide treatment plans.

It added that clinicians and healthcare systems should also actively pursue evidence of health disparities in patient diagnosis and treatment and use efforts to limit the impact of these disparities on clinical outcomes.

Antiplatelet and antithrombotic therapy

Medical therapy is a cornerstone of the guideline. For asymptomatic PAD, single antiplatelet therapy is reasonable to reduce the risk of MACE.

For the first time, low-dose rivaroxaban (2.5 mg twice daily), combined with low-dose aspirin (81 mg daily), is advised to reduce the risk of MACE and MALE. This recommendation also applies to patients who had endovascular or surgical revascularization.

Lipid-lowering and antihypertensive therapy

Treatment with a high-intensity statin is indicated in PAD to achieve an LDL-C reduction of ≥50 percent. In patients already on maximally tolerated statins but whose LDL-C remains at ≥70 mg/dL, it is reasonable to add a PCSK9^*** inhibitor and ezetimibe – a recommendation absent in both the 2016 ACC/AHA guideline and the 2017 ESC PAD guideline. [Eur Heart J 2018; 39:763-816]

For those with PAD and hypertension, antihypertensive therapy is recommended to reduce the risk of MACE. A blood pressure of <130/80 mm Hg is encouraged.

“All patients with PAD would need rigorous medical therapy,” said writing committee chair Dr Heather Gornik from the University Hospitals Harrington Heart & Vascular Institute and Case Western Reserve University School of Medicine, Cleveland, Ohio, US. “We have a lot of recommendations, but they’re not as sexy as the interventions. People are debating over endovascular or surgical techniques, but PAD patients are not even on basic medical therapy or quitting smoking.”

As in the 2016 ACC/AHA PAD guideline, smoking cessation is advised, as is the avoidance of exposure to second-hand smoke.

Diabetes and PAD

In patients with PAD and type 2 diabetes, use of GLP-1^# agonists (liraglutide and semaglutide) and SGLT2^## inhibitors (canagliflozin, dapagliflozin, and empagliflozin) have been shown to reduce the risk of MACE. “A coordinated effort among clinicians is essential, and a diabetes care plan should be tailored for each patient based on clinical status and risk factors,” the writing committee highlighted.

Exercise and foot care

Structured exercise, including supervised exercise therapy and community-based or structured home-based programmes, is a core component of care for patients with PAD. Both can be initial treatment options for patients with functionally limiting claudication.

“Another crucial recommendation is foot care across the whole spectrum of PAD,” Gornik said. Podiatrists and other specialists with expertise in foot care, wound-healing therapies, and foot surgery are equally important members of the multispecialty team.

The new guidance also emphasizes collaborative vascular care. Gornik said care for patients with PAD, particularly those with CLTI, is optimized when delivered by a multispecialty care team.

Revascularization for CLTI, ALI

Revascularization (endovascular, surgical, or hybrid) is recommended to prevent limb loss in patients with CLTI and can improve QoL and functional status in those with claudication unresponsive to pharmacotherapy and structured exercise.

Gornik emphasized that team-based multispecialty care is optimal for CLTI. “On top of revascularization, therapies for wound care, managing infection, and pressure offloading [for those with diabetic foot ulcers] are all important adjunctive components of care in these patients.”

In patients with ALI and a salvageable limb, revascularization (endovascular or surgical, including catheter-directed thrombolysis) is indicated to prevent irreversible tissue damage and amputation.

Takeaways

Overall, the guideline reinforces the importance of longitudinal follow-up. Ongoing care should focus on cardiovascular and limb-risk reduction with medical therapy, optimizing functional status and QoL and, when indicated, revascularization, which requires ongoing surveillance.

“For us to move the needle on the outcomes in PAD, we need to work together,” Gornik emphasized.