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Peripheral artery disease

What's new

Updated 2024 ACC/AHA guidelines for the diagnosis and management of peripheral artery disease.

Background

Overview

Definition
PAD is a term that encompasses diseases characterized by narrowing of arteries distal to the aortic arch (non-cardiac and non-intracranial).
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Pathophysiology
The most common cause of PAD is atherosclerosis; less common causes include inflammatory disorders of the arterial wall (vasculitis) and noninflammatory arteriopathies, such as FMD. Athero-thrombosis due to hypercoagulable states may also lead to the development of PAD.
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Epidemiology
In patients ≥ 40 years of age living in the US, the incidence and prevalence of PAD are estimated at 2.35% and 10.69%, respectively.
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Disease course
The key clinical presentations of PAD are intermittent claudication and critical limb ischemia. Intermittent claudication refers to symptoms of pain in the muscles of the lower extremities that are brought on by physical activity and relieved by rest. Critical limb ischemia is a more severe manifestation of PAD that presents as rest pain, ischemic ulceration or gangrene of the foot.
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Prognosis and risk of recurrence
PAD is associated with increased mortality rates, with most deaths occurring due to coronary artery disease (40-60%) and cerebrovascular disease (10-20%). Critical limb ischemia is associated with an estimated 1-year mortality of 20-25%, and an estimated 5-year mortality of 40-50%.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of peripheral artery disease are prepared by our editorial team based on guidelines from the American Heart Association (AHA/HRS/ACC/ACCP 2024), the European Society for Vascular Surgery (ESVS 2024), the Vascular and Endovascular Surgery Society (VESS/SCAI/ABC/SVM/SVN/SVS/AHA/AACVPR/ACC/APMA/SIR 2024), the American College of Radiology (ACR 2022), the Canadian Cardiovascular Society (CCS 2022), the European...
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Screening and diagnosis

Indications for screening, general population: as per ESVS 2024 guidelines, Do not obtain screening for lower extremity PAD with ABI in asymptomatic individuals without increased cardiovascular risk.
D
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  • Indications for screening (patients at risk)

  • Indications for screening (before cardiovascular procedures)

  • Indications for screening (HF)

Diagnostic investigations

ABI, indications: as per ESVS 2024 guidelines, Obtain ABI as the appropriate test to establish the diagnosis of lower extremity PAD.
B

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  • ABI (treadmill)

  • TBI

  • Other perfusion assessment modalities

  • 6MWD

  • Diagnostic imaging

  • Screening for other arterial diseases

  • Screening for CVD risks

  • Patient-reported outcomes

  • Laboratory tests

  • ABI (technical considerations)

  • History and physical examination

Medical management

General principles: as per ESVS 2024 guidelines, Offer a stepwise approach in patients with intermittent claudication, providing risk factor management, best medical treatment, and exercise therapy as a first step and revascularization as a second step in compliant patients with continued disabling limb symptoms.
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  • Management of claudication (cilostazol and naftidrofuryl)

  • Management of claudication (other agents)

  • Management of hypertension (targets)

  • Management of hypertension (drugs)

  • Management of diabetes mellitus

  • Antiplatelet therapy (asymptomatic)

  • Antiplatelet therapy (symptomatic)

  • Anticoagulation therapy

  • Lipid-lowering therapy

  • Chelation therapy

Nonpharmacologic interventions

Exercise therapy: as per ESVS 2024 guidelines, Advise striving for at least 150-300 minutes a week of moderate-intensity or 75-150 minutes a week of vigorous-intensity aerobic physical activity to reduce all-cause and cardiovascular mortality and cardiovascular morbidity in all patients with lower extremity PAD (including asymptomatic stages).
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  • Smoking cessation

  • Dietary changes

  • Supplements

Therapeutic procedures

Indications for revascularization, symptomatic: as per AACVPR/ABC/ACC/AHA/APMA/SCAI/SIR/SVM/SVN/SVS/VESS 2024 guidelines, Weight the potential benefits with respect to the QoL, walking performance, and overall functional status against the risks and durability of intervention and possible need for repeated procedures in patients with functionally limiting claudication being considered for revascularization.
B
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  • Indications for revascularization, asymptomatic

  • Choice of revascularization, general principles

  • Choice of revascularization, aortoiliac

  • Choice of revascularization, femoropopliteal

  • Choice of revascularization, infrapopliteal

Perioperative care

Preoperative risk assessment: as per CCS 2022 guidelines, Do not use the RCRI for preoperative assessment of cardiac risk in patients undergoing peripheral arterial surgery.
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Specific circumstances

Female patients
As per ESVS 2024 guidelines:
Offer similar evidence-based cardiovascular primary and secondary preventive strategies in males and females with PAD.
B
Do not use hormone replacement therapy with estrogen or progestin for the prevention of CVD in postmenopausal females.
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  • Patients requiring OACs

  • Patients undergoing coronary artery intervention

Patient education

General counseling: as per ESVS 2024 guidelines, Provide patient-centered counseling with each new medical prescription and include appropriate recommendations to change modifiable risk factors, lifestyle, and health behavior in patients with lower extremity PAD.
B

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  • Foot care

Preventative measures

Influenza vaccination: as per ESVS 2024 guidelines, Offer annual influenza vaccination to reduce the risk of severe influenza infection in patients with lower extremity PAD.
B

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  • COVID-19 vaccination

Follow-up and surveillance

Serial clinical assessment: as per AACVPR/ABC/ACC/AHA/APMA/SCAI/SIR/SVM/SVN/SVS/VESS 2024 guidelines, Obtain longitudinal follow-up with routine clinical evaluation, including assessment of limb symptoms and functional status, lower extremity pulse and foot assessment, and progress of risk factor management. in patients with PAD with or without revascularization.
B
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  • Post-revascularization assessment (clinical)

  • Post-revascularization assessment (imaging)

  • Post-revascularization antithrombotic therapy

  • Management of restenosis

Quality improvement

Hospital requirements: as per ESC/ESVS 2018 guidelines, Set up a multidisciplinary vascular team in healthcare centers to make decisions for the management of patients with PADs.
B

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  • Public health measures

  • Research considerations