How to refine your approach to peripheral arterial disease
Early recognition, management of comorbid conditions, and appropriate treatment of peripheral arterial disease can help you improve your patient’s outcome.
PRACTICE RECOMMENDATIONS
❯ Use the ankle-brachial index for diagnosis in patients with history/physical exam findings suggestive of peripheral arterial disease (PAD). A
❯ Strongly encourage smoking cessation in patients with PAD as doing so reduces 5-year mortality and amputation rates. B
❯ Use structured exercise programs for patients with intermittent claudication prior to consideration of revascularization; doing so offers similar benefit and lower risks. A
❯ Recommend revascularization for patients who have limb ischemia or lifestyle-limiting claudication despite medical and exercise therapy. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Genetics. A study performed by the National Heart Lung and Blood Institute suggested that genetic correlations between twins were more important than environmental factors in the development of PAD.11
Smoking. Most population studies show smoking to be the greatest modifiable risk factor for PAD. An analysis of the NHANES data yielded an odds ratio (OR) of 4.1 for current smokers and of 1.8 for former smokers.1 Risk increases linearly with cumulative years of smoking.1,2,9,10
Diabetes is another significant modifiable risk factor, increasing PAD risk by 2.5 times.2 Diabetes is also associated with increases in functional limitation from claudication, risk for acute coronary syndrome, and progression to amputation.1
Hypertension nearly doubles the risk for PAD, and poor control further increases this risk.2,9,10
Chronic kidney disease (CKD). Patients with CKD have a progressively higher prevalence of PAD with worsening renal function.1 There is also an association between CKD and increased morbidity, revascularization failure, and increased mortality.1
Two additional risk factors that are less well understood are dyslipidemia and chronic inflammation. There is conflicting data regarding the role of individual components of cholesterol and their effect on PAD, although lipoprotein (a) has been shown to be an independent risk factor for both the development and progression of PAD.12 Similarly, chronic inflammation has been shown to play a role in the initiation and progression of the disease, although the role of inflammatory markers in evaluation and treatment is unclear and assessment for these purposes is not currently recommended.12,13
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