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
Statins reduce cardiovascular events in PAD patients. A large study demonstrated that 40 mg of simvastatin has an NNT of 21 to prevent a coronary or cerebrovascular event in PAD, similar to the NNT of 23 seen in treatment of CAD.27 Statins also reduce adverse limb outcomes. A registry of atherosclerosis patients showed that statins have an NNT of 56 to prevent amputation in PAD and an NNT of 28 to prevent worsening claudication, critical limb ischemia, revascularization, or amputation.28
Antiplatelet therapy with low-dose aspirin or clopidogrel is recommended for symptomatic patients and for asymptomatic patients with an ABI ≤ 0.9.13 A Cochrane review demonstrated significantly reduced mortality with nonaspirin antiplatelet agents vs aspirin (NNT = 94) without increase in major bleeding.29 Only British guidelines specifically recommend clopidogrel over aspirin.31
Dual antiplatelet therapy has not shown consistent benefits over aspirin alone. ACC/AHA guidelines state that dual antiplatelet therapy is not well established for PAD but may be reasonable after revascularization.13
Voraxapar is a novel antiplatelet agent that targets the thrombin-binding receptor on platelets. However, trials show no significant coronary benefit, and slight reductions in acute limb ischemia are offset by increases in major bleeding.13
For patients receiving medical therapy, ongoing evaluation and treatment should be based on claudication symptoms and clinical assessment.
Medical therapy for claudication
Several medications have been proposed for symptomatic treatment of intermittent claudication. Cilostazol is a phosphodiesterase inhibitor with the best risk-benefit ratio. A Cochrane review showed improvements in maximal and pain-free walking distances compared to placebo and improvements in quality of life with cilostazol 100 mg taken twice daily.32 Adverse effects included headache, dizziness, palpitations, and diarrhea.29
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