From the Journals

PAD guidelines: Consensus needed between U.S. and Europe



Recent advances in the management of peripheral artery disease (PAD) have resulted in new guideline creation in both the United States and Europe.

atherosclerosis_Plaque_stable Vizualis/Thinkstock

While there is considerable consensus between the guidelines, there are multiple differences in emphasis and a differing approach to the types and quality of evidence used to back recommendations, according to a comparative review published in the Journal of the American College of Cardiology. The American Heart Association and American College of Cardiology, together with other organizations, issued an update to their previous guidelines on the management and diagnosis of lower extremity PAD in 2016. In 2017, the European Society of Cardiology in conjunction with the European Society for Vascular Surgery updated their own comprehensive guidelines.

Both the U.S. and the European guidelines stress the importance of lowering risk factors for PAD. This includes stopping smoking, lipid and blood pressure management, and controlling glucose, according to Aaron P. Kithcart, MD, of Brigham and Women’s Hospital, Boston, and Joshua A. Beckman, MD, of Vanderbilt University, Nashville, Tenn.

However, the U.S. guidelines focus more on moderating lifestyle factors, including the pursuit of regular physical activity and the use of supervised exercise, whereas the European guidelines focus considerable attention on recommendations for revascularization in patients with limb-threatening ischemia.

Perhaps the major source of variation between the two sets of guidelines, according to the reviewers, are based upon the intended audiences: “The American document limits its focus to PAD but is applicable to practitioners of every background, whereas the European guideline extends the discussion to all PADs to include carotid and vertebral, upper extremities, mesenteric, and renal arteries in addition to lower-extremity artery disease; but is designed to be a source for cardiologists.”

Accordingly, the ESC/ESVS guidelines approach medical therapy with a more holistic flavor, whereas the ACC/AHA guidelines are specific to the lower-extremity complications of atherosclerosis, according to the reviewers.

Both sets of guidelines come to the conclusion that there is a need for more evidence to identify patients who are at the greatest risk of tissue loss, but overall they differ in their approach to available data. The ACC/AHA is more inclusive of smaller, well-done nonrandomized studies, whereas the ESC/ESVS relegates small studies to Level of Evidence: C. “We believe this difference drives the variation of therapeutic recommendations more than any other factor,” the authors note.

More randomized studies would align recommendations across both organizations, according to Dr. Kithcart and Dr. Beckman (JACC 2018;72:2789-801).

“The management of PAD has progressed a great deal over the last decade. ... Several clinical trials over the coming years should help clarify how revascularization should be approached, and which patients are most likely to benefit. Until then, maintaining good cardiovascular health, including regular physical activity, smoking cessation, lipid-lowering therapy, blood pressure management, and glucose control have the most benefit in patients with PAD,” the researchers concluded.

Dr. Beckman served as a consultant for several pharmaceutical companies, and on the data and safety monitoring board for Bayer and Novartis. Dr. Kithcart reported that he has no relevant conflicts.

SOURCE: Kithcart, AP et al. JACC 2018;72:2789-801.

Next Article: