Advancing Our Knowledge in Atherosclerotic Peripheral Vascular Disease

Atherosclerotic peripheral vascular diseases are prevalent in the US and other nations. Peripheral artery disease (PAD) affects over 200 million people worldwide and nearly 8.5 million Americans. As a manifestation of atherosclerosis, it is associated with significant cardiovascular morbidity and mortality¹. When unrecognized or inadequately treated, PAD may be life threatening and disabling. Central to the management of the patient with PAD is the primary care provider (PCP) who is under increasing pressure to selectively triage appropriate patients to specialists for care, but it is unclear if current PCP knowledge of PAD is ready to meet this demand. Also, whereas the cardiovascular physician is generally knowledgeable about atherosclerosis and the treatments needed to prevent it and its complications, such as myocardial infarction and stroke, there is often less appreciation of the salient features of PAD, its diagnosis, and the measures requisite to effectively improving symptoms and preventing limb loss. Timely institution of therapies to mitigate risk and improve symptoms of PAD depends on recognition and diagnosis. Moreover, the treatment landscape for PAD is on the cusp of evolution, with new therapies and devices in development. Taken together, there is a need for new education and awareness efforts geared to both healthcare providers and patients.

The American Heart Association has contributed greatly to advance and disseminate the knowledge base for the diagnosis and treatment of vascular disorders. PAD clinical practice guidelines², consensus documents such as the Atherosclerotic Vascular Disease Conference Proceedings³ and scientific statements including PAD in Women⁴, and Measurement and Interpretation of the Ankle-Brachial index⁵. However, it’s been almost 10 years since the original PAD guidelines were published². Accordingly, the 2016 AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease Clinical Practice Guidelines6 represents a significant step forward in addressing the needs of patients and providing evidence-based recommendations for physicians to diagnose and treat PAD. The writing committee includes a broad representation of disciplines involved in PAD patient care and research, and the document offers comprehensive recommendations across the spectrum of peripheral artery disease. It includes recommendations for asymptomatic patients, patients with claudication or atypical leg symptoms, patients with critical limb ischemia, and patients with acute limb ischemia. Recommendations include the clinical assessment and use of the ankle:brachial index to identify and diagnose PAD in patients with symptoms, abnormal physical findings or at increased risk, and indications for physiologic testing and anatomic imaging to aid in diagnosis and plan revascularization procedures. The Guidelines also provide evidence-based recommendations for risk factor treatment, such as smoking cessation, statins and antiplatelet medication to reduce the risk of comorbid cardiovascular events, and for structured exercise training and pharmacotherapy to improve walking ability and functional status in patients with intermittent claudication. Importantly, there are recommendations to guide the use of both endovascular and surgical revascularization in patients with lifestyle-limiting claudication and those with critical limb ischemia, and recommendations which address management of acute limb ischemia.

The 2016 AHA/ACC Peripheral Artery Disease Clinical Practice Guidelines is an important advance in providing tools to clinicians for identifying, diagnosing and treating patients with PAD. Improved awareness and recognition of PAD leading to early comprehensive treatment can positively influence long term outcomes for many of these patients.