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Top Ten Things to Know:
Optimal Exercise Programs for Patients With Peripheral Artery Disease

By Amy West Pollak, MD, MS, FAHA, Assistant Professor Cardiovascular Medicine, Mayo Clinic, Florida

  1. This scientific statement serves as a comprehensive clinical resource regarding the evidence supporting exercise for patients with peripheral artery disease (PAD) and lower extremity symptoms, the underlying pathophysiology related to the walking impairment, and outlines the role of supervised exercise training (SET) as well as home-based walking programs and alternative exercise approaches.
     
  2. In 2017 there was a national coverage determination of supervised exercise therapy (SET) for Medicare beneficiaries with symptomatic PAD, resulting in implementation of SET programs across the country.  This scientific statement outlines the specific components of a recommended SET program and highlights the supporting evidence. 
     
  3. Affecting > 8 million Americans, lower extremity PAD often results in exertional leg symptoms including claudication, atypical leg discomfort and impaired walking ability.  Exercise programs, both supervised and home-based improve peak walking time and time to claudication for patients with PAD.
     
  4. Functional impairment and decline in walking performance in patients with PAD can occur without claudication and the resulting sedentary lifestyle is associated with decreased quality of life and poorer cardiovascular health. 
     
  5. The exercise limitation in patients with lower extremity PAD is multifactorial related to abnormal arterial blood flow in the large blood vessels, local microcirculatory changes, and changes in calf muscle structure and metabolic activity.
     
  6. Treadmill-based exercise therapy for patients with PAD teaches patients to walk until moderate-severe discomfort occurs in their legs, followed by short periods of rest to allow their symptoms to resolve.  The exercise intensity should elicit mild claudication within 5 minutes and moderate to severe claudication within the first 10 minutes, with cycles of exercise/rest repeated over a 30- to 60-minute exercise session.
     
  7. The supervised exercise should occur three times per week for a total of 12 weeks, followed by lifetime maintenance walking of at least twice per week.
     
  8. Home-based walking exercise, an alternative to SET when patients are unable to come for supervised sessions, suggests that patients write down their walking exercise goals and record their walking exercise each week, and this information be reviewed periodically by a health care provider with specific feedback provided to the patient. The home-based walking program can start with as little as 10 minutes of walking exercise per session and increasing walking exercise per session by approximately 5 minutes per week until the patient is walking for exercise during 45 to 50 minutes per session (excluding rest periods).
     
  9. For patients with lower extremity PAD who are unable to do walking exercise, alternative strategies such as arm ergometry, leg cycling and resistance training can be considered. 
     
  10. The 2016 AHA/ACC guidelines on the management of patients with lower-extremity PAD include recommendations supporting exercise therapy for patients with PAD. Supervised exercise therapy as well as structured community or home-based exercise programs which include alternative strategies of exercise therapy, can be beneficial to improve walking ability, functional status and quality of life. Future studies should focus on identifying optimal exercise programs for patients with PAD and delineate biologic pathways by which exercise improves walking performance in PAD.

Citation

Treat-Jacobson D, McDermott MM, Bronas UG, Campia U, Collins TC, Criqui MH, Gardner AW, Hiatt WR, Regensteiner JG, Rich K, on behalf of the American Heart Association Council on Peripheral Vascular Disease, Council on Quality of Care and Outcomes Research, and Council on Cardiovascular and Stroke Nursing. Optimal exercise programs for patients with peripheral artery disease: a scientific statement from the American Heart Association [published online ahead of print December 13, 2018]. Circulation. DOI: 10.1161/CIR.0000000000000623