2024 ACC/AHA Guideline for the Management of Lower Extremity Peripheral Artery Disease
21 Jan, 2025 | 12:44h | UTCIntroduction:
This summary highlights key points from the 2024 ACC/AHA guideline on managing patients with lower extremity peripheral artery disease (PAD). It addresses diagnosis, risk stratification, and treatment strategies to reduce major adverse cardiovascular events (MACE) and major adverse limb events (MALE), focusing on four clinical subsets of PAD—asymptomatic PAD, chronic symptomatic PAD, chronic limb-threatening ischemia (CLTI), and acute limb ischemia (ALI). Its overarching goal is to optimize cardiovascular risk reduction, preserve limb function, and improve quality of life (QOL).
Key Recommendations:
- Clinical Assessment and Diagnosis
- Perform a thorough history and physical examination in patients at risk of PAD (e.g., older adults, those with diabetes, hypertension, dyslipidemia, smokers, or known atherosclerosis).
- Measure the ankle-brachial index (ABI) to establish the diagnosis of PAD; use toe-brachial index (TBI) for patients with noncompressible arteries.
- Obtain imaging (e.g., duplex ultrasound, CT angiography, MR angiography) when planning revascularization or in cases with inconclusive ABI.
- Risk Factor Management (Guideline-Directed Medical Therapy)
- Antiplatelet and Antithrombotic Therapy:
- Recommend single antiplatelet therapy (e.g., aspirin or clopidogrel) for symptomatic PAD to reduce MACE.
- Consider low-dose rivaroxaban (2.5 mg twice daily) plus low-dose aspirin in patients at low bleeding risk to reduce MALE.
- Lipid-Lowering Therapy:
- Initiate high-intensity statin therapy in all patients with PAD to reduce cardiovascular and limb events.
- Add ezetimibe or a PCSK9 inhibitor if LDL-C levels remain above target (≥70 mg/dL).
- Blood Pressure Control:
- Target a systolic blood pressure <130 mm Hg in patients with PAD; ACE inhibitors or angiotensin-receptor blockers can further reduce cardiovascular risk.
- Diabetes Management:
- Optimize glycemic control, especially in CLTI; newer agents (e.g., SGLT2 inhibitors, GLP-1 receptor agonists) can reduce cardiovascular risk in PAD with type 2 diabetes.
- Smoking Cessation:
- Strongly advise cessation of all forms of tobacco and nicotine; offer pharmacotherapy (e.g., varenicline, bupropion, nicotine replacement) and behavioral counseling.
- Antiplatelet and Antithrombotic Therapy:
- Exercise Therapy
- Supervised Exercise Therapy (SET):
- A cornerstone of care for patients with claudication to improve walking performance and quality of life.
- Generally performed 3 times per week for at least 12 weeks in a supervised setting (e.g., cardiac rehab facility).
- Structured Community-Based (Home-Based) Programs:
- Include regularly prescribed walking regimens, with periodic clinical follow-up and coaching to promote adherence.
- Supervised Exercise Therapy (SET):
- Revascularization for Chronic Symptomatic PAD
- Initial Approach:
- Offer revascularization (endovascular, surgical, or hybrid) if patients have functionally limiting claudication that fails to improve with medical therapy and structured exercise.
- Endovascular vs. Surgical:
- Select a strategy based on lesion characteristics, availability of adequate vein conduit, and patient comorbidities.
- Combining revascularization with supervised exercise generally yields better functional outcomes.
- Common Femoral Disease:
- Surgical endarterectomy remains a highly durable option.
- Endovascular approaches can be considered for select cases, particularly where surgical risk is high or anatomy is favorable.
- Initial Approach:
- Management of Chronic Limb-Threatening Ischemia (CLTI)
- Team-Based Care:
- Collaborate with vascular specialists, podiatrists, wound-care experts, and other clinicians for optimal outcomes.
- Revascularization Goals:
- Prevent amputation, heal wounds, and reduce rest pain.
- Both endovascular and surgical methods can be effective; selection depends on anatomy, available vein conduit, and patient risk profile (e.g., the BEST-CLI and BASIL-2 trials guide decisions).
- Adjunctive Wound Care:
- Use local wound management (e.g., debridement, negative pressure therapy, offloading) to facilitate healing.
- Treat infection aggressively; urgent revascularization plus antibiotics is essential.
- Pressure Offloading:
- Custom footwear and casts/shoes reduce plantar pressure and help prevent or heal foot ulcers.
- Team-Based Care:
- Acute Limb Ischemia (ALI)
- Immediate Recognition:
- Suspect ALI in patients with sudden onset of pain, pallor, pulselessness, paresthesia, and paralysis.
- Determine limb viability (categories I–III) rapidly.
- Treatment:
- Begin anticoagulation (e.g., IV unfractionated heparin) unless contraindicated.
- Urgent revascularization (surgical embolectomy, catheter-directed thrombolysis, or mechanical thrombectomy) for salvageable limbs.
- Monitor for compartment syndrome and consider fasciotomy if needed.
- Immediate Recognition:
- Preventive Foot Care
- Educate patients on self-inspection, daily hygiene, and protective footwear.
- Screen regularly for high-risk conditions (neuropathy, calluses, deformities, infection).
- Promptly address any foot lesions to avoid progression to ulceration, infection, or gangrene.
- Longitudinal Follow-Up
- Schedule regular visits to monitor:
- Cardiovascular risk factor control (lipids, blood pressure, glycemic targets, smoking).
- Lower extremity symptoms, functional status, and foot health.
- Need for repeat ABI, duplex ultrasound, or imaging after revascularization to detect restenosis.
- Reinforce adherence to structured exercise, medication regimens, and foot care strategies.
- Schedule regular visits to monitor:
Conclusion:
These recommendations underscore the importance of personalized, multidisciplinary care that addresses both cardiovascular and limb-related outcomes in patients with lower extremity PAD. A combination of comprehensive risk-factor modification, supervised or structured exercise programs, and strategic use of revascularization can significantly reduce the risk of major limb loss, improve symptoms, and enhance QOL. Ongoing follow-up is critical to detect disease progression, optimize therapy, and maintain patient engagement in preventative care.
Reference:
2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024; DOI: https://doi.org/10.1161/CIR.0000000000001251