6 things you need to know about 2024 ESVS Guidelines on asymptomatic PAD

Despite affecting hundreds of millions worldwide, Peripheral Arterial Disease (PAD) is a severely underdetected cardiovascular condition. This is because of two factors: it is largely asymptomatic and not well-known in the public domain.

The European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication put these two facts at the forefront. This blog discusses six highlights of this document – from its specific focus on asymptomatic PAD to the unique introduction of a summary for patients.

In this blog, you will learn the following about the 2024 ESVS Guidelines:

1. Focus on asymptomatic PAD and intermittent claudication
2. Recommendation of TBI as an additional measurement method in PAD diagnostics
3. Recommendation of the 6MWT for asymptomatic and IC patients
4. Introduction of bleeding score for PAD patients before antithrombotic therapy
5. Emphasis on exercise therapy for patients with intermittent claudication
6. Plain language summary for patients

1. Focus on asymptomatic PAD and intermittent claudication

The European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication is the first prominent guideline that specifically focuses on the diagnosis and treatment of:

• asymptomatic lower limb PAD (Rutherford grade 0/Fontaine stage I); and
• intermittent claudication (Rutherford grade I-III/Fontaine stage IIa and IIb).

The focus on these two clinical stages comes seven years after the latest PAD-related ESC/ESVS guidelines, namely the 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS), which focus on a variety of PADs. In contrast, the 2024 ESVS Guidelines centre on lower extremity PAD, defined as “obstructive atherosclerotic disease of the arteries from the distal aorta to the foot”. [1]

Asymptomatic Peripheral Arterial Disease shares the same risk factors and pathophysiology as symptomatic PAD. Asymptomatic PAD is often considered as an early stage. Studies show that progression rates vary from 5% over five years to 21% within one year, and the Limburg PAOD Study (1988) found that 9% of asymptomatic PAD cases developed intermittent claudication (IC) over a seven-year follow-up. [1]

There are several factors that contribute to the underdetection of PAD symptoms: [1]

• physical inactivity: Even if patients have significant arterial lesions, symptoms may not appear without increased blood flow.
• coexisting conditions like angina, congestive heart failure, chronic obstructive pulmonary disease or musculoskeletal problems can limit the patient’s ability to walk and thus the onset of symptoms.
• altered pain perception in the lower extremity, e.g. due to diabetes and/or peripheral neuropathy.

These factors highlight the importance of early screening and detection efforts because many patients with PAD remain unaware of their condition until it progresses to a more severe stage. The 2024 ESVS Guidelines recommend considering focus screening with Ankle-Brachial Index (ABI) measurements for the following clinically asymptomatic individuals at higher risk of PAD: [1]

• all individuals aged 65 years or more;
• all individuals between 50 and 64 years with any of the following risk factors for atherosclerosis:
  • diabetes
  • history of smoking
  • hyperlipidaemia
  • hypertension
  • chronic kidney disease
  • family history of PAD
• all individuals younger than 50 years with diabetes & one other risk factor for atherosclerosis
• all individuals with known atherosclerotic disease in another vascular bed

PAD is diagnosed if the ABI measurement is outside the normal range (0.91-1.39). This is indicative of stenosis or occlusion, and the patient is regarded at high risk of future cardiovascular events. A value ≥ 1.4 should be considered inconclusive. [1]

In the summary for patients, the 2024 ESVS Guidelines state the following: “ankle brachial index (ABI) measurement should be available in all healthcare centres and is a good way to identify the disease as early as possible in patients at risk in primary care.” [1]

2. Recommendation of TBI as an additional measurement method in PAD diagnostics

The Toe-Brachial Index is recommended as an additional measurement method in confirming the PAD diagnosis in the following cases: [1]

• upon suspicion of a falsely elevated ABI result due to incompressible arteries;
• upon clinical suspicion of PAD despite normal ABI levels.

The Toe-Brachial Index is measured because digital arteries are less frequently affected by incompressibility. A TBI lower than 0.7 is considered abnormal.

3. Recommendation of the 6MWT for asymptomatic and IC patients

The 6-minute walk test (6MWT) was not discussed in the Guidelines from 2017. The 2024 ESVS Guidelines describe it as a commonly used corridor-based walking test, with studies showing its retest reliability. [2] Its use is recommended in the following cases:

• as an objective assessment for patients who have not reported any leg symptoms during exertion; [2]
• for assessing the severity of known intermittent claudication (IC). In this case, it is used for measuring the claudication distance (i.e. the distance that the patient manages to walk until the claudication symptoms appear). For patients with known IC, the 6-minute walk test is recommended as “the primary walking capacity test” because it corresponds to the daily walking situations better than e.g. the treadmill test. [3] In this, it should also be noted that corridor-based tests and treadmill tests are not interchangeable when measuring the patient’s walking endurance. [4]

4. Introduction of an easy-to-implement bleeding score for PAD patients before antithrombotic therapy

PAD management often involves two key drug classes: lipid-lowering drugs and antithrombotic drugs. Statin therapy has been shown to improve walking distance for patients with intermittent claudication, reducing the rates of major adverse cardiovascular events and major limb events.

Antithrombotic drugs are usually not used for asymptomatic PAD, but in advanced PAD stages – during and after lower limb revascularisation to prevent atherothrombotic complications and maintain vascular patency. However, the use of these drugs is associated with bleeding risk.

The recommendation of the 2024 ESVS Guidelines is that all patients with lower limb peripheral arterial disease should be evaluated as to the bleeding risk and individual medication benefit before starting antithrombotic treatment. The evaluation should be performed on the basis of suitable prediction scores.

The 2024 ESVS Guidelines introduce the practical OAC3-PAD bleeding score, originally developed by a German health insurance company. This score identifies key predictors of a major bleeding risk within a year, which include: [5]

• oral anticoagulation (prior use)
• age > 80 years
• chronic limb-threatening ischemia
• congestive heart failure
• chronic kidney disease
• prior bleeding event
• anaemia
• dementia (vascular or unspecified; anti-dementia medication)

On the basis of their score, the patient is stratified into one of four risk groups, with one-year major bleeding rates ranging from 1.3% to 6.4%.

The antithrombotic therapy should be tailored to each patient and started after a joint treatment decision of the patient and the clinician.

5. Emphasis on exercise therapy for patients with intermittent claudication

The 2024 ESVS Guidelines highlight supervised exercise therapy (SET) as the recommended first-line treatment for IC (intermittent claudication) patients. It effectively increases pain-free and maximum walking distance, improves health-related quality of life, and reduces self-reported functional impairment. Nevertheless, despite strong evidence of its benefits, access to SET remains limited in many countries, with only a small proportion of IC patients receiving this effective intervention.

When SET is not feasible, patients may be encouraged to join an exercise-based cardiac rehabilitation programme to improve walking distance and functional capacity. The start or continuation of SET is also recommended for patients who have undergone revascularisation.  This reduces the need for secondary revascularisation.

6. Information for patients

The 2024 ESVS Guidelines place emphasis on patient-centred, joint decision making in the management and treatment of PAD in its various phenotypes. For this reason, the ESVS Guidelines also include a section with a plain-language summary of important PAD facts for patients. This includes the definition of PAD, the description of its different stages as well as the explanation of why it is dangerous and who it affects.

This patient-focused approach is unique among guidelines issued by major medical associations, which typically target healthcare professionals exclusively. By expanding the usability of its 2024 PAD Guidelines to include patients, the ESVS acknowledges the vital role that patient awareness and education play in managing PAD. Empowering patients with clear, accessible information contributes to early detection and promotes active participation in treatment decisions. This proactive approach is particularly significant given the severe consequences of untreated PAD, which can include major cardiovascular events, limb loss, and even death.

What is the ESVS?

The European Society for Vascular Surgery (ESVS) was founded in London (UK) in 1987. It is a leading scientific and professional organisation that sets the standards for preventing and managing vascular disease. It drives scientific advancements in vascular care, and serves as a premier training body with standardised education pathways.