Optimal Medical Management of Peripheral Arterial Disease

Particularly in the emerging stage, treatment of peripheral artery disease (PAD), can be a straightforward, but may become complicated in patients with comorbid conditions. The approach in more severe cases, when limb viability is already threatened, is significantly different and requires a more radical course of action. However, even these high-risk patients benefit from a comprehensive management programme.

In this blog you will learn:

• Suboptimal treatment of PAD patients.
• Modifiable risk factors for PAD.
• Conservative management of PAD.
• Role of statins in management of PAD.
• General recommendations.

Are PAD patients treated less extensively and efficiently?

The prevalence of PAD is on the rise, from 202 million in 2010 to almost 237 million adults in 2015, and this trend is predicted to continue for the near future (1, 2). Undiagnosed and untreated, PAD can progress into critical limb ischaemia, the last and most severe stage, which is associated with a very high risk of mortality and amputation (3, 4, 5, 6, 7).

However, despite this, screening for PAD is sporadic, even in developed healthcare systems, and often bypasses high-risk patients that would benefit most. A comprehensive study conducted in the UK found that about 40% of patients with lower-extremity ulcers had not received an Ankle-Brachial Index (ABI) assessment or it was unclear whether a recording had been taken (8).

The reasons for such a terrible situation are numerous, ranging from patchy knowledge about the prevalence of PAD to use of largely inaccurate and unreliable diagnostic methods (9). There are ways of remedying that, like increasing the time allocated to each patient that comes for a consultation, or utilisation of modern diagnostic devices for ABI (10, 11, 12, 13). The same could be said for the management of risk factors, although they are in the domain of patients and not physicians, who can advise and support the former.

Which are modifiable risk factors for PAD?

Like many other CVDs, particularly those of an atherosclerotic nature, PAD has several well-defined risk factors (14). The most prominent modifiable risk factor is tobacco smoking, although some believe that diabetes mellitus should be in its place. However, the fact remains that only type 2 diabetes incidence is associated with an unhealthy lifestyle, while the cause of type 1 is strongly connected to genetic factors and, therefore, out of the individual’s control.

Smoking, on the other hand, is and many still choose to smoke despite an overwhelming amount of evidence of its harmfulness. From the perspective of cardiovascular health specifically, it is estimated that 10% of all cardiovascular deaths globally per year (about 1.7 million deaths) are due to smoking (15). Second-hand smoke is responsible for an additional 360,000 cardiovascular deaths every year (16). Smokers, especially females, are at greater risk of PAD and suffer worse outcomes than non-smokers (17, 18, 19).

Fortunately, smoking cessation reverses or at least mitigates some of the harmful effects like arterial stiffness. Benefits include decreasing the overall risk of PAD, improvement of claudication symptoms, and decrease in the risk of amputation, graft failure, restenosis after endovascular revascularisation, myocardial infarction (MI), and mortality (20, 21, 22, 23, 24).

Other prominent modifiable risk factors for PAD are hypertension, hyperlipidaemia, and obesity (25, 26, 27). Treatment and management of PAD is more difficult in patients who are simultaneously in several risk groups.

What is conservative treatment & management of PAD?

All treatment regimens for PAD should include a conservative component that includes diligent hyperglycaemia management, smoking cessation, hypertension and hyperlipidaemia management, and lifestyle changes such as maintaining a healthy weight, a balanced diet, and appropriate levels of physical activity (28). A part of conservative management Medications like beta blockers, ACE inhibitors, antiplatelet medications, and statins and cilostazol are, therefore, also a part of conservative management.

What is the role of medications in PAD management?

The primary role of various medications that benefit patients with PAD is reducing the likelihood of additional cardiovascular issues and events that may follow a diagnosis of PAD. Individuals with pre-existing coronary artery disease (CAD) should be on a therapy consisting of a combination of beta blockers, antiplatelet medication, and angiotensin-converting enzyme (ACE) inhibitors (28). The latter have a proven record of reduction of cardiovascular events in patients with PAD by themselves (29, 30). Managing hyperlipidaemia with statins is likewise beneficial (31).

The results of the Heart Protection Study (HPS) conducted in the United Kingdom encompassing patients who were subjected to a daily regime of 40 mg of simvastatin over a 5-year period are particularly telling (32). They had a 12% reduction in total mortality, 17% reduction in vascular mortality, 27% reduction in strokes, 24% reduction in CAD-related events and a 16% reduction in (non-coronary) revascularisation procedures (32).

Even patients with multiple risk factors for PAD, but no history of positive diagnosis should be on statin therapy (28). Lastly, patients with symptomatic PAD, i.e. with intermittent claudication, should be considered for cilostazol, which increases the pain-free walking distance (33).

Optimal medical management of PAD consists of a comprehensive programme encompassing lifestyle modifications and pharmacologically supported management of hypertension, hyperlipidaemia and intermittent claudication.

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Ensuring you have the best possible insight into your cardiovascular patients’ condition. Monitoring your cardiovascular risk patients’ trends and providing them with continuously reliable assessment is a challenge.