Overview of PAD guidelines

Learn about the latest guidelines for Peripheral Artery Disease (PAD)/Lower Extremity Artery Disease (LEAD) diagnosis and management.

Despite the ongoing best efforts of the World Health Organisation (WHO) and regional governmental and non-governmental health organisations, cardiovascular diseases (CVDs) remain the number one cause of mortality in the world, accounting for 17.9 million deaths in 2016 alone(1). Most of those deaths (up to 85 %) were attributed to heart attacks and strokes [1]. The underlying causes of this grim statistic are numerous and, amongst others, include the prevalence of sedentary lifestyles and a comorbid lack of physical activity, unhealthy eating habits and an ageing population.
 

Cardiovascular diseases (CVDs) remain the number one cause of mortality in the world, accounting for 17.9 million deaths in 2016 alone.


 
Besides being the leading cause of mortality, CVDs have far-reaching psychosocial and economic consequences, especially coronary artery disease (CAD) and strokes. Studies have shown higher rates of mood and anxiety disorders in individuals with CAD in comparison to individuals without CAD (gender and age adjusted) [2]. Furthermore, a 2018 report from the American Heart Association estimated that between 2013 and 2014 the direct and indirect cost of CVDs and strokes amounted to $329.7 billion (€291.9 billion) and predicted that the cost associated with heart failures (HF) alone would rise from $30.7 billion in 2012 to $69.7 billion in 2030 [3]. The economic impact of this is also significant within the EU, with CVDs estimated as costing $237.1 billion (€210 billion) annually [4].

Despite advances in diagnostic tools and methods, some CVDs remain undiagnosed until they present acute symptoms that require immediate intervention. It has even been estimated that at least 25 % of individuals with a heart condition have sudden death or non-fatal myocardial infarctions without prior (detectable) symptoms [5]. Amongst CVDs there are mild symptoms that may mimic other medical conditions or can often be entirely asymptomatic, and these are also known as Peripheral Artery Disease (PAD).

PAD, often referred to as Lower Extremity Artery Disease (LEAD) is a circulatory disorder involving an abnormal narrowing of arteries other than those supplying the heart and brain. The lower limbs are most often affected, hence the term LEAD, but it can also affect arteries in other parts of the body. It is highly prevalent, with an estimated 202 million people living with PAD in 2010 [6]. This number has likely increased with and ageing population (old age is a risk factor for PAD) and better diagnostic methods (1 minute ABPI measurement) suitable for large scale screening.


 

Diagnostic guidelines

 
There have been many recent advances, discoveries and inventions in the field of diagnostic tools and methods, although some are easier and more affordable to perform in primary health care facilities than others. Presented below are the diagnostic guidelines for PAD as published in the 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS) [7]. Please note that the guidelines presented differ from those outlined by the American College of Cardiology (ACC) and the American Heart Association (AHA). Please consult the 2016 AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease for a more comprehensive overview [8]. More information about the differences between these guidelines can be found in ACC/AHA Versus ESC Guidelines for Diagnosis and Management of Peripheral Artery Disease.

Please note that the following guidelines are presented in an abbreviated format and are limited to the diagnostic methods generally available to primary care physicians. Please consult full ESC (EVSE) guidelines for more in-depth information.
 

Clinical history assessment

 

  • Family history of CVD.
  • Personal history of: hypertension, diabetes– dyslipidaemia, smoking (currently, in the past, possible passive smoking exposure), prior CVD, Chronic Kidney Disease (CKD), a sedentary lifestyle, poor dietary habits, history of cancer radiation therapy, or psycho-social factors.
  • Transient of permanent neurological symptoms.
  • Arm exertion pain, particularly if associated with dizziness or vertigo.
  • Symptoms suggesting angina or dyspnoea.
  • Abdominal pain, particularly in relation to eating and associated with weight loss.
  • Walking impairment/claudication: type (fatigue, aching, cramping, discomfort, burning), location (buttock, thigh, calf or foot), timing (triggered by exercise, uphill rather than downhill, quickly relieved with rest or chronic), or distance.
  • Lower limb pain (including foot) at rest and evolution at upright or recumbent position.
  • Poorly healing wounds of the extremities.
  • Physical activity assessment (functional capacity and causes of impairment).
  • Erectile dysfunction.

 

Clinical examination

 

  • Auscultation and palpitation of cervical and supraclavicular areas.
  • Careful inspection of the upper extremities, including hands (i.e. colour, skin integrity).
  • Palpitation of upper extremity pulses.
  • Blood pressure measurement of both arms and notation of inter-arms difference.
  • Auscultation at different levels including the flanks, peri-umbilical region and groin.
  • Abdominal palpation, palpation of femoral, popliteal, dorsalis pedis and posterior tibial artery pulses and a temperature gradient assessment.
  • Careful inspection of lower limbs, including feet (i.e. colour or presence of any cutaneous lesions). Findings suggestive of lower extremity arterial disease, including calf hair loss and muscle atrophy, should be noted.
  • Peripheral neuropathy assessment in case of diabetes or LEAD: sensory loss (monofilament testing), ability to detect pain and touch sensitivity (sharp examination pin and cotton wool), vibration impairment (128 Hz tuning fork), deep tendon reflexes examination, or sweating.
  • Ankle-brachial pressure index (ABPI) measurement. The simplest and most accurate non-invasive method for the diagnosis of PAD and monitoring the progress of the disease. There are two established methods of measuring ABPI: the Doppler Method. A standard diagnostic method requiring specialised operator training. Takes about 30 min to properly perform, and the Oscillometric Method. A diagnostic method that can be performed by general medical staff without special/only minimal training. Takes about 1 min to perform properly.

*Note: Recent studies have shown that the oscillometric method, as used by the MESI ABPI MD diagnostic device, is a superior method for large scale screening of patients in outpatient settings (i.e. general practice facilities). You can read the full report here [8].
 

ABPI Values, Interpretation and Recommended Actions

 
ABPI values and interpretation with recommended action
 

Laboratory testing

 

  • Fasting plasma glucose
  • Fasting serum lipid profile: total cholesterol, triglycerides, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol.
  • Serum creatinine and creatinine clearance
  • Urine analysis (urinary protein by dipstick test, microalbuminuria)
  • Blood count
  • Uric acid
  • Either glycated haemoglobin if fasting plasma glucose > 5.6 mmol/L (101 mg/dL) or impaired glucose tolerance test when there is doubt*
  • Lipoprotein (a) if there is a family history of premature CVD*
  • Quantitative proteinuria if positive dipstick test*

*Note: Additional test, based on findings from clinical history, examination and other (routine) laboratory tests.
 

Treatment guidelines

 
As in the case of diagnostic guidelines, there are discrepancies in the ESC/ESVS and ACC/AHA treatment guidelines. Presented below are the ESC/ESVS guidelines. Please note that best practices are limited to those most familiar to general practitioners. Please consult the complete ESC (EVSE) guidelines [link] for more in-depth information or the AHA/ACC guidelines [link] for a comprehensive overview.
 

Best medical therapy recommendations

 

  • Smoking cessation is recommended for all patients with PAD,
  • Healthy diet and physical activity are recommended for all patients with PAD,
  • Statins are recommended in all patients with PAD,
  • In patients with PAD, it is recommended to reduce LDL-C to < 1.8 mmol/L (70 mg/dL) or decrease it by > 50%, if baseline values are 1.8–3.5 mmol/L (70–135 mg/dL),
  • For diabetic patients with PAD, strict glycaemic control is recommended,
  • Antiplatelet therapy is recommended for patients with symptomatic PAD,
  • For patients with PADs and hypertension, it is recommended that blood pressure is controlled at < 140/90 mmHg, and
  • Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin-receptor blockers (ARBs) should be considered as a first-line therapy for patients with PADs and hypertension.

Learn about the current diagnostic guidelines for PAD and help your patients avert serious health issues, such as limited mobility, skin ulcers, infections, gangrene (requiring amputation of an affected limb) and ultimately death (due to other PAD-related CVDs).

A brief introduction to PAD.
 
What is MESI ABPI and its benefits?
 
References:

[1] https://www.who.int/en/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2048744/

[3] https://www.ahajournals.org/doi/10.1161/CIR.0000000000000558

[4] http://www.ehnheart.org/images/CVD-statistics-report-August-2017.pdf

[5] https://www.ahajournals.org/doi/full/10.1161/hc4201.097189

[6] https://www.ncbi.nlm.nih.gov/pubmed/23915883

[7] https://academic.oup.com/eurheartj/article/39/9/763/4095038

[8] http://www.heraldopenaccess.us/fulltext/Non-Invasive-Vascular-Investigation/Comparison-of-Ankle-Brachial-Index-ABI-Measurement-between-a-New-Oscillometric-Device-MESI-ABPI-Md-and-the-Standard-Doppler-Method.pdf