PAD Awareness Month: The Latest AHA Scientific Statement highlights screening and prevention as essential

The month of September was PAD Awareness Month. It is an excellent opportunity to get the general public acquainted with this frequent but largely underdiagnosed condition. For MESI Ltd., however, early PAD detection and prevention are something we work and educate on every day.  

For this reason, we will use the occasion of the recent PAD Awareness Month to review the integration of the latest PAD findings into health policies and guidelines. Today, we are focusing on the Scientific Statement from the American Heart Association on LEPAD (lower extremity peripheral artery disease). Published only a few months ago, the Statement brings the latest recommendations and guidelines of worldwide relevance, with the emphasis on screening and prevention as key in battling PAD. 

A video says more than a thousand words, we are also presenting you a video lecture by Matjaž Špan, MD, discussing this Statement and successful lower extremity arterial assessment.  

In this blog you will learn: 

• About the American Heart Association (AHA) 
• Reasons for the latest AHA Scientific Statement on PAD
• Key recommendations and findings from the Statement
• Importance of PAD screening in primary care: a video of Matjaž Špan, MD 

About the American Heart Association 

Founded in 1924, the American Heart Association educates the general public about healthy living, supports cardiovascular medical research, furthers cardiac care, and aims to influence medical and other stakeholders through guidelines on cardiovascular conditions and their prevention.  

2021 marks five years since the publication of the 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease. In June this year, however, the American Heart Association published a Scientific Statement dedicated to PAD. It was made by a working group consisting of experts in cardiology, vascular medicine, vascular surgery and general internist medicine.  

Reasons for the latest AHA Scientific Statement on PAD  

The aim of the Statement is to raise awareness and start the fight against PAD at primary care level. PAD is a condition impacting up to 230 million adult people globally. Although it is alarmingly prevalent and connected with high risk of e.g. stroke, coronary heart disease and amputations, neither patients nor doctors sufficiently consider its importance. As a result, PAD is understudied, underrecognised, underdiagnosed and undertreated. This is due to several factors:   

• The Ankle-Brachial Index, the first-line diagnostic test for PAD, is not readily available at clinics. For this reason, the tests are not carried out frequently enough and on all risk groups. 
• The term ‘peripheral arterial disease’ may give the impression that this condition is not that fatal or important. However, this could not be further from the truth. The term ‘peripheral’ simply means that it is not a condition within the heart itself.  
• Conditions like stroke and myocardial infarction receive much more public and professional attention compared to PAD. They are much more well-known, but as stated above, PAD can be a precursor of heart conditions, so it is vital to catch it at an early stage.  
• PAD symptoms such as pain, cramps or difficulty walking may be dismissed as results of arthritis, spinal degenerative disease or ageing in general. In this way, elderly patients may not be referred on to further testing even though they are a risk group. 
• Often, people with this condition experience no symptoms at all. 

Key recommendations and findings from the Statement 

The key recommendation of the Statement is that PAD screening with ABI be urgently implemented in high-risk populations. TBI or simultaneous measurement of ABI and TBI should be employed if suspecting medial artery calcification, e.g. in cases of chronic kidney disease (CKD) or diabetes. 

Other key findings are that many PAD risks are the same as cardiovascular risks. The following certainly merit highlighting:  

• smoking: for people who stop smoking, the risk for coronary heart disease is again at the baseline in 20 years; with PAD, it takes 30 years for the risk to return to the same level as with non-smokers; 
• diabetes: the PAD risk is 2-3 times higher for people with diabetes than those without; 
• hypertension: there seems to be a robust association of PAD with elevated blood pressure 
• sedentary lifestyle and lack of physical activity (which can also be due to depression); 
• air pollution: living in urban environments increases the risk of PAD two or three times; the situation is similar with population living in the proximity of roadways. 

PAD is often underappreciated, but the Statement finds and warns that it is connected with severe complications: 

• according to studies, PAD cases have increased yearly since 1990, along with years of lost lives, years lived with disability, and disability-adjusted life years; 
• in the US, estimation of PAD prevalence was recommended due to the epidemic incidence of diabetes and obesity;  
• PAD (as opposed to no PAD) has been associated with severe leg outcomes. It needs to be noted that the number of diabetes-related amputations in connection with diabetes has started rising; 
• PAD and its severity have been connected with dementia and cognitive impairment. 

Importance of early PAD screening in primary care: a video of Matjaž Špan, MD 

PAD is gradual, but progressive in nature. For this reason, it is difficult to detect it without testing. The importance of timely lower extremity arterial assessment in connection with the Statement is discussed in this video by Matjaž Špan, MD, a specialist of cardiovascular and vascular surgery:  

The message of the video and the Statement is that there are a number of implementation gaps regarding PAD control, especially at primary care level. 

More should be done to raise PAD awareness of both doctors and patients. Exercise should be advocated as a strong factor in PAD prevention and preventive therapy. When the condition is diagnosed, however, supervised exercise therapy and home-based exercise are seriously underutilised in contrast to medical therapies for PAD.

High-risk populations should be screened for PAD at primary care level, using ABI. TBI should be more widely used, especially for​ ABI >1.4, with the emphasis on patients with diabetes or chronic kidney disease.​ TBI also merits more attention at research level.