Diagnosis and Treatment of Lower Extremity PAD Addressed in New Multisociety Guideline

May 22, 2024—A comprehensive new multisociety guideline on the management of lower extremity peripheral artery disease (PAD) has been published by Gornik et al in Circulation and Journal of the American College of Cardiology, emphasizing that timely diagnosis and proper management—including coordinated care from a multispecialty team—are essential to help prevent amputation and other cardiovascular complications and to allow patients with PAD to live longer lives with better physical function and improved quality of life.

Development of the guideline was led by the American Heart Association (AHA) and the American College of Cardiology (ACC) Joint Committee on Clinical Practice Guidelines and developed with and endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Podiatric Medical Association, the Association of Black Cardiologists, the Society for Cardiovascular Angiography and Interventions, the Society for Vascular Medicine, the Society for Vascular Nursing, the Society for Vascular Surgery, the Society of Interventional Radiology, and the Vascular & Endovascular Surgery Society.

The AHA and ACC summarize the document as providing the latest evidence-based recommendations to guide clinicians in the diagnosis and treatment of lower extremity PAD across its four clinical presentation subsets: asymptomatic disease, chronic symptomatic PAD, chronic limb-threatening ischemia (CLTI), and acute limb ischemia (ALI). The guideline includes recommendations on medical therapy, diabetes, foot care, smoking cessation, exercise, and addressing disparities in PAD care and outcomes in patients from under-resourced communities in the United States.

A “take-home message” of the document is that revascularization (endovascular, surgical, or hybrid) should be used to prevent limb loss in patients with CLTI and can be used to improve quality of life and functional status in patients with claudication not responsive to medical therapy and structured exercise. The guideline specifically addresses revascularization for asymptomatic PAD (section 7); revascularization techniques and registries for chronic symptomatic PAD and CLTI (section 8); and revascularization for claudication from chronic symptomatic PAD (section 9). The management of CLTI and ALI are covered in sections 10 and 11, respectively.

The AHA/ACC noted that although there are highly effective medical, endovascular, and surgical therapies for PAD, historically, many people with PAD have been undertreated or do not receive guideline-directed medical therapies at the same rate as patients with other cardiovascular diseases. The announcement also highlighted the 2021 publication of the PAD National Action Plan, which outlined strategic goals to improve awareness, detection, and treatment of PAD nationwide, and proposed a goal of reducing nontraumatic limb amputation in the United States by 20% by 2030. For a summary of the PAD National Action Plan and insights from it cowriting chairs, see Endovascular Today's prior coverage.

Heather L. Gornik, MD, who is Chair of the guideline writing committee and lead author of the publication, addressed the document’s recommendations in the AHA/ACC announcement.

“Because of the complexities of PAD, to improve outcomes and reduce the risk of limb loss for these patients, a multispecialty care team approach that is focused on comprehensively addressing risk factor management, foot care, and revascularization is needed to promote collaboration, avoid duplication of care, and optimize patient outcomes,” commented Dr. Gornik, who is Codirector of the Vascular Center at the University Hospitals Harrington Heart & Vascular Institute and Professor of Medicine at Case Western Reserve University School of Medicine, both in Cleveland, Ohio. “It’s important to recognize the signs and symptoms of PAD and move quickly to initiate treatment to improve outcomes and reduce risks. With these updated guidelines, we have the tools necessary to make a positive impact on outcomes in our patients with PAD. Now, we need to work together to implement them as broadly as possible.”

An expanded discussion on putting the 2024 PAD Guideline into practice will be featured in a forthcoming edition of Endovascular Today.