ACCF/AHA Publish Updated Guidelines for PAD Management

September 29, 2011—The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) announced the release of an updated guideline for the diagnosis and management of peripheral arterial disease (PAD). This guideline, which is intended to help guide clinical decision making related to PAD and improve patient outcomes, includes expanded criteria for using the ankle-brachial index (ABI) for earlier diagnosis, increased efforts to ensure all patients have access to smoking cessation services, improved use of clot-preventing medications, as well as a more focused definition of effective interventions for avoiding limb amputations and treating aortic aneurysms.

The document was published online ahead of print in the Journal of the American College of Cardiology and in the AHA's journal, Circulation.

According to the ACCF and AHA, the guideline updates the original 2005 recommendations and reflects a thorough review of the new evidence-based clinical trial and other clinical data. It was developed in collaboration with representatives from the Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery.

“This document provides agreed-upon approaches and treatments for PAD that vascular surgeons, vascular medicine specialists, cardiologists, pulmonologists, interventional radiologists, and primary care clinicians can apply to help improve patient care,” commented Thom Rooke, MD, Chair of the guidelines writing group. “This guideline is especially important for PAD, which is often still treated less aggressively than heart disease, and we know that many patients do not yet receive ideal care.”

The ACCF and AHA noted that the guideline includes a recommendation to lower the age at which ABI diagnostic testing should be performed in the practice setting from ≥ 70 years of age to ≥ 65 years of age. This decision was based on mounting evidence demonstrating that people ≥ 65 years have a one in five chance of having either symptomatic or asymptomatic PAD.

“Age alone appears to define a patient population at such a high risk of PAD that we can justify using a cost-effective and risk-free test like the ABI,” said Dr. Rooke. “It's important to remember, when we check ABI to detect PAD in a patient without clear-cut leg symptoms, it is known that we are effectively assessing overall heart and vascular health. If PAD is detected, effective risk reduction medications are available to lower this risk.”

The guideline recommendations include strengthening efforts to help individuals with PAD quit smoking and, in turn, lower rates of heart attack, stroke, and lower limb amputations; this includes consistently asking current and former smokers about tobacco use at each visit, as well as proactively offering support through counseling, pharmacologic therapies, and/or formal smoking cessation programs.

The guidelines also recommend considering leg artery angioplasty as a first line treatment for certain individuals with severe PAD who may face amputation. The guidelines note that angioplasty does not provide an ideal treatment for all patients with PAD, therefore for patients in whom a life span > 2 years is anticipated, open vascular surgery may be more durable and most effective. Also, they recommend understanding new data that shows that aortic aneurysms can be safely treated by both surgical and endovascular treatments with nearly equal efficacy and safety.

Alan T. Hirsch, MD, Vice Chair of the writing group, stated, “When PAD is undetected and poorly managed, it is among the most costly cardiovascular diseases. Delays in care and inadequate use of proven risk reduction therapies continue to put lives at stake. While there have been progressive improvements in PAD care, it appears that even simple interventions, like appropriate prescription of smoking cessation and exercise are not utilized by clinicians, health care systems, and payers. We still have a long way to go; the opportunity for prevention and earlier, life-saving interventions is immense. This guideline provides a roadmap.” Dr. Hirsch added that additional promotion of guideline use by hospitals and health systems would be expected to lead to major improvements in clinical outcomes.