Clinical assessment of lower extremity peripheral arterial disease

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AHA/ACC Guidelines on Management of Lower Extremity PAD
Guidelines for Clinical Assessment of Lower Extremity PAD
Guidelines for Diagnostic Testing for suspected PAD
Guidelines for Screening for Atherosclerotic Disease in Other Vascular Beds in patients with Lower Extremity PAD
Guidelines for Medical Therapy for Lower Extremity PAD
Guidelines for Structured Exercise Therapy for Lower Extremity PAD
Guidelines for Minimizing Tissue Loss in Lower Extremity PAD
Guidelines for Revascularization of Claudication in Lower Extremity PAD
Guidelines for Management of CLI in Lower Extremity PAD
Guidelines for Management of Acute Limb Ischemial in Lower Extremity PAD
Guidelines for Longitudinal Follow-up for Lower Extremity PAD
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2] Kosar Doraghi, M.D.[3]

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease (DO NOT EDIT)

Recommendations for History and Physical Examination to Assess for PAD (DO NOT EDIT)

Class I

"1. (In patients at increased risk of PAD, a comprehensive medical history and review of symptoms to assess for exertional leg symptoms, lower extremity rest pain, and lower extremity wounds or other ischemic skin changes should be performed.) (Level of Evidence: B-NR)"

”2. (In patients at increased risk of PAD, a comprehensive vascular examination and inspection of the legs and feet should be performed regularly) (Level of Evidence: B-NR)"

Recommendations for Resting ABI and Additional Physiological Testing (DO NOT EDIT)

Class I

"1. (In patients with suspected PAD, toe pressure/toe-brachial index (TBI) with waveforms should be performed when the resting ABI is >1.40 (noncompressible).) (Level of Evidence: B-NR)"

”2. (Patients with suspected chronic symptomatic PAD (ie, exertional nonjoint-related leg symptoms) and normal or borderline resting ABI (>0.90 and ≤1.40, respectively) should undergo exercise treadmill ABI testing to evaluate for PAD.) (Level of Evidence: B-NR)"

Class Ila

"1. (In patients with PAD and an abnormal resting ABI (≤0.90), the exercise treadmill ABI test can be useful to objectively assess the functional status and walking performance.) (Level of Evidence: B-NR)"

"1. (In patients with chronic symptomatic PAD, it is reasonable to perform segmental leg pressures with PVR and/or Doppler waveforms in addition to the resting ABI to help delineate the anatomic level of PAD.) (Level of Evidence: C-LD)"

”2. (In patients with suspected CLTI, it is reasonable to use toe pressure/TBI with waveforms, transcutaneous oxygen pressure (TcPO2), and/or skin perfusion pressure (SPP) in addition to ABI for assessment of arterial perfusion and to establish the diagnosis of CLTI.) (Level of Evidence: B-NR)"

”3. (In patients with CLTI with nonhealing wounds or gangrene, it can be useful to use toe pressure/TBI with waveforms, TcPO2, SPP, and/or other local perfusion measures to determine the likelihood of wound healing without or after revascularization.) (Level of Evidence: B-NR)"

Recommendations for Imaging for PAD (DO NOT EDIT)

Class I

"1. (In patients with functionally limiting claudication with inadequate response to GDMT (including structured exercise) for whom revascularization is being considered, duplex ultrasound, computed tomography angiography (CTA), magnetic resonance angiography (MRA), or catheter angiography of the lower extremities is useful for assessment of anatomy and severity of disease and to determine potential revascularization strategy.) (Level of Evidence: B-NR)"

”2. (In patients with CLTI, duplex ultrasound, CTA, MRA, or catheter angiography is useful to determine revascularization strategy.) (Level of Evidence: B-NR)"

Class II

"1. (In patients with suspected PAD (ie, potential signs and/or symptoms) with inconclusive ABI and physiological testing, noninvasive imaging with duplex ultrasound, CTA, or MRA may be considered to establish the diagnosis of PAD) (Level of Evidence: C-EO)"

Class III

"1. (In patients with a confirmed diagnosis of PAD in whom revascularization is not being considered, CTA, MRA, or catheter angiography should not be performed solely for anatomic assessment.) (Level of Evidence: B-NR)"

Recommendation for Amplifiers of Cardiovascular and Limb-Related Risk in Patients With PAD (DO NOT EDIT)

Class I

"1. (In the evaluation of patients with PAD, clinicians should assess for and incorporate the presence of PAD-related risk amplifiers (Table 9) when developing patient-focused treatment recommendations) (Level of Evidence: C-EO)"

Recommendation for Health Disparities in PAD (DO NOT EDIT)

Class I

"1. (Clinicians and health care systems should actively pursue evidence of health disparities in diagnosis, treatment, and outcomes for patients with PAD and use efforts to limit the impact of these disparities on clinical outcomes.) (Level of Evidence: C-EO)"

Recommendation for Management of PAD in Older Patients(DO NOT EDIT)

Class III

"1. (In older patients (ie, ≥75 years of age) with PAD, assessment for geriatric syndromes (Table 10), such as frailty, sarcopenia, malnutrition, and mobility impairment, can be useful to identify high-risk patients, including before revascularization, and to provide safe and goal-concordant care.) (Level of Evidence: B-NR)"

Antiplatelet and Antithrombotic Therapy for PAD (DO NOT EDIT)

Recommendations for Antiplatelet and Antithrombotic Therapy for PAD (DO NOT EDIT)

Class I

"1. (In patients with symptomatic PAD, single antiplatelet therapy is recommended to reduce the risk of MACE.) (Level of Evidence: A)"

”2. (In patients with symptomatic PAD, single antiplatelet therapy with clopidogrel alone (75 mg daily) is recommended to reduce the risk of MACE.) (Level of Evidence: B)"

”2. (In patients with symptomatic PAD, single antiplatelet therapy with aspirin alone (range, 75-325 mg daily) is recommended to reduce the risk of MACE.) (Level of Evidence: C-LD)"

"1. (In patients with symptomatic PAD, low-dose rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin is effective to reduce the risk of MACE and MALE.) (Level of Evidence: A)"

"1. (After endovascular or surgical revascularization for PAD, antiplatelet therapy is recommended.) (Level of Evidence: B-R)"

"1. (After endovascular or surgical revascularization for PAD, antiplatelet therapy is recommended.) (Level of Evidence: A)"

Antiplatelet and Antithrombotic Therapy for PAD (DO NOT EDIT)

Recommendations for Antiplatelet and Antithrombotic Therapy for PAD (DO NOT EDIT)

Class IIa

"1. (After endovascular revascularization for PAD, dual antiplatelet therapy with a P2Y12 antagonist and low-dose aspirin is reasonable for at least 1 to 6 months) (Level of Evidence: C-LD)"

”2. (After endovascular or surgical revascularization in patients with PAD who require full-intensity anticoagulation for another indication and are not at high risk of bleeding, adding single antiplatelet therapy is reasonable) (Level of Evidence: C-LD)"

”3. (In patients with asymptomatic PAD, single antiplatelet therapy is reasonable to reduce the risk of MACE) (Level of Evidence: C-EO)"

Class IIb

"1. (In patients with symptomatic PAD without recent revascularization, the benefit of dual antiplatelet therapy is uncertain) (Level of Evidence: B-R)"

”2. (In patients with symptomatic PAD, the benefit of vorapaxar added to existing antiplatelet therapy is uncertain) (Level of Evidence: B-R)"

"1. (After surgical revascularization for PAD with a prosthetic graft, dual antiplatelet therapy with a P2Y12 antagonist and low-dose aspirin may be reasonable for at least 1 month) (Level of Evidence: B-R)"

Class III

"1. (In patients with PAD without another indication (eg, atrial fibrillation), full-intensity oral anticoagulation should not be used to reduce the risk of MACE and MALE.) (Level of Evidence: A)"

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease

Recommendations for History and Presentation:

Class I

"1. Patients at increased risk of PAD ( (Table 1) should undergo a comprehensive medical history and a review of symptoms to assess for exertional leg symptoms, including claudication or other walking impairment, ischemic rest pain, and non healing wounds.(Level of Evidence: BNR)"

"2. Patients at increased risk of PAD (Table 1) should undergo vascular examination, including palpation of lower extremity pulses (i.e., femoral, popliteal, dorsalis pedis, and posterior tibial), auscultation for femoral bruits, and inspection of the legs and feet.(Level of Evidence: BNR)"

"3. Patients with PAD should undergo noninvasive blood pressure measurement in both arms at least once during the initial assessment.(Level of Evidence: BNR)"

Table1: Patients at Increased Risk of PAD*
Age ≥65 y Age 50–64 y, with risk factors for atherosclerosis (e.g., diabetes mellitus, history of smoking, hyperlipidemia, hypertension) or family history of PAD Age <50 y, with diabetes mellitus and 1 additional risk factor for atherosclerosis Individuals with known atherosclerotic disease in another vascular bed (e.g., coronary, carotid, subclavian, renal, mesenteric artery stenosis, or AAA)
*Adapted from 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease