Peripheral arterial disease medical therapy

Peripheral arterial disease Microchapters
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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: Cafer Zorkun, M.D., Ph.D. [2] Aarti Narayan, M.B.B.S [3]

Medical Therapy

Reducing cardiovascular risk

• Smoking cessation
• Antithrombotics
  • Aspirin
  • Warfarin
  • Clopidogrel
• Treat hypertenion
  • ACEI
  • Beta blockers
• Control diabetes
• Statins

Treatment of claudication

Therapeutic choices and evidence

Intervention	Benefits on treadmill/QoL	Limitations	PAD Cohort Indicated
Exercise	100% Improved	Availability and motivation	50% - 85%
Cilostazol	50% Improved	CHF, Medication adverse effects	50% - 85%
Angioplasty	Improvement	Proximal arteries best	10% - 15%
Surgery	150% Improved	Graft failure, high morbidity and mortality	< 5%

Treatment of acute occlusion

• ICU admission, anticoagulation, electrolytes, acid- base and renal status
• Monitor limb status and need for fasciotomy
• If limb not immediately threatened,
  • Thrombolutic therapy - 14 days
  • Percutaneous transluminal angioplasty
• Surgery: Thromboembolectomy, bypass grafting
  • Send sample for pathologic examination (myxoma may be present)

2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (Updating the 2005 Guideline) - Recommendations for Antiplatelet and Antithrombotic Drugs (DO NOT EDIT)

Class I

"1. Antiplatelet therapy is indicated to reduce the risk of MI, stroke, and vascular death in individuals with symptomatic atherosclerotic lower extremity PAD, including those with intermittent claudication or critical limb ischemia, prior lower extremity revascularization (endovascular or surgical), or prior amputation for lower extremity ischemia. (Level of Evidence: A) "

" 2. Aspirin, typically in daily doses of 75 to 325 mg, is recommended as safe and effective antiplatelet therapy to reduce the risk of MI, stroke, or vascular death in individuals with symptomatic atherosclerotic lower extremity PAD, including those with intermittent claudication or critical limb ischemia, prior lower extremity revascularization (endovascular or surgical), or prior amputation for lower extremity ischemia.(Level of Evidence: B) (changed from A to B)"

" 3. Clopidogrel (75 mg per day) is recommended as a safe and effective alternative antiplatelet therapy to aspirin to reduce the risk of MI, ischemic stroke, or vascular death in individuals with symptomatic atherosclerotic lower extremity PAD, including those with intermittent claudication or critical limb ischemia, prior lower extremity revascularization (endovascular or surgical), or prior amputation for lower extremity ischemia. (Level of Evidence: B)"

Class III (No Benefit)

"1. In the absence of any other proven indication for warfarin, its addition to antiplatelet therapy to reduce the risk of adverse cardiovascular ischemic events in individuals with atherosclerotic lower extremity PAD is of no benefit and is potentially harmful due to increased risk of major bleeding. (Level of Evidence: B)(changed from C to B)"

Class IIa

"1. Antiplatelet therapy can be useful to reduce the risk of MI, stroke, or vascular death in asymptomatic individuals with an ABI less than or equal to 0.90. (Level of Evidence: C)"

Class IIb

"1. The usefulness of antiplatelet therapy to reduce the risk of MI, stroke, or vascular death in asymptomatic individuals with borderline abnormal ABI, defined as 0.91 to 0.99, is not well established. (Level of Evidence: A)"

"2. The combination of aspirin and clopidogrel may be considered to reduce the risk of cardiovascular events in patients with symptomatic atherosclerotic lower extremity PAD, including those with intermittent claudication or critical limb ischemia, prior lower extremity revascularization (endovascular or surgical), or prior amputation for lower extremity ischemia and who are not at increased risk of bleeding and who are at high perceived cardiovascular risk. (Level of Evidence: B)"

2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Medical and Pharmacological Treatment for CLI (DO NOT EDIT)

Class III

"1. Parenteral administration of pentoxifylline is not useful for the treatment of CLI. (Level of Evidence: B)"

2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Thrombolysis for Acute and Chronic Limb Ischemia (DO NOT EDIT)

Class I

"1. Catheter-based thrombolysis is an effective and beneficial therapy and is indicated for patients with acute limb ischemia (Rutherford categories I and IIa) of less than 14 days’ duration. (Level of Evidence: A)"

Class IIa

"1. Mechanical thrombectomy devices can be used as adjunctive therapy for acute limb ischemia due to peripheral arterial occlusion. (Level of Evidence: B)"

Class IIb

"1. Catheter-based thrombolysis or thrombectomy may be considered for patients with acute limb ischemia (Rutherford category IIb) of more than 14 days’ duration.(Level of Evidence: B)"

2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Prostaglandins use in CLI (DO NOT EDIT)

Class III

"1. Oral iloprost is not an effective therapy to reduce the risk of amputation or death in patients with CLI. (Level of Evidence: B)"

Class IIb

"1. Parenteral administration of PGE-1 or iloprost for 7 to 28 days may be considered to reduce ischemic pain and facilitate ulcer healing in patients with CLI, but its efficacy is likely to be limited to a small percentage of patients. (Level of Evidence: A)"

2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Angiogenic Growth Factors use in CLI (DO NOT EDIT)

Class IIb

"1. The efficacy of angiogenic growth factor therapy for treatment of CLI is not well established and is best investigated in the context of a placebo-controlled trial. (Level of Evidence: C)"

2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Lipid-Lowering Drugs in PAD Patients (DO NOT EDIT)

Class I

"1. Treatment with a hydroxymethyl glutaryl (HMG) coenzyme-A reductase inhibitor (statin) medication is indicated for all patients with PAD to achieve a target LDL cholesterol level of less than 100 mg per dL.(Level of Evidence: B)"

Class IIa

"1. Treatment with an HMG coenzyme-A reductase inhibitor (statin) medication to achieve a target LDL cholesterol level of less than 70 mg per dL is reasonable for patients with lower extremity PAD at very high risk of ischemic events. (Level of Evidence: B)"

"2. Treatment with a fibric acid derivative can be useful for patients with PAD and low HDL cholesterol, normal LDL cholesterol, and elevated triglycerides. (Level of Evidence: C)"

2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Antihypertensive Drugs in PAD Patients (DO NOT EDIT)

Class I

"1. Antihypertensive therapy should be administered to hypertensive patients with lower extremity PAD to achieve a goal of less than 140 mm Hg systolic over 90 mm Hg diastolic (nondiabetics) or less than 130 mm Hg systolic over 80 mm Hg diastolic (diabetics and individuals with chronic renal disease) to reduce the risk of MI, stroke, congestive heart failure, and cardiovascular death. (Level of Evidence: A). "

"2. Beta-adrenergic blocking drugs are effective antihypertensive agents and are not contraindicated in patients with PAD. (Level of Evidence: A). "

Class IIa

"1. The use of angiotensin-converting enzyme inhibitors is reasonable for symptomatic patients with lower extremity PAD to reduce the risk of adverse cardiovascular events. (Level of Evidence: B). "

Class IIb

"1. Angiotensin-converting enzyme inhibitors may be considered for patients with asymptomatic lower extremity PAD to reduce the risk of adverse cardiovascular events. (Level of Evidence: C). "

2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Diabetes Therapies in PAD Patients (DO NOT EDIT)

Class I

"1. Proper foot care, including use of appropriate footwear, chiropody/podiatric medicine, daily foot inspection, skin cleansing, and use of topical moisturizing creams, should be encouraged and skin lesions and ulcerations should be addressed urgently in all diabetic patients with lower extremity PAD. (Level of Evidence: B)"

Class IIa

"1. Treatment of diabetes in individuals with lower extremity PAD by administration of glucose control therapies to reduce the hemoglobin A1C to less than 7% can be effective to reduce microvascular complications and potentially improve cardiovascular outcomes. (Level of Evidence: C)"

2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)- Recommendations for Homocysteine-Lowering Drugs in PAD Patients (DO NOT EDIT)

Class IIb

"1. The effectiveness of the therapeutic use of folic acid and B12 vitamin supplements in individuals with lower extremity PAD and homocysteine levels greater than 14 micromoles per liter is not well established. (Level of Evidence: C)"

2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Exercise and Lower Extremity PAD Rehabilitation (DO NOT EDIT)

Class I

"1. A program of supervised exercise training is recommended as an initial treatment modality for patients with intermittent claudication. (Level of Evidence: A). "

"2. Supervised exercise training should be performed for a minimum of 30 to 45 minutes, in sessions performed at least 3 times per week for a minimum of 12 weeks. (Level of Evidence: A). "

Class IIb

"1. The usefulness of unsupervised exercise programs is not well established as an effective initial treatment modality for patients with intermittent claudication. (Level of Evidence: B). "

2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Cilostazol use in Claudication (DO NOT EDIT)

Class I

"1. Cilostazol (100 mg orally 2 times per day) is indicated as an effective therapy to improve symptoms and increase walking distance in patients with lower extremity PAD and intermittent claudication (in the absence of heart failure). (Level of Evidence: A). "

"2. A therapeutic trial of cilostazol should be considered in all patients with lifestyle-limiting claudication (in the absence of heart failure). (Level of Evidence: A). "

2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Pentoxifylline use in Claudication (DO NOT EDIT)

Class IIb

"1. Pentoxifylline (400 mg 3 times per day) may be considered as second-line alternative therapy to cilostazol to improve walking distance in patients with intermittent claudication. (Level of Evidence: A)"

"2. The clinical effectiveness of pentoxifylline as therapy for claudication is marginal and not well established. (Level of Evidence: C)"

2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Other Proposed Medical Therapies in Claudication (DO NOT EDIT)

Class III

"1. Oral vasodilator prostaglandins such as beraprost and iloprost are not effective medications to improve walking distance in patients with intermittent claudication. (Level of Evidence: A). "

"2. Vitamin E is not recommended as a treatment for patients with intermittent claudication. (Level of Evidence: C). "

"3. Chelation (e.g., ethylenediaminetetraacetic acid) is not indicated for treatment of intermittent claudication and may have harmful adverse effects. (Level of Evidence: A). "

Class IIb

"1. The effectiveness of L-arginine for patients with intermittent claudication is not well established. (Level of Evidence: B)"

"2. The effectiveness of propionyl-L-carnitine as a therapy to improve walking distance in patients with intermittent claudication is not well established. (Level of Evidence: B)"

"3. The effectiveness of ginkgo biloba to improve walking distance for patients with intermittent claudication is marginal and not well established. (Level of Evidence: B)"

FDA Approved Drugs:

• Pentoxifylline
• Cilostazol

  • Side effects:

    • Headache
    • Diarrhea
    • Gastric upset
    • Palpitations
    • Dizziness

Drugs Under Investigation:

• Atorvastatin
• Rosiglitazone
• Propionyl- L-Carnitine
• L-Arginine
• Prostaglandins
• Angiogenic Factors: VEGF,bFGF

Chronic Pharmacotherapies

• Antiplatelet therapy is indicated for all patients with PAD unless contraindicated for a compelling reason
• Aspirin is recommended, which reduces vascular events and appears to prevent peripheral arterial occlusion after revascularization procedures

References

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