Contemporary and Optimal Medical Management of Peripheral Arterial Disease

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Key points

  • Atherosclerotic lower extremity peripheral arterial disease (PAD) is a highly prevalent condition associated with a significant increase in risk of all-cause mortality and cardiovascular morbidity and mortality.

  • PAD is underdiagnosed and undertreated.

  • Treatment is focused on 2 primary objectives: (1) lowering cardiovascular risk and cardiovascular disease (CVD) event rates and (2) improvement in symptoms and quality of life.

  • Contemporary multidisciplinary and intersociety guidelines exist to

Background

PAD refers to the stenosis, occlusion, or aneurysmal change of upper extremity and/or lower extremity arteries.1, 2 Although the term, PAD, can be used to categorize a variety of disease entities and presentations, the acute and chronic conditions associated with atherosclerosis are the most common. The focus of this review is on the epidemiology, risk factors, and medical management of nonacute atherosclerotic lower extremity PAD.

Epidemiology

PAD affects more than 8 million adults in the United States alone.3 PAD is a disease of aging, with an increase in disease prevalence from 10% in individuals aged 65 to more than 30% in octogenarians.4, 5 Concomitant PAD is highly prevalent in individuals with new or established cerebrovascular or coronary artery disease, with prevalence rates greater than 30%.6, 7 Many studies have demonstrated equal prevalence among genders but there is a well-described ethnic disparity, with PAD afflicting

Pathophysiology

Claudication symptoms occur due to a mismatch in oxygen demand and delivery in the skeletal muscles. Arterial insufficiency and PAD most often occur due to insidious progression in the severity of atherosclerosis, but other processes can also cause reduced arterial blood flow (Box 1). The presence and severity of symptoms are also affected by other physiologic factors (muscle mechanics and energy metabolism, endothelial function, collateral blood flow, oxygen delivery, and carrying capacity)

Screening and diagnosis

Given the frequency of asymptomatic and atypical presentations of PAD, with the low sensitivity of disease detection by history alone, accurate diagnosis hinges on effective screening of patients at risk for PAD. Patients considered at high risk for PAD and who should be considered for screening include1, 16

  • People under age 50 with diabetes and 1 additional atherosclerotic risk factor

  • People aged 50 and older with diabetes and/or smoking history

  • Anyone greater than 65 years of age

  • Those with known

Risk factors

The risk factors for atherosclerotic PAD are similar to the risk factors that promote atherosclerotic changes in other arterial vascular beds, with differences in the magnitude of risk conferred by each risk factor on PAD development.

Medical treatment

Complete recommendations for the optimal medical management of patients with PAD are in the recently published and updated American College of Cardiology Foundation/American Heart Association (ACCF/AHA) task force guidelines on the management of patients with PAD, which were developed in collaboration with the Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery.1, 16 According to these

Summary

PAD is an underdiagnosed and undertreated condition that is associated with a considerable increase in morbidity and mortality. Patients with PAD, regardless of symptom status, are at high risk of future cardiovascular events and mortality and require aggressive medical intervention and education. This is not always achieved in the primary care setting. Unfortunately, by the time PAD is diagnosed, the deleterious effects and risks associated with the condition have become well established.

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