Management of Lower Extremity Peripheral Artery Disease: Guidelines From the ACC/AHA

Peripheral artery disease (PAD) is a common cardiovascular disease that impacts walking, overall function, and quality of life. It also increases the risk of amputation, myocardial infarction, stroke, and death. The American College of Cardiology and American Heart Association (ACC/AHA) have released guidelines for the management of PAD.

ACC/AHA defines four PAD subsets: asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia. Patients can move into and out of subsets due to deterioration from disease progression or improvement of symptoms with treatment.

Recognizing risk factors for PAD helps identify patients who may benefit from further investigation because PAD symptoms can be subtle or delayed. Indicators include age older than 65 years; patients 50 to 64 years of age with risk factors for atherosclerosis such as diabetes, history of smoking, dyslipidemia, hypertension, chronic kidney disease, or a family history of PAD; or patients younger than 50 years with diabetes and additional signs of atherosclerosis.

Although one-third of patients report typical exertional claudication symptoms, including aching, burning, cramping, or fatigue in the buttock, thigh, calf, or ankle that resolves after less than 10 minutes of rest, most have other exertional symptoms. Advanced PAD may include ischemic rest pain or nonhealing lower extremity wounds. Physical examination often includes abnormal lower extremity pulses. Subtle signs, including asymmetric hair growth, pallor, erythema, nail bed changes, and calf muscle atrophy, may be seen. Severe PAD may include vascular bruits, nonhealing wounds, or gangrene. Patients with diabetes should be evaluated for peripheral neuropathy.

In patients with history or examination findings suggestive of PAD or those with an increased risk, obtaining a resting ankle-brachial index (ABI), which compares blood pressure at the ankle with that in the arm, is recommended. An abnormal ABI is a ratio of 0.90 or less, borderline is 0.91 to 0.99, and normal is 1.00 to 1.40. For noncompressible arteries (ABI of more than 1.40), the toe-brachial index should be measured. The toe-brachial index is the ratio of the first toe pressure divided by the highest brachial artery pressure. A toe-brachial index of 0.70 or less is diagnostic for PAD. ABI and toe-brachial index are not useful for the diagnosis of chronic limb-threatening ischemia; at least 25% of patients will have borderline or normal values.

Imaging with duplex ultrasonography, computed tomography angiography, magnetic resonance angiography, or angiography should be considered only if ABI is inconclusive or to plan revascularization for chronic limb-threatening ischemia.