New PAD Guidelines Stress Comprehensive Care, Endorse Structured Exercise

Think of the new AHA/ACC clinical practice guidelines on lower extremity peripheral artery disease (PAD) as more of a “reboot” in the approach to the condition than just an update to prior guideline documents.

So says Cleveland Clinic cardiologist and vascular medicine specialist Heather Gornik, MD, who served as vice chair of the guideline writing committee and unveiled the guidelines at the American Heart Association’s Scientific Sessions 2016. The document, which replaces AHA/ACC guidelines last updated in 2011, was simultaneously published online in the American Heart Association journal Circulationand the Journal of the American College of Cardiology.

“The writing committee started from scratch with a review of the latest evidence and formulation of recommendations focused on comprehensiveness of care for patients with PAD,” says Dr. Gornik. “The scope of our recommendations this time extends across the spectrum of PAD to include patients with claudication or atypical leg symptoms and those with more severe disease, such as critical limb ischemia.”

Structured exercise endorsed

One key addition is the new guidelines’ explicit recommendation for all patients with PAD to participate in a structured exercise program. The program should be individualized to the patient and include specific guidance for exercise type, frequency, intensity and duration. While a supervised program in a hospital or outpatient facility is noted to be most effective, the recommendation acknowledges home- or community-based walking or alternative regimens (such as upper-body exercises) as options.

The key is structure. “Unstructured community- or home-based walking programs that consist of providing general recommendations to patients with claudication to simply walk more are not efficacious,” the guidelines state.

The document emphasizes “the vital importance of insuring access to supervised exercise programs” and notes that currently “only a minority of patients with PAD participate in such programs because of lack of reimbursement by third-party payers.”

Other notable changes

The new guidelines introduce a section dedicated to revascularization for claudication, with recommendations for both endovascular and surgical approaches, in addition to the section on management of critical limb ischemia, which has been enhanced with recommendations on wound healing therapy. Also noteworthy is a new section with recommendations for acute limb ischemia.

Even while covering more of the spectrum of PAD management, the guidelines do so in a more succinct and visual way, with an abundance of algorithms and tables. Particularly notable are new algorithms outlining evidence-based approaches to diagnosis and imaging for patients with suspected PAD.

While recommendations for medical management of PAD remain broadly consistent with those in the previous guidelines, the new version gives a class IIb recommendation to the use of dual antiplatelet therapy (aspirin and clopidogrel) as a “reasonable” option for reducing risk of limb-related events in patients with symptomatic PAD after lower extremity revascularization.

Other updates of note:

• Prior smoking cessation recommendations have been extended to strongly advise patients to avoid second-hand smoke.
• An annual flu shot is now endorsed for all patients with PAD to avoid cardiovascular complications of influenza.

More multidisciplinary than ever

Dr. Gornik sees the multidisciplinary nature of the writing committee as a strength of the guidelines and a source of their enhanced comprehensiveness. “We had vascular surgeons, cardiologists, vascular medicine specialists, interventional radiologists, nurses, exercise specialists, an anesthesiologist and others working together to review the evidence and make recommendations,” she says. Among them was her fellow Cleveland Clinic vascular medicine specialist Mehdi Shishehbor, DO, MPH, PhD, who is also an interventional cardiologist.

Broad dissemination of the guidelines to improve the care of patients with PAD has been the team’s guiding objective, Dr. Gornik says. “Despite being a major cause of cardiovascular mortality, morbidity and impaired quality of life, PAD is still often underrecognized and undertreated,” she notes. “We want to get PAD out of the shadows and into the forefront so that affected patients are properly diagnosed and treated to improve their quality of life and outcomes.”

For more perspectives on the new guidelines from Dr. Gornik, check out this one-minute video.