New guidelines issued for the management of patients with peripheral arterial disease.
While peripheral arterial disease (PAD) afflicts 12 to 20 million Americans, it lacks the clinical glamour of the coronaries and carotids. But PAD had its day in the sun Tuesday with a major new set of guidelines of its own.
In an effort to increase PAD awareness among clinicians and patients, a coalition of medical and surgical vascular specialists, led by the American Heart Association and American College of Cardiology, unveiled a document on PAD from A to Z. The guideline addresses prevention, diagnosis and management of lower extremity PAD, renal arterial disease, mesenteric arterial disease, as well as aneurysm of the abdominal aorta, its branch vessels and the lower extremities.
In addition to the ACC/AHA, the guidelines were also endorsed by 38 professional organizations.
A central theme of the guidelines is early detection and treatment of PAD. "We don’t want physicians to wait until patients complain about symptoms," said Alan T. Hirsch, M.D., of the University of Minnesota and chair of the PAD guideline writing committee.
Instead, he said, physicians should ask patients specific questions to help define high-risk groups. Additionally, physicians should make more use of the ankle-brachial index as well as a complete abdominal examination.
They suggest interventions such as use of lipid-lowering drugs, blood pressure control, and exercise to stop or slow the progression of disease.
And while the guidelines are touted as the first all inclusive document, they do not address the role of atherectomy for treatment of PAD in the legs. Christopher J. White, M.D., of the Ochsner Clinic in New Orleans and a member of the guideline-writing group, said that while atherectomy devices have demonstrated safety for treatment of PAD, they "have not been adequately tested in terms of efficacy." So the guidelines are silent on atherectomy but say that both bypass surgery and angioplasty are recommended treatment options.
The guidelines identify these six characteristics of individuals at risk for lower-extremity PAD:
· Age less than 50 with diabetes and one other atherosclerosis risk factor
· Age 50 to 69 with history of smoking or diabetes
· Age older than 70
· Leg symptoms with exertion (suggestive of claudication) or ischemic rest pain
· Abnormal lower extremity pulse examination
· Known atherosclerotic coronary, carotid or renal arterial disease
Clinical clues to renal artery stenosis include:
· Onset of hypertension before age 30 or severe hypertension after age 55
· Accelerated, resistant or malignant hypertension
· Development of new azotemia or worsening renal function after administration of ACE inhibitor or ARB agent
· Unexplained atrophic kidney or size discrepancy between kidneys of more than 1.5 cm
· Sudden unexplained pulmonary edema
· Unexplained renal dysfunction
· Multi-vessel coronary artery disease
· Unexplained congestive heart failure
· Refractory angina
Mesenteric arterial disease is rare and the guidelines note that there are no randomized trials of diagnosis or treatment of intestinal ischemia. The guidelines recommend including acute intestinal ischemia in the differential diagnosis for:
· Patients with acute abdominal pain out of proportion to physical findings and who have a history of cardiovascular disease
· Patients who develop acute abdominal pain after arterial interventions in which catheters traverse the visceral aorta or any proximal arteries or who have arrhythmias or recent myocardial infarction
In the U.S. risk factors for abdominal aortic aneurysm include:
· Male gender
· Age 60 or older
· Smoking history
· Family history
· Established atherosclerosis
Be aware that the new peripheral arterial disease guidelines recommend the use of targeted questions to identify patients.
Explain to patients that the guidelines, issued by the major cardiovascular professional societies, emphasize the relationship between coronary artery disease and peripheral arterial disease.
Journal of the American College of Cardiology
Hirsh AT et al "ACC/AHA Guidelines for the Management of Patients with Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)." Guidelines for the Management of Patients with Peripheral Arterial Disease. Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WRC, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM Jr., White CJ, White J, White RA. ACC/AHA guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease [Lower Extremity, Renal, Mesenteric, and Abdominal Aortic]). Circulation. 2006;vol 113:.
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