PAD guidelines undergo facelift

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Image source: Spectranetics

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) released updated guidelines Sept. 29 for the management and treatment for peripheral artery disease (PAD). The updates included recommended changes in practices for diagnostics, medications, interventions and patient services.

PAD affects 8 million Americans, and up to 20 percent of the PAD population is 65 years or older, according to the Heart Disease and Stroke Statistics 2011 Update.

Vice Chair of the Writing Group Alan T. Hirsch, MD, a professor at the Lillehei Heart Institute and cardiovascular division at the University of Minnesota Medical School in Minneapolis, emphasized that PAD can be costly and deadly if undetected or managed inadequately. In research based on the Reduction of Atherothrombosis for Continued Health (REACH) registry, his team found a high rate of hospitalizations for study participants with PAD—23 percent for asymptomatic PAD patients and 31 percent for symptomatic patients.

The average two-year hospitalization cost per patient with asymptomatic PAD was $7,445. The average two-year cost for PAD patients with a history of revascularizations was $11,693.

“This guideline is especially important for PAD, which is often still treated less aggressively than heart disease, and we know that many patients do not receive ideal care,” Thom W. Rooke, MD, a professor of vascular medicine at the Mayo Clinic in Rochester, Minn., and chair of the writing group, said in a statement.

Updated recommendations include:

  • Lowering the age for the ankle-brachial index (ABI) diagnostic testing in the practice setting from 70 years of age to 65 years or older, in keeping with new findings of prevalence in the younger age group;
  • Improved use of anticlotting agents;
  • Increasing efforts to help smokers with PAD quit the habit with better access to smoking cessation programs, counseling, pharmacologic therapies and consistently inquiring about tobacco use during patient visits;
  • Considering leg artery angioplasty as a first line of treatment for some people with severe PAD who may face amputation; and
  • Recognizing that traditional open surgical and less invasive endovascular treatments for aortic aneurysms are nearly equally efficacious and safe.

Rooke highlighted ABI as a cost-effective and risk-free test that offers opportunities for early intervention. “[W]hen we check ABI to detect PAD in a patient without clear-cut leg symptoms, it is known that we are effectively assessing overall heart and vascular health,” he said. “If PAD is detected, effective risk reduction medications are available to lower this risk.

“While there have been progressive improvements in PAD care, it appears that even simple ‘interventions’ like appropriate prescription of smoking cessation and exercise are not utilized by clinicians, healthcare systems and payors,” Hirsch said in a statement. "We still have a long way to go; the opportunity for prevention and earlier life-saving interventions is immense. This guideline provides a road map.”

The guidelines are designed to help cardiologists, vascular surgeons, vascular medicine specialists, interventional radiologists, pulmonologists, and primary care physicians care for patients with PAD, which is often asymptomatic.

The guidelines update the original 2005 recommendations and are based on a review of new evidence-based clinical trials and other data that were assessed by members of the ACCF, AHA, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Vascular Medicine and the Society for Vascular Surgery.

The guidelines will be published in the Nov. 1 issue of the Journal of the American College of Cardiology and are now available online here.