New guidelines outline performance measures for PAD

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To better define guidelines for the most optimal treatment approaches of peripheral artery disease (PAD), new American College of Cardiology Foundation/American Heart Association (ACCF/AHA) key performance measures aim too address how to best treat patients with PAD, because the guidelines are currrently unclearly defined.

Despite the fact that PAD has a high prevalence in the adult population—12 percent—the disease often goes diagnosed because patients present with atypical symptoms or no ischemic symptoms related to the legs.

“Patients with peripheral artery disease have the highest rate of heart attacks, stroke and cardiovascular death—higher than people with coronary artery disease—yet they remain under treated,” said Jeffrey W. Olin, DO, professor of medicine at the Mount Sinai School of Medicine in New York City and chair of the writing committee. “Therapies simply aren’t given with the same intensity. These patients receive antiplatelet therapy (aspirin or clopidogrel) or statin therapy much less frequently than patients with coronary artery disease despite their high cardiovascular event rate.”

Therefore, the task force chose the following PAD key performance measures:
  • Measurement of ankle brachial index (ABI) in patients at risk for PAD;
  • Statin therapy for lowering low-density lipoprotein cholesterol in PAD patients;
  • Smoking cessation intervention for PAD patients;
  • Antiplatelet therapy for patients with a history of symptomatic PAD to reduce the risk of MI, stroke or vascular death;
  • Supervised exercise for patients with intermittent claudication;
  • Lower extremity vein bypass graft surveillance with ABI and duplex ultrasound of lower extremity vein bypass site; and
  • Monitoring abdominal aortic aneurysms that are between 4 cm and 5.4 cm in diameter.

The researchers said that measuring ABI can easily diagnose PAD with an index that is less than or equal to 0.90.

The task force said that antiplatelet therapy has been recommended as a treatment for PAD by the Inter-Society Consensus for the Management of PAD guidelines; however, it said that antiplatelet therapy should only be included as a treatment measure in patients with a history of symptomatic PAD. This is due to the fact that other documents have questioned the efficacy of aspirin in asymptomatic PAD patients.

In addition, the task force also included that physicians should perform a vascular review of systems for lower extremity PAD in persons with a history of walking impairment, claudication or ischemic rest pain and non-healing wounds in patients who are at a risk for lower extremity PAD. Additionally, an “at risk” population pulse exam should be performed in the lower extremities of patients at risk for PAD.

However, the authors added the aforementioned reviews as test measures only, not key performance measures, and should be used for internal quality improvement only rather than pay-for-performance or public reporting programs.

The task force said that the following measures should be considered, but were not listed under PAD key performance indicators:
  • Lower extremity endovascular revascularization surveillance;
  • Chronic critical limb ischemia and acute limb ischemia;
  • Renal and mesenteric artery disease;
  • Exercise treadmill testing;
  • CT angiography and MR angiography;
  • Management of hypertension and diabetes; and
  • Screening for abdominal aortic aneurysm.

While the authors said that the most important aspect of performance measures are outcome measures, certain limitations currently exist and should limit their use as measures of accountability and public reporting . The authors said that the measures should be used as tools to assist physicians in their own performance.

The task force concluded: “Outcome measurements, however, should be considered in future revisions of the PAD performance measures.”

The performance measures will be published in the December 14/21 issue of the Journal of the American College of Cardiology and co-published in the Dec. 14 issue of Circulation, the Journal of Vascular Nursing, the Journal of Vascular Surgery and the Vascular Medicine Journal.