Guideline for peripheral arterial disease updated in the USA


The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA), along with collaborating societies, have recently released an updated guideline for peripheral arterial disease to help guide clinical decision-making related to the disease and improve patient outcomes.

The guideline includes expanded criteria for using the ankle-brachial index for earlier diagnosis, increased efforts to ensure all patients have access to smoking cessation services, improved use of clot-preventing medications, as well as a more focused definition of effective interventions for avoiding limb amputations and treating aortic aneurysms.


The updated guideline recommends that measurement of the ankle-brachial index should be performed in patients 65 years of age or older. In the 2005 guidelines, the recommendation was for ankle-brachial index to be used in patients 70 years or older. This decision was based on mounting evidence demonstrating that people 65 and older have a one in five chance of having either symptomatic or asymptomatic peripheral arterial disease.


“Age alone appears to define a patient population at such a high risk of peripheral arterial disease that we can justify using a cost-effective and risk-free test like the ankle-brachial index,” said Thom Rooke, professor of Vascular Medicine, Mayo Clinic, Rochester, USA, and chair of the writing group. “It is important to remember, when we check ankle-brachial index to detect peripheral arterial disease in a patient without clear-cut leg symptoms, it is known that we are effectively assessing overall heart and vascular health. If peripheral arterial disease is detected, effective risk reduction medications are available to lower this risk.”


Antiplatelet therapy is recommended for asymptomatic patients with an ankle-brachial index less than 0.90, but is not recommended for those with a borderline score. Oral anticoagulants are not recommended as an addition to antiplatelet therapy.


The guideline also recommends considering percutaneus transluminal angioplasty as a first line treatment for certain individuals with severe peripheral arterial disease who may face amputation. Since angioplasty does not provide an ideal treatment for all patients with peripheral arterial disease, for those in whom a lifespan greater than two years is anticipated, open vascular surgery may be more durable and most effective, it finds.


Another emphasis in the new guideline is on understanding new data showing that aortic aneurysms can be safely treated by both traditional open surgical and less-invasive endovascular with nearly equal efficacy and safety.


“This document provides agreed upon approaches and treatments for peripheral arterial disease that vascular surgeons, vascular medicine specialists, cardiologists, pulmonologists, interventional radiologists and primary care clinicians can apply to help improve patient care,” said Rooke. “This guideline is especially important for peripheral arterial disease, which is often still treated less aggressively than heart disease, and we know that many patients do not yet receive ideal care.”


The ACCF/AHA guideline, which updates the original 2005 recommendations, reflects a thorough review of new evidence-based clinical trial and other clinical data. It was developed in collaboration with representatives from the Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery.


The focused update of this guideline will be published in the 1 November 2011 issue of the Journal of the American College of Cardiology and is available online ahead of print in the Journal of the American College of Cardiology and in Circulation.