On 8 August, the UK’s National Institute of Health and Clinical Excellence (NICE) published a clinical guideline on the diagnosis and management of lower limb peripheral arterial disease.
The guideline makes a number of key recommendations that aim to resolve the considerable uncertainty and variations in practice that currently exist in this area due to rapid changes in diagnostic methods, endovascular treatments and vascular services which are associated with the emergence of new sub-specialties in vascular surgery and interventional radiology. The guideline also seeks to improve outcomes for patients.
Key priorities for implementation identified in the guideline include:
- Offer all people with peripheral arterial disease information, advice, support and treatment regarding the secondary prevention of cardiovascular disease, in line with published NICE guidance on:
– smoking cessation
– diet, weight management and exercise
– lipid modification and statin therapy
– the prevention, diagnosis and management of diabetes
– the prevention, diagnosis and management of high blood pressure
– antiplatelet therapy.
Assess people with suspected peripheral arterial disease by:
– asking about the presence and severity of possible symptoms of intermittent claudication
– examining the legs and feet for evidence of critical limb ischaemia, for example ulceration
– examining the femoral, popliteal and foot pulses
– measuring the ankle brachial pressure index.
- Offer contrast-enhanced magnetic resonance angiography for people with peripheral arterial disease who need further imaging (after duplex ultrasound) before considering revascularisation.
- Offer a supervised exercise programme to all people with intermittent claudication.
- Ensure that all people with critical limb ischaemia are assessed by a vascular multi-disciplinary team before treatment decisions are made.
- Do not offer major amputation to people with critical limb ischaemia unless all options for revascularisation have been considered by a vascular multi-disciplinary team.
“Lower limb peripheral arterial disease is not only potentially life-threatening, but the severe pain that can be associated with the disease can have a large impact on the quality of life of people with the condition because of the effects of restricted mobility on independence, social life, recreation and work. However, despite improvements in diagnostic methods, together with the emergence of new treatments and organisational changes in the provision of vascular services, it is clear that there is considerable uncertainty and variation in practice across England and Wales, resulting in less than optimal outcomes for some patients with suspected or confirmed peripheral arterial disease,” said Mark Baker, director of the Centre for Clinical Practice at NICE. “This guideline aims to resolve that uncertainty and variation by highlighting clear diagnostic and treatment pathways and in doing so improve outcomes for patients.”
Jonathan Michaels, professor of Clinical Decision Science, University of Sheffield, and chair of the Guideline Development Group, said: “This guideline provides clear recommendations on reducing the risk of future circulatory problems, and on accurate diagnosis and treatment of the disease in the legs. The importance of lifestyle changes is emphasised, particularly the benefit of exercise and supervised exercise programmes. For those requiring further treatments for their leg symptoms the recommendations cover modern diagnostic methods, surgery and less invasive treatments, which should be available from multi-disciplinary teams able to offer a full range of specialist treatments.”
Duncan Ettles, consultant vascular interventional radiologist, Hull Royal Infirmary and member of the Guideline Development Group, said: “Peripheral arterial disease has a relatively high incidence within the UK but is clear that recognition and treatment of the problem shows significant regional variation. The guideline provides clear advice on the initial assessment and management of people with peripheral arterial disease in primary care and important recommendations for better provision of supervised exercise programmes for patients with intermittent claudication. The guideline also adds weight to the case for better availability of non-invasive imaging, particularly magnetic resonance angiography, in patients being investigated for peripheral arterial disease. In patients with critical limb ischaemia the guideline supports early referral to secondary care to avoid the potential for failed revascularisation and amputation.”
Anita Sharma, GP principal, clinical director Vascular and Elective Care Clinical Commissioning Group, Oldham and member of the Guideline Development Group, said: “Patients with peripheral arterial disease are under diagnosed and undertreated despite the fact that it is associated with an increased risk of cardiovascular mortality. Patients with asymptomatic peripheral arterial disease are just as likely to progress to critical ischaemia as those with symptoms. An early diagnosis by doing ankle brachial pressure index measurement, introducing risk reduction strategies and maximising secondary prevention can slow down the progression of the condition and this can be easily done in primary care. For me as a GP peripheral arterial disease management means Prevent an Amputation and Death due to cardiovascular event.”
Peter Maufe, patient representative on the guideline development group, said: “For many patients with peripheral arterial disease, modifiable risk factors such as smoking, poor diet and lack of exercise have probably played a significant part in the development of their condition. One of the key recommendations in the guideline therefore is to offer all people with peripheral arterial disease appropriate information, advice, support and treatment in line with current NICE guidance on a number of important modifiable risk factors including smoking cessation, diet, weight management and exercise. Importantly, the guideline also recommends that all patients with intermittent claudication are offered a supervised exercise programme.”
NICE’s website offers the next tools to help with the implementation of the guideline:
- Costing tools – to help estimate the costs and savings anticipated
- Baseline assessment tool – for assessing compliance against the guideline
- Clinical audit tools – for monitoring and improving local practice
- Shared learning – examples from practice where people have implemented this guideline