New guidelines for peripheral artery disease released by the Canadian Cardiovascular Society

New guidelines for the identification and management of peripheral artery disease (PAD) have been released by the Canadian Cardiovascular Society (CCS). They were written with primary care physicians in mind, as well as specialists. “We’ve written the guidelines so you can be in practice anywhere, read it, and implement many of the recommendations to help manage patients with peripheral artery disease,” said co-chair of the CCS guidelines committee, Dr. Sonia Anand. She is a vascular medicine specialist and professor of medicine at McMaster University. Read: Low-dose aspirin for CVD and colorectal cancer prevention no longer recommended “The reality is many of our patients with PAD fall through the cracks. They are underdiagnosed and undertreated. They’re discharged from hospital after vascular surgery, the surgeon recommends to the FP to care for them and the FP may not be fully familiar with contemporary PAD management because they don’t get a lot of training in this,” she said. The guidelines were published in the May 2022 issue of the Canadian Journal of Cardiology and are available from the CCS website. PAD affects about one in five Canadians over the age of 50. PAD is associated with significant cardiovascular (CV) and cerebrovascular morbidity and mortality, as well as limb loss. The biggest risk factors for PAD are advancing age, smoking, and diabetes. The risk of both major adverse cardiovascular events (MACE) as well as major adverse limb events (MALE) among PAD patients is underrecognized by many physicians, Dr. Anand told the Medical Post. “The typical presentation of patients with MALE is usually marked by acute severe limb pain due to ischemia caused by a sudden or progressive loss of blood to the legs which requires urgent surgery. Severe cases can lead to amputation,” she said. Previous guidelines for PAD were published in 2005. But since then, a number of important clinical trials were published that helped demonstrate the effectiveness of behavioural therapies, medications and combinations. “What’s exciting about these guidelines is they are centered around a detailed evidence synthesis and recommendations regarding effective medical therapies for PAD. The guideline present the benefit and risk for both the CV as well as the limb events,” she said. For example, new studies over the past five years “have really built confidence in our recommendations for certain therapies. Those include exercising, lowering cholesterol, lowering blood sugar, controlling blood pressure, and using newer blood thinning combinations,” she said. One notable change is that the previous guidelines recommended a single aspirin a day for PAD patients to prevent a limb blood clot. But the new guideline recommends an aspirin together with the low dose rivaroxaban. There are a total of 56 recommendations and each shows the level of evidence they are based on. Recommendations based on high-quality evidence, include smoking cessation interventions, structured exercise programs for claudication, lipid-modifying therapy, antithrombotic therapy with a single antiplatelet agent or dual pathway inhibition (low-dose rivaroxaban and aspirin). For the hypertensive patients, it recommends treatment with an angiotensin converting enzyme or angiotensin receptor blocker. And, for those with diabetes, a sodium-glucose cotransporter 2 inhibitor should be considered. A key thing for family doctors to do is to assist their patients in quitting smoking. “We really emphasize smoking cessation because it’s such as potent risk factor. Quitting smoking before peripheral vascular surgery, increases the chance of keeping your artery open if you stop smoking. The guidelines discuss the evidence for various quit aids that physicians can address with their patient,” Dr. Anand said. Surgical recommendations have also evolved, and the guidelines now say that autogenous or vein grafts are more effective than prosthetic grafts for surgical bypasses for claudication or chronic limb-threatening ischemia which involve the popliteal or distal arteries. New endovascular techniques and hybrid procedures are also discussed for certain patients. They also point out that the evidence for perioperative risk stratification for PAD patients who undergo surgery remains weak. The guidelines also address diagnostic challenges, including dealing with asymptomatic patients. Often these patients are identified because they are in hospital for another cardiovascular reason. Atherosclerosis is evident in their legs, yet these patients report no leg discomfort. While asymptomatic PAD usually may be an early sign of disease, it’s still a marker of high risk for major CV and limb events, Dr. Anand said. For the symptomatic patient, a key thing to watch for and ask about (especially in patients over 50 with risk factors) is pain in the legs when walking. A key clue is that the pain is relieved by rest. Doctors can go through a number of questions to determine if their patients symptoms of leg discomfort sounds like PAD. “If they suspect PAD, they can refer them on for testing of blood pressures in the leg relative to the blood pressure in the arms—known as the Ankle Brachial Index (ABI) test. A vascular ultrasound can be performed in addition to the ABI to get a more detailed understanding of the location of the PAD,” Dr. Anand said.

New guidelines for peripheral artery disease released by the Canadian Cardiovascular Society

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