Article : Focused Update: ACC/AHA Guidelines...

Focused Update: ACC/AHA Guidelines on Peripheral Arterial Disease

Revised recommendations emphasize early detection of PAD, prevention of cardiovascular events, and the equivalence of surgical and endovascular revascularization.

Sponsoring Organizations: American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society for Vascular Medicine, Society for Vascular Surgery

Background and Purpose: Changes to recommendations for the management of lower-extremity arterial and abdominal aortic disease reflect clinical-study evidence published since completion of the 2005 guidelines. The 2005 recommendations regarding renal and mesenteric arterial disease remain unchanged in the absence of new pivotal studies of disease in these segments.


Key Points:

1. Because peripheral arterial disease (PAD) is often underdiagnosed and undertreated before limb ischemic symptoms become severe, an ankle–brachial index (ABI) should now be obtained in all nondiabetic patients with suspected lower-extremity PAD who are aged ?65, rather than ?70, as previously recommended (Class I).

2. The range of normal ABI values is defined as 1.0 to 1.4, and the range of abnormal values as ?0.9. ABI values >1.4 indicate noncompressible arteries, and values of 0.91 to 0.99 are considered borderline (Class I).

3. No prospective, randomized, controlled trials have examined the effects of smoking-cessation strategies on cardiovascular events in patients with lower-extremity PAD. However, observational studies show that 5.0% of smoking-cessation attempts involving physicians are successful, compared with 0.1% of attempts in individuals who try to quit spontaneously. Therefore, the recommendations for smoking-cessation interventions have been expanded:

  •     The novel agent varenicline demonstrated superior smoking-cessation rates in several randomized, controlled comparisons with nicotine replacement and bupropion (which yield 1-year quit rates of 16% and 30%, respectively) and is now recommended (Class I).
  •     Caution is advised in the use of bupropion or varenicline, which have been associated with reports of changes in behavior, such as hostility, agitation, depressed mood, and suicidal thoughts.

4. The Class I recommendation for clopidogrel as an alternative to aspirin therapy is unchanged. However, a Class IIb recommendation to consider the combination of aspirin and clopidogrel in patients with symptomatic lower-extremity PAD has been added.

5. Additional evidence has bolstered the Class III recommendation against the use of anticoagulation therapy in addition to antiplatelet therapy in PAD patients.

6. Long-term follow-up shows no significant difference in outcomes of open surgery versus balloon angioplasty, either in amputation-free or overall survival in patients with critical limb ischemia or in rates of overall and aneurysm-related morbidity and mortality in patients with abdominal aortic aneurysm. Lower procedural mortality with endovascular aneurysm repair was not sustained; thus, clinicians should choose the method of aneurysm repair that is deemed to be most appropriate for individual patients.


Citation(s):


Rooke TW et al. 2011 ACCF/AHA Focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2011 Nov 1; 58:2020.

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