AHA/ACC Issue Updated PAD Guidelines

Patients with peripheral artery disease should participate in structured exercise programs to improve their functional status and quality of life, as well as to reduce leg symptoms, say new recommendations out yesterday from the American Heart Association and American College of Cardiology.

The guidelines replace an earlier 2011 document and are published in both Circulation and the Journal of the American College of Cardiology.

Heather Gornik, MD (Cleveland Clinic, Cleveland, OH), vice chair of the writing committee, said a new guideline was overdue given a number of new advances and growth of the evidence base for PAD.

“It has been designed to be a very user-friendly document easily incorporated into clinical practice rather than a ‘textbook’ on PAD,” Gornik told TCTMD in an email. “The [information] regarding a diagnostic approach to claudication and [critical limb ischemia], for example, has been put into a flow diagram for the clinician.”

Led by writing committee chair Marie D. Gerhard-Herman, MD (Harvard Medical School, Boston, MA), the guidelines recommend supervised, structured exercise in a hospital or outpatient facility for a minimum of 30 to 45 minutes per session, at least 3 times a week for a minimum of 12 weeks. Alternatively, structured community- or home-based exercise programs are recommended if they incorporate specific training regimens similar to those of a supervised program. General recommendations to simply walk more “are not efficacious” for improving quality of life and walking outcomes, Gornik said.

“There are emerging data and protocols for structured ‘semisupervised’ exercise programs for PAD that are home-based or community-based but involve oversight of healthcare providers and motivational tools such as step counters,” she commented. “These types of programs have demonstrated efficacy for PAD patients in small studies, though supervised exercise remains the gold standard.”

As part of their advocacy priorities, the committee also says they support “the vital importance of insuring access to supervised exercise programs for patients with PAD.”

Another new element of the guidelines is strongly worded advice for PAD patients to avoid secondhand smoke. While the previous version of the guidelines stressed smoking cessation and helping patients develop a plan for quitting, the 2016 version states: “Patients with PAD should avoid exposure to environmental tobacco smoke at work, at home, and in public places.”

Also new is a recommendation that PAD patients receive an annual flu shot to avoid CV complications of the flu.

In terms of continued gaps in knowledge about PAD, the writing committee says more research is needed to isolate risk factors that contribute to progression from asymptomatic to symptomatic disease. They also say randomized controlled trials are needed to determine the value of using the ankle-brachial index to identify asymptomatic patients who may benefit from medical therapy to reduce their cardiovascular risk. Diet also is mentioned with regard to future research, with an eye toward trying to improve outcomes and modify the natural history of PAD.

Two drug-coated balloons have been approved for PAD since the prior guidelines were released, but Gornik said the committee “did not dive into the very technical aspects of intervention (which balloon, which stent, etc). That technical specificity was beyond the scope of this document and may be better suited to appropriate use documents, which outline very specific clinical scenarios where one sort of device is more appropriate than others.”