PAD
Maria G. Tanzi, PharmD
Lower extremity peripheral artery disease (PAD), a strong predictor for future adverse cardiovascular outcomes, remains underrecognized in current clinical practice, according to a new scientific statement from the American Heart Association (AHA) published online July 28, 2021, in Circulation.
“Orchestrated efforts among different parties (e.g., health care providers, researchers, expert organizations, and health care organizations) will be needed to increase the awareness and understanding of PAD and improve the diagnostic approaches, management, and prognosis of PAD,” wrote AHA in their scientific statement.
PAD is the third leading cause of atherosclerotic morbidity following coronary heart disease and stroke. Critical limb ischemia and amputation is another severe complication of PAD, which can be devastating for patients.
Reasons for lack of awareness
AHA cited several reasons for the under-recognition of PAD by clinicians, such as diagnostic modalities not being readily available in most clinics; for example, the ankle-brachial index, the thought that leg diseases are not fatal, and the concern that the diagnosis of PAD would not necessarily change clinical practice. Additionally, symptoms of PAD, like difficulty walking, may be mistaken for changes from the normal aging process or from diseases such as hip or knee arthritis or spinal stenosis.
Evidence-based management
The prevalence of PAD in adults 40 years and older in the United States is estimated to be about 7%, or approximately 8.5 million people.
Traditional cardiovascular risk factors such as diabetes, smoking, dyslipidemia, and hypertension increase the risk for PAD. AHA also lists some non-conventional risk factors such as HIV and depression.
Patients with depression and PAD have been shown to have worse functional outcomes and a poorer quality of life. AHA notes that this might be because depression may lead to medication non-adherence or a decrease in physical activity.
Smoking cessation is a vital component to the management of PAD. In addition, other lifestyle modifications, such as participation in an exercise program, can benefit patients with the disease. Supervised exercise is a recommended intervention to improve walking impairment for patients with PAD.
In terms of medications, patients with PAD are generally treated with an antiplatelet and a statin in addition to other agents used to manage concurrent conditions such as diabetes and hypertension. Some of the specific recommendations from the 2016 AHA/American College of Cardiology guideline on the management of PAD published in Circulation include the following:
- Statins are recommended for all patients with PAD.
- Aspirin alone (range 75–325 mg/day) or clopidogrel alone (75 mg/day) is recommended to reduce the risk of cardiovascular events in patients with symptomatic PAD.
- Antiplatelet therapy is reasonable to reduce the risk of CV events for those with asymptomatic PAD.
- Antihypertensive agents should be given to patients with hypertension. Those with diabetes should be managed appropriately. Angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers are listed in the guideline as useful agents in patients with PAD.
- Anticoagulation should not be used to reduce cardiovascular ischemic events in patients with PAD.
- Cilostazol is listed as an effective therapy to improve symptoms and increase walking distance in patients with claudication, and pentoxifylline is noted not to be effective for the treatment of claudication.
Takeaways for pharmacists
Pharmacists can play a significant role in increasing awareness around PAD and managing patients with the disease. Pharmacists are well-positioned to provide smoking cessation counseling and recommend proven interventions to help patients quit. Adherence to recommended treatments can also be assessed at the pharmacy to ensure patients with PAD are receiving the most appropriate regimen (i.e., an antiplatelet and statin). Pharmacists can also educate patients on other healthy lifestyle modifications such as the importance of physical activity and eating a heart-healthy diet.