For the 9 million Americans affected by peripheral artery disease (PAD)—and those at risk—the just-released 2011 PAD clinical guidelines could be life-altering. The new recommendations combine state-of-the-art options for vascular care with time-honored medical wisdom.

"Patients want to know there are easier and better treatments for artery disease," says Thom W. Rooke, MD, professor of Vascular Medicine at The Mayo Clinic and chair of the 2011 PAD guidelines writing group. "I think it's important patients understand that some of the oldfashioned things we've recommended, like 'Don't smoke' or even the old humorous cliché 'Take two aspirin and call me in the morning' are actually becoming more important as time goes on."

"Guided" tour
PAD occurs when the leg arteries become clogged or narrowed by plaque buildup, causing reduced blood flow to the legs. This can result in pain when walking, disability and amputation. The presence of PAD may also indicate blockages in other arteries, including those in the heart and brain, thus increasing risk of heart attack or stroke. However, with early diagnosis and effective management, PAD is highly treatable.

The 2011 PAD guidelines—a joint report of the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA), updated the original 2005 recommendations—address five areas of diagnosis and treatment: (1) PAD diagnostic testing; (2) smoking cessation; (3) clot-preventing medications; (4) treatment to prevent leg amputation; and (5) management of abdominal aortic aneurysm.

Age matters
The first recommendation concerns the age at which a patient should first undergo an ankle-brachial index (ABI), a PAD diagnostic test in which blood pressure at the arms and ankles are compared. The ABI was previously recommended for people age 70 or older or those 50 or older with diabetes or a history of tobacco smoking. But on the basis of a large German study in which the test detected PAD in 21 percent of subjects age 65 or older, the new guidelines recommend ABI testing at age 65 rather than 70.

The value of an earlier ABI goes beyond the discovery of PAD in the leg, says Dr. Rooke. "It's one of the best ways we have of identifying patients who may have undetected coronary and carotid disease and deciding who's really at risk and who ought to be treated."

"Eight-hundred-pound gorilla"
The second area of guideline modification involves intensifying efforts to help patients quit smoking and remain smoke-free.

"Of all the things we can affect that cause atherosclerosis or PAD, [smoking] is the biggest by far," says Dr. Rooke. "It's bigger than hypertension. It's bigger than diabetes. It's the gigantic 800-pound gorilla out there."

According to the new recommendations, patients who are smokers or former smokers should be asked about tobacco use at every healthcare provider visit. Further, smokers should be assisted with counseling and developing a cessation plan which may include pharmacotherapy.

"Since 2005, we've come up with some new medications. Varenicline [Chantix] is one of them," says Dr. Rooke. "This drug is something the guideline group thought was potentially so effective at getting people to stop smoking that we ought to make sure smokers are aware of it as well as all of the older drugs that can help them quit smoking."

Risk-reduction agents
A key risk for PAD patients is heart attack or stroke due to development of clots in the arteries that supply the heart or brain. Consequently, the 2011 guidelines emphasize the importance of antiplatelet drugs.

Says Alan T. Hirsch, MD, vascular medicine specialist and cardiologist at the University of Minnesota and vice chair of the 2011 writing group, "Both aspirin and clopidogrel [Plavix] are effective agents in lowering [heart attack and stroke] rates and one of them should be used in every patient with known PAD so long as there is no known bleeding risk or allergy."

Endovascular alternatives
For patients with critical limb ischemia, a severe form of PAD in which blood flow to the extremities is seriously decreased, prevention of leg amputation is the most pressing issue. In the past, this generally meant open surgery as the initial procedure.

The updated recommendations acknowledge catheter procedures such as balloon angioplasty and stenting as viable options. This is due, in part, to a multi-center United Kingdom study, which compared the two treatment strategies and showed similarity in patient outcomes.

This guideline, says Dr. Hirsch, "brings angioplasty and stenting to an earlier-use status, so patients need not fear an open surgical approach as a first-line therapy."

For limb-saving procedures in healthier patients who are anticipated to require a more durable artery repair, he says, surgery is still preferred.

Finally, likewise for abdominal aortic aneurysms, a host of recent studies have shown that, with appropriate patient selection, open surgical and endovascular catheter-based treatments can be used with nearly equal efficacy and safety.

The 2011 guidelines reflect the reasonable nature of performing endovascular repairs on aneurysms.

Proactive patients
"I think [all] of these guidelines are things that, if I were a patient, I would be interested in knowing," says Dr. Rooke. "When a patient walks into my office with an aneurysm or needing a revascularization procedure, one of the things they're most anxious about is, 'Is this going to require an open operation, or am I going to be able to get this done with a balloon or laser?'"

Dr. Hirsch encourages patients to familiarize themselves with the guidelines. "The earlier [PAD is] diagnosed and the more actively the patient manages [it]," he says, "the greater the chances they will be alive with both legs, feeling well, and enjoying their lives."