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Last Updated: 12/31/2013  

Peripheral Arterial Disease

Prevention
  • Encourage tobacco cessation in patients who smoke.

  • Target blood pressure <140/90 mm Hg for most patients.

  • Treat patients with diet therapy and a high-intensity statin for patients with atherosclerotic disease, LDL ≥190 mg/dL, and if they have diabetes and a 10-year coronary heart disease risk of ≥7.5%.

  • Treat patients with diet therapy and at least a moderate-intensity statin if they have diabetes and a 10-year calculated coronary heart disease risk between 5% and 7.5%.

  • Treat patients with diabetes with diet, exercise, and drug therapy to achieve a goal of HbA1c <7%.

Screening
  • Do not screen the general population for PAD.

Diagnosis
  • Ask about leg fatigue, pain or numbness with ambulation, impotence, and nonhealing leg foot ulcers.

  • Look for absent pedal pulses, bruits, and ulcers between or on the tips of toes, especially with pale or irregular borders.

  • Use the resting ABI to establish the diagnosis of lower extremity PAD in patients with resting ABI <0.90.

  • Obtain an exercise or stress ABI in patients with history consistent with claudication but an ABI >0.90.

  • Obtain digital subtraction arteriography in patients with indications for an intervention, using magnetic resonance arteriography as an alternative test in patients at high risk for contrast nephropathy or contrast allergy.

  • Diagnose acute limb ischemia with the six P's: pain, poikilothermia, pulselessness, paralysis, paresthesias, pallor.

Hospitalization
  • Hospitalize patients with acute limb ischemia for emergent revascularization to maintain limb salvage.

  • Hospitalize patients with infected wounds for intravenous antibiotics, elevation, topical wound care, and early debridement if there is evidence of bacteremia.

Therapy
  • Urge all patients with PAD who smoke to stop tobacco use.

  • Recommend ambulation for 30 to 40 minutes, four to five times per week, to improve walking distance.

  • Recommend a diet low in saturated fats and high in fresh vegetables and fruits.

  • Recommend a statin if no contraindications exist, regardless of total cholesterol level.

  • Use aspirin as a first-line antiplatelet agent for primary prevention of cardiovascular morbidity.

  • Assess benefits and harms of cilostazol, 100 mg orally twice daily, as an adjunctive treatment for claudication, and pentoxifylline in patients who do not tolerate cilostazol.

  • Offer primary amputation for selected patients with severe symptomatic disease.

DOI: 10.7326/d231
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Authors and Disclosures:
Peter Henke, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Peter Henke, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.

The following editors of ACP Smart Medicine have nothing to disclose: Deborah Korenstein, MD, FACP, Editor in Chief; Richard B. Lynn, MD, FACP, Editor; and Davoren Chick, MD, FACP, Editor.

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