By AMERICAN HEART ASSOCIATION NEWS

PAD

NEW ORLEANS — All people with peripheral artery disease in their legs should take statins and blood thinners to reduce their risk of dying from heart attacks and strokes, according to treatment guidelines published Sunday by the American Heart Association and American College of Cardiology.

Experts say peripheral artery disease, or PAD, is often underdiagnosed and affects nearly 9 million people in the U.S. alone. It occurs when plaque builds up in the arteries and the legs don’t get enough blood, causing pain and difficulty walking. PAD can lead to sores that don’t heal, gangrene and amputations. Those most at risk are people over 65, smokers and people with diabetes or heart disease.

While PAD patients’ top fear often is losing a leg, “the greater risk is of heart attack, stroke, or dying,” said Heather Gornik, M.D., a cardiologist and vascular medicine specialist at the Cleveland Clinic in Ohio and vice-chair of the writing committee for the guidelines. “A patient with PAD is a patient who has atherosclerosis throughout the body.”

The guidelines recommend statins and blood thinners to control cholesterol and prevent blood clots for all PAD patients. Statins reduce cholesterol in the blood, slowing its ability to narrow arteries. Blood thinners such as aspirin or clopidogrel help prevent dangerous clots.

AHA/ACC guidelines offer best practices for healthcare providers across the nation, based on the latest scientific evidence.

The new guidelines, which update the last comprehensive guidelines released in 2005, also include recommendations for structured exercise programs. Most PAD patients benefit from supervised or home-based structured programs that help with leg pain and walking endurance in patients with PAD, the guidelines found.

Exercise is a low-cost, low-risk effective treatment for people with mild to moderate PAD and can reduce the need for costlier, invasive procedures, said Michael Conte, M.D., chief of vascular and endovascular surgery at the University of California San Francisco Medical Center.

The best structured exercise programs include instructions about the type, frequency, intensity and duration of exercise and should be adapted to each patient, according to the guidelines

Niten Singh, M.D., professor of surgery at the University of Washington in Seattle, recommends structured exercise for all his patients with PAD and claudication, or calf pain.

However, supervised exercise has not been available to most PAD patients who would benefit from it because it’s not reimbursed by insurance, Gornik said.

That could change next year, though. In September, the AHA asked the Centers for Medicare and Medicaid Services to provide Medicare coverage of supervised exercise therapy.  A number of specialty societies and individual specialists submitted comments supporting the move. The agency is considering AHA’s request and is expected to make a decision next June.

Because smoking is a top risk factor for PAD, the new guideline advises avoiding secondhand smoke and continues to recommend that smokers quit.

“It’s hard to quit and stay quit when you’re surrounded by tobacco,” Conte said.

PAD should be top-of-mind for physicians treating those with established risk factors such as age, diabetes and smoking, Conte said.

The guidelines recommend care from an interdisciplinary team, including endocrinologists, wound care experts, foot specialists, rehabilitation experts and people who help with prosthetics, Gornik said.

“In some ways it takes a village to care for a patient with PAD,” she said.

The guidelines also offered diagnosis guidance.

For people with signs and symptoms of PAD, it should start with a measurement called the ankle brachial index. ABI compares blood pressure in the arms and legs to detect significant narrowing of leg arteries. The test is also reasonable as a diagnosis for people who lack obvious signs but are at elevated risk, according to the new guidelines.

Patients with severe PAD, including those with leg pain while resting or with a non-healing wound, may require procedures to open up the arteries and restore blood flow, according to the guidelines.

Conte said it’s important that patients with severe forms of PAD get prompt medical assessment because many have a limb amputated before anyone even attempts to restore blood flow.

The guidelines are well-timed as the U.S. and global population ages and more awareness is needed, experts said.

“The ‘silver tsunami’ is coming, and we’re going to have a lot more patients who have PAD,” Singh said.