Peripheral Arterial Disease Management (ACC/AHA 2024)

Algorithm Steps

1. ▶

   Start

   Suspected PAD

   Leg symptoms or risk factors for PAD

   1. ●

      Action

      Clinical Assessment

      History, examination, risk factors

      • Symptoms: claudication, rest pain, non-healing wounds
      • Risk factors: smoking, diabetes, HTN, dyslipidemia, age >65
      • Examine pulses (femoral, popliteal, DP, PT)
      • Skin changes, hair loss, muscle atrophy
      • Screen high-risk: diabetes, smoking hx, CAD, renal disease
      1. ●

         Action

         Ankle-Brachial Index (ABI)

         First-line diagnostic test

         • Normal: 1.00-1.40
         • Borderline: 0.91-0.99
         • Mild-moderate PAD: 0.41-0.90
         • Severe PAD: ≤0.40
         • Non-compressible: >1.40 (calcified vessels)
         1. ◆

            Decision

            ABI Result

            Determines diagnosis and severity

            1. ●

               Action

               Normal ABI (1.00-1.40)

               PAD unlikely but consider exercise ABI

               • If symptoms persist: exercise ABI
               • 20% drop post-exercise = PAD
               • Consider other causes of leg pain
               • Risk factor modification regardless
            2. ●

               Action

               Borderline ABI (0.91-0.99)

               Exercise ABI recommended

               • Treadmill exercise test
               • Positive if ABI drops >20% post-exercise
               • Initiate medical therapy if confirmed
               • Consider TBI if high suspicion
               1. ●

                  Action

                  Guideline-Directed Medical Therapy

                  Foundation for all PAD patients (Class I)

                  • High-intensity statin (LDL reduction >50%)
                  • Antiplatelet: aspirin 75-325 mg OR clopidogrel 75 mg
                  • Blood pressure control (<130/80 mmHg)
                  • Diabetes management (if applicable)
                  • Smoking cessation (CRITICAL)
                  1. ◆

                     Decision

                     Symptom Classification

                     Guides additional therapy

                     • Asymptomatic: no leg symptoms
                     • Claudication: leg pain with walking, relieved by rest
                     • CLTI: rest pain, tissue loss, gangrene (separate algorithm)
                     1. ●

                        Action

                        Asymptomatic PAD

                        Medical therapy + surveillance

                        • GDMT as above
                        • Walking exercise encouraged
                        • Annual ABI monitoring
                        • Screen for other ASCVD (coronary, carotid)
                        • No routine revascularization
                        1. ●

                           Action

                           Long-Term Surveillance

                           Ongoing monitoring and risk reduction

                           • Annual clinical assessment
                           • ABI if symptoms change
                           • Continue GDMT indefinitely
                           • Screen for progression to CLTI
                           • Manage concomitant CAD, cerebrovascular disease
                           1. ✓

                              Outcome

                              Stable PAD

                              Symptoms controlled with medical therapy; annual follow-up

                           2. ✓

                              Outcome

                              Disease Progression

                              5-10% progress to CLTI over 5 years; cardiovascular events more common

                     2. ●

                        Action

                        Claudication Management

                        Exercise therapy first-line

                        • Supervised exercise therapy (Class I)
                        • 30-45 min sessions, 3x/week, 12 weeks minimum
                        • Cilostazol 100 mg BID if no CHF (Class IIa)
                        • Community/home-based exercise alternative
                        • Reassess after 3-6 months
                        1. ●

                           Action

                           Cilostazol

                           Pharmacotherapy for claudication

                           • 100 mg PO BID
                           • Contraindicated in heart failure
                           • Trial 3-6 months for effect
                           • Modest improvement in walking distance
                           • Discontinue if no benefit
                        2. ◆

                           Decision

                           Revascularization Consideration

                           If lifestyle-limiting despite therapy

                           • Failed exercise program
                           • Lifestyle-limiting claudication despite GDMT
                           • Favorable anatomy
                           • Patient preference (shared decision-making)
                           • Not for mild or non-limiting claudication
                           1. ●

                              Action

                              Revascularization Strategy

                              Endovascular vs surgical based on anatomy

                              • Endovascular: less morbidity, shorter recovery
                              • Surgical: more durable for complex disease
                              • TASC A/B: endovascular preferred
                              • TASC C/D: surgical often better
                              • CLTI algorithm for threatened limb
            3. ●

               Action

               Low ABI (≤0.90)

               PAD confirmed

               • Diagnoses PAD
               • Correlate with symptoms
               • Assess severity: 0.41-0.90 mild-moderate, ≤0.40 severe
               • Initiate comprehensive PAD therapy
            4. ●

               Action

               Non-Compressible (>1.40)

               Calcified vessels - use alternative tests

               • Common in diabetes, CKD, elderly
               • Use toe-brachial index (TBI)
               • TBI <0.7 suggests PAD
               • Toe pressure <30 mmHg = severe ischemia
               • Pulse volume recordings (PVR)