Medical Management of Peripheral Arterial Disease: Deciphering the Intricacies of Therapeutic Options

Figure 1. Overview of European and American Guidelines for Peripheral Arterial Disease (PAD) Secondary Prevention. Recommendation class (eg, I-A) provided in parentheses. ACEi, angiotensin-converting enzyme inhibitor; ACS, acute coronary syndrome; AF, atrial fibrillation; ARB, angiotensin receptor blocker; BP, blood pressure; DAPT, dual antiplatelet therapy; HbA1c, hemoglobin A1c; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; NOAC, non–vitamin k antagonist oral anticoagulation; OAC, oral anticoagulation; VKA, vitamin K antagonist. *Use of statins recommended until LDL-C < 1.4 mmol/L for patients with baseline LDL-C levels > 2.8 mmol/L or until > 50% reduction in LDL-C levels for patients with LDL-C levels between 1.4 and 2.8 mmol/L. If the targets are not met, ezetimibe is recommended as second-line therapy (I-B), and evolocumab is recommended as third-line therapy (I-A). **A Class I-A recommendation was provided for antiplatelet monotherapy use in symptomatic PAD patients, and a Class IIa-C recommendation was provided for asymptomatic PAD patients with ankle-brachial index < 0.9.

Figure 2. Treatment algorithm for peripheral arterial disease (PAD) patients. CAD, coronary artery disease; DBP, diastolic blood pressure; HbA1c, hemoglobin A1c; LDL-C, low-density lipoprotein cholesterol; PCSK-9, proprotein convertase subtilisin/kexin type 9; SBP, systolic blood pressure; SGLT2, sodium–glucose cotransporter 2. * Consider addition of nicotine replacement therapy, bupropion, varenicline, or telephone therapy. † Consider referral for a structured home-based exercise program, if available. ‡ HbA1c targets may increase or decrease depending on patient's functional capacity, risk for hypoglycemia, and risk of microvascular complications. § Target blood pressure range may vary based on patient comorbidities such as diabetes mellitus, kidney disease, cardiomyopathy, and CAD.