Medical management of peripheral arterial disease

Abstract

The goals of treatment of PAD are symptom relief and cardiovascular disease risk modification, which can be achieved with a dedicated exercise program and medical therapy. Smoking is a strong risk factor for the development and progression of PAD, and smoking cessation is highly recommended. Diabetes mellitus should be aggressively managed with tight glycemic control. BP should be adequately controlled per Joint National Commission-8 (JNC-8) recommendations, and angiotensin converting enzyme (ACE) inhibitors may be beneficial for treatment of hypertension with PAD. It is safe to use beta blockers in patients with PAD. Aggressive control of lipids with the use of high intensity statin therapy may be useful in treatment of PAD. Disease progression depends upon the patient’s level of activity and can be objectively assessed by a deteriorating ABI. Pharmacologic treatment with antiplatelet therapy is effective in reducing future cardiovascular events. Low dose aspirin may be used in these patients. Other antiplatelet medications such as clopidogrel, dipyridamole and ticlopidine have been studied in patients with PAD. Clopidogrel has been shown to be superior to low dose ASA. Current guidelines do not recommend dual antiplatelet therapy for PAD. Pharmacotherapy with phosphodiesterase inhibitors such as cilostazol may also have some role. Improvement in intermittent claudication (IC) symptoms is best achieved with regular exercise. A study done in 2012 showed that subjects on optimal medical therapy (OMT) plus a supervised exercise program had a significant increase in the peak walking time, compared to either OMT alone or OMT plus percutaneous revascularization.