Advances in management of ‘under-recognized, underdiagnosed, undertreated’ condition will save life and limb for thousands of Canadians

Major update of CCS treatment guidelines for Peripheral Arterial Disease highlights important new approaches to care

Better diagnostics and drug treatments, improved lifestyle management, and new surgical interventions are part of the first major update in almost two decades of clinical practice guidelines for peripheral arterial disease (PAD), a serious condition that affects more than 800,000 Canadians.

Despite the growing prevalence of PAD, which is characterized by blocked and damaged blood vessels in the limbs, it is “often under-recognized, underdiagnosed, and undertreated,” says Dr. Beth Abramson, co-chair of the Canadian Cardiovascular Society Guidelines for Peripheral Arterial Disease expert panel.

Damaged blood vessels in the limbs leave the heart starved for blood, and lead to the development of cardiovascular and cerebrovascular disease.

“We know if you have diseased blood vessels in your legs you’re at high risk for blood vessel disease in your heart or in the arteries that go to your brain,” says Dr. Abramson, who is the Paul Albrechtsen Professor in Cardiac Prevention and Women’s Health and Associate Professor of Medicine at the University of Toronto. “And the more vascular beds that are affected, the worse someone’s outcome.”

The challenge with PAD is it’s often hard to detect. Unlike the chest pain that results from blockages in the heart, damaged vessels in the limbs don’t usually cause symptoms that patients view as potentially serious – symptoms such as fatigue, pain or cramping in the leg that goes away with rest.

The good news is that, when diagnosed, there are new drugs and therapies available to treat these high-risk patients, as well as new and important evidence-based behavioural changes.

“We have a host of anti-platelet and anti-thrombotic combinations and cholesterol-lowering medications and good evidence in this population to reduce serious symptoms and Major Adverse Limb Events (MALE) such as an amputation,” Dr. Abramson says. “We know that from a quality-of-life and quantity-of-life perspective, if the patient ends up with an amputation, their subsequent risk of death and disability is very high.”

The guidelines are a call-to-action for frontline providers and include these six takeaways:

• Assess and ask: Patients who smoke, those who have diabetes, high blood pressure, elevated cholesterol, and individuals who are older than age 50 are at the highest risk. “We can make a difference if we ask the right questions to care for patients with PAD,” Dr. Abramson says. Ask patients about claudication (limb discomfort or limb fatigue with walking). It is a link to serious cardiovascular problems.
• Do the appropriate vascular studies: If there is concern that someone has blood vessel disease or is at high risk, do the ankle brachial index (ABI), an inexpensive, noninvasive test that involves measuring the systolic BP at the arm and ankle while the patient is lying on their back. The guidelines provide tools and videos on ABI in the index.
• Reinforce the need for exercise, and encourage patients to push themselves to walk to the point of pain. “We know that walking routinely will promote blood vessel function and allow people to walk further in the long term,” Dr. Abramson says.
• Help patients quit smoking. Of all risk factors, tobacco exposure through cigarette smoking is the most strongly associated with the development and progression of PAD and its complications. Although always a challenge for health-care providers, clinical approaches include intensive counselling, pharmacological therapy (from nicotine replacement therapy such as gum and patches, to bupropion and varenicline, to e-cigarettes with nicotine).
• Ensure blood pressure, lipids and glucose levels are treated and controlled. “There are newer drugs available to treat these high-risk patients in addition to behavioural changes that we know are important and evidence-based,” Dr. Abramson says. “We need to treat with medications in addition to lifestyle changes in patients with PAD and prescribe anti-platelets, anti-thrombotics, cholesterol drugs such as statins, icosapent ethyl, ACE inhibitors, and, where appropriate, more potent cholesterol drugs such as PCSK-9 inhibitors.”
• Think about when bypass procedures and revascularization are needed, and when to refer patients to vascular surgeons. Urgency is required when there are blue or black toes or ulcers or significant intermittent claudication that affects quality of life.