Pharmacological Treatment of Peripheral Artery Disease

Bonaca MP, Creager MA.
Pharmacological Treatment and Current Management of Peripheral Artery Disease. Circ Res 2015;116:1579-1598.

The following are 10 key points from this review of pharmacological treatment for peripheral artery disease (PAD):

  1. Patients with PAD are at heightened risk of both systemic cardiovascular adverse events and limb-related morbidity.
  2. Optimal treatment of PAD includes both lifestyle changes (including smoking cessation and exercise) and optical medical therapy.
  3. Smoking cessation is the single most important modifiable risk factor for PAD. Five-year survival may be two times higher in quitters compared to nonquitters with PAD. A combination of counseling and pharmacological therapy offers patients the best chance of successfully quitting tobacco. Pharmacological treatment options include nicotine replacement, bupropion, and varenicline.
  4. Pharmacological therapy for PAD patients targets broad risk factors for major cardiovascular events and limb-related morbidity.
  5. Observational data and subgroup analysis of randomized trials support the efficacy of statin therapy for reducing adverse cardiac events in PAD patients. Recent American College of Cardiology/American Heart Association guidelines recommend using high-intensity statins (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) in PAD patients ≤75 years of age.
  6. The use of antihypertensive therapy, especially angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin-receptor blockers (ARB), offers benefit for systemic cardiovascular event reduction in PAD patients with a target ≤140/90 mm Hg. Use of beta-blockers is not first-line therapy, but also not contraindicated for PAD patients.
  7. While diabetes mellitus (DM) is closely linked to macrovascular cardiovascular risk, trials of DM control have not been shown to consistently reduce macrovascular complication. Intensive DM therapy may be associated with harm in patients with established cardiovascular disease.
  8. The use of antiplatelet and anticoagulant therapy must balance the benefit in ischemic risk reduction with the risk of bleeding complications. PAD patients should receive antiplatelet monotherapy (aspirin or clopidogrel). Vorapaxar can be combined with either aspirin or clopidogrel to reduce cardiovascular events in PAD patients without a history of stroke or transient ischemic attack. Warfarin is not indicated unless another indication is present (e.g., mechanical valve or atrial fibrillation).
  9. Exercise is the most effective noninvasive intervention to improve claudication symptoms in PAD patients. While supervised exercise has the best evidence, the lack of universal coverage limits its availability.
  10. Pharmacological treatments are greatly underutilized in PAD. Data suggest that as few as 19-27% of eligible PAD patients receive statin, ACE-I/ARB, and antiplatelet therapy.

Clinical Topics: Anticoagulation Management, Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Nonstatins, Novel Agents, Statins, Exercise

Keywords: Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Anticoagulants, Antihypertensive Agents, Aspirin, Bupropion, Diabetes Mellitus, Exercise, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Peripheral Arterial Disease, Platelet Aggregation Inhibitors, Risk Factors, Risk Reduction Behavior, Smoking Cessation

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