Prognia
Back to Guidelines
American Heart AssociationCardiology2024advanced

Management of Patients With Lower Extremity Peripheral Artery Disease

Published by American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines · ACC/AHA Class of Recommendation and Level of Evidence

20Tables
8Figures
Read Full Guideline (Free)

Summary

AI-generated

Lower extremity PAD is a common cardiovascular disease associated with an increased risk of amputation, myocardial infarction, stroke, and death. This comprehensive guideline updates the 2016 AHA/ACC PAD Guideline, providing evidence-based practices for clinical assessment, physiological testing, and interdisciplinary management—including GDMT, structured exercise, wound care, and revascularization strategies.

peripheral artery diseasePADrivaroxabanaspirinhigh‑intensity statinACC/AHAcardiologyguidelines

Key Takeaways

  • 1
    Peripheral artery disease (PAD) is a common cardiovascular disease associated with increased risk of amputation, myocardial infarction, stroke, and death, as well as impaired quality of life.
  • 2
    This guideline defines 4 clinical subsets of PAD: asymptomatic PAD, chronic symptomatic PAD (including claudication), chronic limb-threatening ischemia (CLTI), and acute limb ischemia (ALI).
  • 3
    Detection of PAD is primarily accomplished through history, physical examination, and resting ankle-brachial index (ABI).
  • 4
    Health disparities in PAD are associated with poor limb and cardiovascular outcomes and must be addressed.
  • 5
    Effective medical therapies include antiplatelet/antithrombotic therapy, lipid-lowering (high-intensity statin), antihypertensive therapy, diabetes management, and smoking cessation.
  • 6
    Low-dose rivaroxaban combined with low-dose aspirin is effective to prevent MACE and MALE in PAD patients not at increased risk of bleeding.
  • 7
    Structured exercise is a core component of care for patients with PAD.
  • 8
    Revascularization should be used to prevent limb loss in CLTI and can improve QOL in claudication unresponsive to medical therapy.
  • 9
    Care for patients with PAD, especially CLTI, is optimized when delivered by a multispecialty care team.
  • 10
    Foot care is crucial for patients with PAD across all clinical subsets.

What's New in This Version

This document supersedes recommendations in the '2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease'.

Key Recommendations

2.2. History and Physical Examination to Assess for PAD

  • Rec_2.2_1

    In patients at increased risk of PAD, a comprehensive medical history and review of symptoms to assess for exertional leg symptoms, lower extremity rest pain, and lower extremity wounds or other ischemic skin changes should be performed.

    1Evidence: B-NRClinical Assessment

3.1. Resting ABI and Additional Physiological Testing

  • Rec_3.1_1

    In patients with history or physical examination findings suggestive of PAD, the resting ABI, with or without ankle pulse volume recordings (PVR) and/or Doppler waveforms, is recommended to establish the diagnosis.

    1Evidence: B-NRDiagnostic Testing

5.1. Antiplatelet and Antithrombotic Therapy for PAD

  • Rec_5.1_1

    In patients with symptomatic PAD, single antiplatelet therapy is recommended to reduce the risk of MACE.

    1Evidence: AMedical Therapy

5.2. Lipid-Lowering Therapy for PAD

  • Rec_5.2_1

    In patients with PAD, treatment with high-intensity statin therapy is indicated, with an aim of achieving a ≥50% reduction in low-density lipoprotein cholesterol (LDL-C) level.

    1Evidence: AMedical Therapy

5.3. Antihypertensive Therapy for PAD

  • Rec_5.3_2

    In patients with PAD and hypertension, a systolic blood pressure (SBP) goal of <130 mm Hg and a diastolic blood pressure target of <80 mm Hg is recommended.

    1Evidence: B-RMedical Therapy

5.4. Smoking Cessation for PAD

  • Rec_5.4_1

    Patients with PAD who smoke cigarettes or use any other forms of tobacco should be advised at every visit to quit or encouraged to maintain cessation.

    1Evidence: ALifestyle/Preventive Care

6. Exercise Therapy for PAD

  • Rec_6_1

    In patients with chronic symptomatic PAD, SET is recommended to improve walking performance, functional status, and QOL.

    1Evidence: AExercise Therapy

9.1. Revascularization for Claudication

  • Rec_9.1_4

    In patients with functionally limiting claudication and hemodynamically significant aortoiliac or femoropopliteal disease with inadequate response to GDMT (including structured exercise), endovascular revascularization is effective to improve walking performance and QOL.

    1Evidence: AInterventional/Surgical

10.1. Team-Based Care for CLTI

  • Rec_10.1_1

    In patients with CLTI, a multispecialty care team should evaluate and provide comprehensive care with goals of complete wound healing, minimizing tissue loss, and preservation of ambulatory status.

    1Evidence: B-NRCare Management

11.2.1. Revascularization for ALI

  • Rec_11.2.1_1

    In patients with ALI and a salvageable limb, revascularization (endovascular or surgical, including catheter-directed thrombolysis) is indicated to prevent amputation.

    1Evidence: AInterventional/Surgical

Scope & Objectives

Clinical Topic

Lower Extremity Peripheral Artery Disease

Objectives

To provide recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

Target Patient Population

Patients with or at risk of developing atherosclerotic and thrombotic disease of the lower extremity arteries (PAD).

Diagnostic Criteria

Resting Ankle-Brachial Index (ABI) <= 0.90 is abnormal. In noncompressible arteries (ABI > 1.40), Toe-Brachial Index (TBI) <= 0.70 is used for diagnosis.

Target Providers

CardiologistsVascular SurgeonsInterventional RadiologistsVascular Medicine SpecialistsPrimary Care CliniciansPodiatristsNursesWound Care Specialists

Patient Criteria & Setting

Therapeutic Area

Cardiovascular Disease

Guideline Scope

DiagnosisManagementRevascularizationPrevention

Inclusion Criteria

  • Asymptomatic PAD
  • Chronic symptomatic PAD (claudication)
  • Chronic limb-threatening ischemia (CLTI)
  • Acute limb ischemia (ALI)

Exclusion Criteria

  • Nonatherosclerotic causes of lower extremity arterial disease (e.g., vasculitis, fibromuscular dysplasia)
  • Pediatric populations
  • Isolated small vessel arterial disease/microangiopathy

Care Settings

Primary CareSpecialty ClinicsHospitalEmergency CareOutpatient Settings

Special Populations

Older adultsPatients with diabetesPatients with chronic kidney diseasePatients with polyvascular diseaseRacial and ethnic minority groups

Evidence Grading

System: ACC/AHA Class of Recommendation and Level of Evidence

Evidence Levels

Level AHigh-quality evidence from more than 1 RCT, meta-analyses of high-quality RCTs, or 1 or more RCTs corroborated by high-quality registry studies.
Level B-RModerate-quality evidence from 1 or more RCTs or meta-analyses of moderate-quality RCTs.
Level B-NRModerate-quality evidence from 1 or more well-designed, well-executed nonrandomized studies, observational studies, registry studies, or meta-analyses of such studies.
Level C-EOConsensus of expert opinion based on clinical experience.
Level C-LDRandomized or nonrandomized observational or registry studies with limitations of design or execution, or physiological/mechanistic studies in human subjects.

Recommendation Strength

Class 1Strong recommendation; Benefit >>> Risk. Uses phrases like 'Is recommended', 'Is indicated/useful/effective/beneficial'.
Class 2aModerate recommendation; Benefit >> Risk. Uses phrases like 'Is reasonable', 'Can be useful/effective/beneficial'.
Class 2bWeak recommendation; Benefit ≥ Risk. Uses phrases like 'May/might be reasonable', 'Usefulness/effectiveness is unknown/unclear/uncertain'.
Class 3: HarmStrong recommendation; Risk > Benefit. Uses phrases like 'Potentially harmful', 'Causes harm', 'Should not be performed/administered/other'.
Class 3: No BenefitModerate recommendation; Benefit = Risk. Uses phrases like 'Is not recommended'.

Safety & Contraindications

Contraindications

  • Cilostazol in patients with congestive heart failure
  • Full-intensity oral anticoagulation for MACE reduction without another indication
  • Vorapaxar in patients with previous stroke
  • Revascularization for Category III (irreversible) acute limb ischemia

Monitoring Guidance

Longitudinal follow-up includes routine clinical evaluation of limb symptoms, functional status, pulse assessment, foot inspection, and ABI/duplex ultrasound surveillance after revascularization procedures.

Authors & Contributors

AACVPRAPMAABCSCAISVMSVNSVSSIRVESS

Guideline Features

Dosing informationFlowcharts includedBased on systematic reviewMultidisciplinaryPatient involvement

Learning Context

Difficulty

advanced

Learning Paths

Peripheral Artery Disease (PAD)Guideline-Directed Management and Therapy (GDMT)Revascularization StrategiesChronic Limb-Threatening Ischemia (CLTI)Acute Limb Ischemia (ALI)Ankle-Brachial Index (ABI)Cardiovascular Risk ReductionMultispecialty Care Team