The following are key points to remember from the 2024 ACC/AHA/multisociety guideline for the management of lower extremity peripheral artery disease (PAD):

1. The clinical presentation of patients with objectively confirmed PAD can be categorized into four clinical subsets: 1) asymptomatic PAD, 2) chronic symptomatic PAD, 3) chronic limb-threatening ischemia (CLTI), and 4) acute limb ischemia.
2. Patients with asymptomatic PAD represent 20-59% of all patients with objectively proven PAD. A significant proportion of patients who report no exertional leg symptoms will develop symptoms during an objective walking test. These patients have an associated increased risk of major adverse cardiovascular events (MACE), including mortality.
3. In patients with a history of physical exam findings suggestive of PAD, a resting ankle-brachial index (ABI) is recommended to establish the diagnosis of PAD (Class 1, Level of Evidence B-NR). In patients at increased risk of PAD, screening for PAD with a resting ABI is reasonable (Class 2a, Level of Evidence B-NR).
4. In patients with suspected CLTI, it is reasonable to use toe pressures or the toe-brachial index with waveforms, transcutaneous oxygen pressure, and/or skin perfusion pressure in addition to the ABI to establish the diagnosis of CLTI (Class 2a, Level of Evidence B-NR).
5. When evaluating patients with PAD, clinicians should assess for and incorporate the presence of PAD-risk amplifiers when developing patient-focused treatment recommendations (Class 1, Level of Evidence C-EO). PAD risk amplifiers include race and ethnicity, geography, structural racism and implicit bias, social determinants of health, age, diabetes, tobacco use, chronic kidney disease, polyvascular disease, microvascular disease, and depression.
6. In patients with symptomatic PAD, single antiplatelet therapy is recommended to reduce the risk of MACE (Class 1, Level of Evidence A). This can be done with aspirin or clopidogrel.
7. In patients with symptomatic PAD and in patients who have undergoing endovascular or surgical revascularization, low-dose rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin is recommended to reduce the risk of MACE and major adverse limb events (MALE) (Level of Evidence 1, Class A for both).
8. In patients with PAD who do not have another indication (e.g., atrial fibrillation), full-intensity oral anticoagulation should not be used to reduce the risk of MACE or MALE (Class 3, Level of Evidence A).
9. In patients with PAD, treatment with high-intensity statin therapy with an aim of achieving a ≥50% reduction in low-density lipoprotein cholesterol (LDL-C) is recommended (Class 1, Level of Evidence A). In patients with PAD who are on a maximally tolerated statin and have an LDL-C ≥70 mg/dL, it is reasonable to add PCSK9 inhibitor therapy and/or ezetimibe (Class 2A, Level of Evidence B-R for both).
10. In patients with PAD and hypertension, antihypertensive therapy should be administered to reduce the risk of MACE (Class 1, Level of Evidence A). These patients should aim for a systolic blood pressure <130 mm Hg and a diastolic blood pressure <80 (Class 1, Level of Evidence B-R). Selective use of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers is recommended to reduce MACE (Class 1, Level of Evidence B-R).
11. In patients with PAD and type 2 diabetes, use of glucagon-like peptide-1 agonists (liraglutide and semaglutide) and sodium-glucose cotransporter-2 (SGLT-2) inhibitors (e.g., canagliflozin, dapagliflozin, and empagliflozin) are effective to reduce the risk of MACE (Class 1, Level of Evidence A).
12. In patients with claudication, cilostazol is recommended to improve leg symptoms and increase walking distance (Class 1, Level of Evidence A). It should not be administered in patients with congestive heart failure of any severity (Class 3, Level of evidence C-LD). Pentoxifylline and chelation therapy are not recommended for the treatment of claudication (Class 3, Level of Evidence B-R for both).
13. In patients with chronic symptomatic PAD, supervised exercise therapy or a structured community-based exercise program with behavioral change techniques is recommended to improve walking performance, functional status, and quality of life (Class 1, Level of Evidence A for both). The benefit of structured walking exercise therapy that avoids moderate-severe ischemia is uncertain (Class 2b, Level of Evidence B-R). Alternative programs of nonwalking structured exercise therapy (e.g., arm ergometry) can be beneficial (Class 2a, Level of Evidence A). The usefulness of unstructured exercise to improve walking performance is uncertain (Class 2B, Level of Evidence B-R).
14. In patients with asymptomatic PAD, it is reasonable to perform revascularization procedures to reconstruct diseased arteries if needed for the safety, feasibility, or effectiveness of other procedures (e.g., transcatheter aortic valve replacement; Class 2A, Level of Evidence B-NR). However, revascularization should not be performed solely to prevent progression of disease (Class 3, Level of Evidence B-NR).
15. In patients with functionally limiting claudication and an inadequate response to guideline-directed medical therapy (including structured exercise therapy), revascularization is a reasonable treatment option to improve walking function and quality of life (Class 2a, Level B-R). Revascularization is not recommended when the patient has an adequate response to guideline-directed medical therapy (including structured exercise; Class 3, Level of Evidence C-EO).
16. In patients with CLTI, revascularization is recommended to minimize tissue loss, heal wounds, relieve pain, and preserve a functional limb (Class 1, Level of Evidence B-R). In patients with CLTI and nonhealing wounds or gangrene, revascularization in a manner that achieves in-line blood flow or maximizes perfusion to the wound bed can be beneficial (Class 2a, Level of Evidence B-NR). In patients with CLTI and ischemic rest pain from multi-level arterial disease, it is reasonable for revascularization to address inflow disease first (Class 2a, Level of Evidence C-LD).
17. In patients with PAD (with or without revascularization), longitudinal follow-up with physical examination is recommended (Class 1, Level of Evidence C-EO). In patients who have undergone revascularization and have new lower extremity signs or symptoms, ABI and arterial duplex ultrasound is recommended (Class 1, Level of Evidence C-LD). In patients who have undergone revascularization without new lower extremity signs or symptoms, the effectiveness of ABI and arterial duplex ultrasound surveillance is uncertain (Class 2b, Level of Evidence B-NR).

Clinical Topics: Vascular Medicine, Atherosclerotic Disease (CAD/PAD)

Keywords: Ankle Brachial Index, Foot Ulcer, Lower Extremity, Peripheral Arterial Disease

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