Managing Peripheral Vascular Disease: A Short Summary of a Long History

Recently I read an excellent review article from 2014 in Nature Reviews/Cardiology¹and it prompted me to revisit how we manage peripheral vascular disease (PVD). The author’s perspective and intent were evident in the title, “10 years of breakthroughs in peripheral vascular disease.” It was a well-guided trip down memory lane that touched on every significant change in the way we have approached PVD over time and brought as almost to the present. The author’s literature review covers a decade of breakthroughs that have impacted quality and outcomes in PVD. It is a fast read and I commend it highly to primary care physicians who see these patients every day.

A synopsis may pique your interest.

It used to be that aspirin was the “be all and end all” of PVD management.¹ But 2 studies (2008,² 2010³) fostered change. Cardiovascular endpoints-and in the 2010 study, lower extremity amputations as well³-were no different between aspirin and placebo groups. The new approach was to rely on clopidogrel.⁴ In fact, studies that added aspirin to clopidogrel saw no impact on outcomes.⁴ Other reviews supported the clopidogrel approach.^5,6 In fact, of the multiple agents and combinations studied at the time, clopidogrel monotherapy had the best benefit-harm profile.⁶ Warfarin does not have a role in PVD treatment unless other indications (eg, atrial fibrillation) are present.

The screening test of choice for PVD-the ankle-brachial index (ABI)-is non-invasive. It is recommended in patients age ≥65 years, aged 50 to 64 years with atherosclerotic risk factors (smoking) or family history, age <50 years with diabetes and 1 additional risk factor, or known atherosclerotic disease in another vascular bed with risk factors, and in those individuals with typical or atypical limb symptoms such as weakness, paresthesias, exertional discomfort, and/or slow healing ulcers.⁷

The review looked at other therapeutic updates for PVD including the role of exercise, importance of blood pressure control, and the benefits of cilostazol for PVD in individuals with claudication.

Supervised exercise training helps those with PVD and intermittent claudication.⁵ The Framingham data demonstrated that hypertension increased claudication incidence 2-fold in men and 4-fold in women.⁷ A focused effort to bring blood pressures below target should now be standard of care. Renin-angiotensin-aldosterone agents are first-line.⁵ Ramipril as an antihypertensive may be associated with additional risk reductions in this group.⁵ Cilostazol increases walking distance and can be used in individuals with PVD and intermittent claudication without LV dysfunction.⁸

The last 10+ years plus have added substantially to the armamentarium directed at PVD. Primary care will continue to play a major role in managing these patients, including their common comorbidities.

References:

1. Creager MA. 10 Years of breakthroughs in peripheral vascular disease. Nature Reviews/Cardiology 2014; 11 at www.nature.com/nrcardio.
2. Fowkes FG, Price JF, Stewart MC, et al. Aspirin for prevention of cardiovascular events in a general population screened for a low ankle brachial index: a randomized controlled trial. JAMA 2010; 303:841-848.
3. Beich J, MacCuish A, Campbell J, et al.  The prevention of progression of arterial disease and diabetes (POPADAD) trial: factorial randomized placebo controlled trial of aspirin and antioxidants in patients with diabetes and asymptomatic peripheral arterial disease. BMJ 2008; 337:1840.
4. Jones WS, Schmit KM, Vemulapalli S, et al. Treatment strategies for patients with Peripheral Artery Disease. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 May. Report No.: 13-EHC090-EF. AHRQ Comparative Effectiveness Reviews.
5. Simmons A, Steffen K, Sanders S. Medical therapy for peripheral arterial disease. Curr Opin Cardiol. 2012; 27:593-597.
6. Katsanos K, Spiliopoulos S, Saha P, et al. Comparative efficacy and safety of different antiplatelet agents for prevention of major cardiovascular events and leg amputations with peripheral arterial dissease: a systematic reivew and network meta-analysis. Plos One Doi:10.1371/journal.pone.0135692, August 14, 2015.
7. Tattersall MC, Johnson HM, Mason PJ. Contemporary and optimal medical management of peripheral arterial disease. Surg Clin N Am. 2013; 93:761-778.
8. Bedenis R, Stewart M, Cleanthis M, et. al. Cilostazol for intermittent claudication. Cochrane Database Syst. Rev. 2014; doi:10.1002/14651858.CD003748.pub4.