ACC/AHA issue new treatment guidelines for peripheral artery disease

"Don't wait for the patient to complain" about symptoms of peripheral artery disease (PAD), American Heart Association (AHA) and American College of Cardiology (ACC) experts urge in their new Peripheral Artery Disease Guidelines issued jointly today. Rather, physicians should have a high level of suspicion and ask specific questions of asymptomatic high-risk patients. The primary emphasis of the new PAD treatment guidelines is early detection of arterial disease "from the diaphragm to the toes." Most individuals can lower their risk of PAD with lifestyle modification, such as a diet low in fat and cholesterol, smoking cessation and exercise. Smokers are 2 to 25 times more likely to develop PAD. Clinicians should "initiate therapy early to maintain functional independence and decrease risk of heart attack, stroke and death," said Dr. Alan T. Hirsch, of the University of Minnesota, Minneapolis at a news conference announcing the new guidelines. Dr. Hirsch was chairman of the writing committee that developed the PAD guidelines. A routine physical examination should include palpation of the lower extremity pulses, including the popliteal artery. An estimated 40% to 50% of popliteal aneurysms are associated with aortic aneurysms, the panelists said. In addition to the usual heart and lung sounds assessed in the seated patient, physicians should include an abdominal exam in the lying position as part of the routine physical. Measurement of the ankle-brachial index "is important even in those with negligible or no symptoms," Dr. Hirsch added. Physicians should have a high level of suspicion for renal stenosis in high-risk patients. Important clinical clues are severe hypertension before the age of 30, malignant hypertension, signs of deteriorating kidney function even with apparently effective ACE inhibitor therapy and unexplained pulmonary edema, Dr. Ziv J. Haskal of New York-Presbyterian Hospital/Columbia University Medical Center in New York City told Reuters Health during the news conference. Identification of aortic stenoses and aneurysms is more difficult during a routine office exam, but Dr. Haskal noted that there is a bill before Congress asking for Medicare inclusion of abdominal ultrasound screening of individuals over the age of 65. Dr. Haskal emphasized that family history is an important predictor of aortic aneurysm and clinicians should be aware that a woman can have a rupture of relatively small aneurysms. Medical interventions include initiation of a supervised exercise program, control of cholesterol levels and blood pressure, control of diabetes, and use of anti-platelet agents and other medications to improve walking tolerance. Statins and ACE inhibitors are key therapies in early medical intervention of PAD. Surgical intervention may be required, including angioplasty and vascular surgical bypass. The guidelines include some "negative" recommendations, co-author Dr. Norman R. Hertzer of the Cleveland Clinic Foundation, Ohio, noted. One of these is that bypass surgery is not indicated for the asymptomatic patient with PAD. "The guidelines clearly include treatment of systemic disease," Dr. Hirsch said. They are not changing medical practice but rather, they are standardizing it, he added. Exclusion of the carotid and thoracic arteries in these guidelines "suggest there is another shoe to drop," Dr. Hirsch noted. Other professional organizations participating in crafting the new AHA/ACC guidelines were the American Association for Vascular Surgery/Society for Vascular Surgery, the Society for Cardiovascular Angiography and Interventions, the Society for Interventional Radiology and the Society for Vascular Medicine and Biology. Societies that have officially endorsed the guidelines are the National Heart, Lung, and Blood Institute, the Society for Vascular Nursing, TransAtlantic Inter-Society Consensus and the Vascular Disease Foundation. Full text of the guidelines can be found at http://www.acc.org or http://heart.org.
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