New Treatment Recommendations to Know
Diagnosis can be difficult, treatments have changed, so pull out your note pad: The Canadian Cardiovascular Society released 2022 Guidelines on Peripheral Arterial Disease (PAD) are out.
Here are 6 things to know:
1. Classic Claudication is rare (< 10% of patients)
Claudication is leg angina: just like the official definition of Typical Angina, claudication is worse with exertion and better at rest. BUT most patients don't present this way, plus in our industry we always think about other causes; the guideline has a list of Neurogenic, Musculoskeletal, Vascular and Other (Restless Legs, Malignancy) to always consider.
2. Use a validated tool to diagnose PAD
The Edinburgh Claudication Questionnaire has 91.3% sensitivity and 99.3% specificity in identifying peripheral arterial disease.
3. Screen for PAD - even in asymptomatic adults at risk
This is not often in Canada but the guideline says we should screen for PAD by ordering ankle-brachial index for patients over 50 years old who have risk factors for PAD.
4. Quit Smoking & Exercise
If a patient is at risk for PAD or has PAD, help them quit using evidence-based non-pharmacologic and pharmacologic strategies. Supervised exercise programs are more strongly recommended than simply recommending exercise - this can improve quality of life!
CLINICAL TIP: "Exercise habits should be asked at every visit with a health practitioner." - 2022 CCS PAD Guidelines |
5. PAD = Statin
Patients with PAD should be on maximally-tolerated dose of statin if they aren't already, PLUS add-on treatment (such as ezetimibe and/or PCSK-9 inhibitor) if they aren't at the targets from the Hyperlipidemia guidelines. This is listed as (Strong Recommendation; High-Quality Evidence).
6. Symptomatic PAD = Blood Thinner or Blood Thinners
If patients with PAD are symptomatic, newer studies show that a direct oral anticoagulant (DOAC) + antiplatelet is recommended for many patients*, especially those at high risk of ischemic events. If they can't tolerate DOAC, some* will qualify for DUAL antiplatelet therapy.
*Check out the full guideline for the full list of indications and all 54 recommendations.