Conclusions

Peripheral vascular disease is an underdiagnosed, under-treated, highly prevalent, age-dependent condition associated with a high mortality rate because of cardiac and cerebrovascular events. Furthermore, PVD has a very strong negative impact on quality of life, and patients have a functional status similar to NYHA Class III symptoms of CHF.

Clinicians must be more diligent in diagnosing and treating PVD. The diagnosis consists of a goal-directed history and physical examination, non-invasive vascular studies, and CTA or MRA. Therapy consists of routine exercise, smoking cessation, treating the appropriate risk factors to their target goals, and relief of ischemic symptoms either pharmacologically or through a revascularization procedure. Patients with CLI, with or without tissue loss, should be referred urgently for revascularization. Figure 27-30 provides an algorithm for management.

KEY TREATMENT

Risk factors for atherosclerosis should be identified and treated to their target goals (SOR: A).

Patients should take aspirin (81-325 mg/day) unless there is a contraindication to aspirin therapy, such as active GI bleeding or a history of allergy to aspirin (SOR: A).

Clopidogrel (75 mg/day) can be used as an alternative to aspirin. Patients at high risk for vascular events may take both clopidogrel (75 mg/day) and aspirin (81 mg/day). Avoid aspirin (325 mg) when used in combination with clopidogrel because of a higher incidence of GI bleeding (SOR: A).

Ticlopidine (250 mg twice daily) may be used as an alternative to clopidogrel for patients with intolerance or allergy to clopidogrel, but routine blood counts must be performed to assess for bone marrow suppression (SOR: A). The safety of long-term combination ticlopidine-aspirin therapy has not been assessed (SOR: C). LDL-C should be lowered to less than 100 mg/dL, or less than 70 mg/dL if the patient has concomitant CAD. A statin should be considered first-line pharmacologic therapy, in addition to diet and exercise. Ezetimibe and/or colesevelam may be added to statin therapy to achieve the target goal (SOR: A). Blood pressure should be lowered to less than 130/80 mm Hg. For patients with vascular disease, ACEIs or ARBs have a vasculoprotec-tive effect and should be considered first-line agents (SOR: A). Diabetic patients should have HbA1c lowered to less than 7%, preferably closer to 6.5%.

Cilostazol (50-100 mg twice daily) is recommended for symptomatic relief of claudication (SOR: A).

Pentoxifylline is not recommended for the treatment of PVD because of a lack of benefit versus placebo (SOR: A). Because of its minimally invasive nature, an endovascular procedure should be considered first-line therapy for revascularization. Surgery is now second-line therapy, when an endovascular approach is not technically feasible (SOR: A). Patients should be referred for a revascularization procedure when an exercise program and cilostazol therapy fail to alleviate ischemic symptoms.

All patients with critical limb-threatening ischemia with or without tissue loss should be urgently referred for a revascularization procedure (SOR: A).

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