ACC/AHA 2006 guidelines on the management of PAD

1. ACC/AHA 2006 guidelines on the management of PAD

2. ACC/AHA 2006 guidelines on the management of PAD • First national guidelines on PAD • Written in collaboration with: • American College of Cardiology • American Heart Association • American Association for Vascular Surgery/Society for Vascular Surgery* • Society for Cardiovascular/Angiography and Interventions • Society of Interventional Radiology • Society for Vascular Medicine and Biology • Endorsed by: • American Association of Cardiovascular and Pulmonary Rehabilitation • National Heart, Lung, and Blood Institute • Society for Vascular Nursing • TransAtlantic Inter-Society Consensus • Vascular Disease Foundation * AAVS/SVS when guidelines were initiated, now merged into SVS. Adapted from Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.

3. Class I: Conditions for which there is evidence for and/or general agreement that a given procedure or treatment is beneficial, useful, and effective Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy Class IIb: Usefulness/efficacy is less well established by evidence/opinion Class III: Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful ACC/AHA definition: Classification of recommendations Class: I IIa IIb III Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.

4. Level of evidence A:Data derived from multiple randomized clinical trials or meta-analyses Level of evidence B:Data derived from a single randomized trial or nonrandomized studies Level of evidence C:Only consensus opinion of experts, case studies, or standard of care ACC/AHA definition: Level of evidence A B C Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.

5. 2006 ACC/AHA PAD guidelines Patients at risk for PAD By specific age • <50 years olddiabetes and one otheratherosclerotic risk factor • 50–69 years oldhistory of smoking or diabetes • ≥70 years oldwith or without risk factors At any age • Exertional leg symptomsor ischemic rest pain • Abnormal pulsein lower extremity • Atherosclerotic disease coronary, carotid, or renal artery Adapted from Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf Accessed March 22, 2006.

6. PAD patients ≥50 yearsInitial presentation* Claudication 10%–35% of patients Asymptomatic 20%–50% of patients Atypical leg pain 40%–50% of patients Varying presentations of patients with PAD The majority of PAD patients do not have the classical symptoms of claudication * Excluding patients with an initial presentation of critical limb ischemia. Adapted from Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.

7. PAD patients are at increased risk for CV ischemic events Up to 1/3 of PAD patients will die in 5 years, 75% from CV causes PAD* (≥50 years old) 5-year outcomes Limb morbidity 70%–80%Stable claudication 10%–20%Worsening claudication 1%–2%Critical limb ischemia CV morbidity 20%Nonfatal CV event (MI or stroke) Mortality 15% to 30% • 75% from CV causes * Patients with an initial clinical presentation of asymptomatic PAD, atypical leg pain, or claudication. Adapted from Hirsch AT et al. Available at: www.acc.org. Accessed March 22, 2006.

8. Asymptomatic patients Individuals with asymptomatic lower extremity PAD should be identified by examination and/or measurement of the ABI (Class I; Level B) Symptomatic patients Patients with symptoms of intermittent claudication should undergo a vascular physical examination, including measurement of the ABI (Class I; Level B) The most cost-effective tool for lower extremity PAD detection is the ABI Class I recommendation:Use of the ankle-brachial index (ABI) Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.

9. Cardiovascular risk reduction vstreatment for claudication symptoms Separate management strategies Pharmacologic treatment for claudication symptoms Cardiovascular risk reduction Clopidogrel: Indicated to reduce the risk of atherothrombotic events (recent MI, recent ischemic stroke, or vascular death) in individuals with established PAD Cilostazol: Indicated to reduce symptoms of intermittent claudication, as indicated by an increased walking distance Clopidogrel prescribing information.

10. 2006 ACC/AHA guidelines for the management of patients with lower extremity atherosclerotic PAD: Antiplatelet therapy* ACC=American College of Cardiology; AHA=American Heart Association. * Clopidogrel was not the only agent recommended. This represents an adaptation from the 2006 ACC/AHA guidelines for the management of patients with PAD. Adapted from Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.

11. ACC/AHA PAD guidelines recommend CV risk reduction and symptom relief Evidence basis for selected treatment recommendations * To improve symptoms and increase walking distance. Adapted from the 2006 ACC/AHA PAD guidelines. Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.