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Lower Extremity Peripheral Artery Disease Without Chronic Limb-Threatening IschemiaA Review

Educational Objective
To review the clinical management of patients with lower extremity peripheral artery disease.
1 Credit CME

Importance  Lower extremity peripheral artery disease (PAD) affects approximately 8.5 million people in the US and approximately 230 million worldwide.

Observations  Peripheral artery disease is uncommon before aged 50 years but affects up to 20% of people aged 80 years and older. It can be noninvasively diagnosed with the ankle-brachial index (ABI), a ratio of Doppler-recorded pressures in the dorsalis pedis and/or posterior tibial artery in each leg to brachial artery pressures. An ABI value less than 0.90 is 57% to 79% sensitive and 83% to 99% specific for arterial stenosis of at least 50%. Intermittent claudication, consisting of exertional calf pain that does not begin at rest and that resolves within 10 minutes of rest, is considered the classic symptom of PAD. However, 70% to 90% of people with an ABI value less than 0.90 either report no exertional leg symptoms (ie, asymptomatic) or report leg symptoms with walking that are not consistent with classic claudication. Over time, people with PAD restrict walking activity or slow walking speed to avoid leg symptoms. Thus, although approximately 75% of people with PAD report no change in leg symptoms over time, those with PAD have significantly greater annual declines in 6-minute walk performance compared with those without it. Approximately 11% of people with PAD develop chronic limb-threatening ischemia, the most severe form of PAD. Compared with people without PAD, those with the disease have approximately twice the rate of all-cause mortality, cardiovascular mortality, and major coronary events at 10-year follow-up. High-dose statins and antiplatelet therapy with or without antithrombotic therapy reduced rates of coronary events and stroke in people with PAD. Supervised treadmill exercise improved 6-minute walk distance by 30 to 35 m, consistent with a clinically meaningful change, whereas effective home-based walking exercise interventions improved 6-minute walk by 42 to 53 m. Effective home-based exercise programs require behavioral methods, including monitoring by a coach.

Conclusions and Relevance  Peripheral artery disease affects approximately 230 million people worldwide and is associated with increased rates of cardiovascular events, lower extremity events, and functional decline compared with that of people without PAD. People with PAD should be treated with the highest dose of statin tolerated, antithrombotic and/or antiplatelet therapy, and exercise.

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Article Information

Corresponding Author: Mary M. McDermott, MD, 750 N Lake Shore Dr, 10th Floor, Chicago, IL 60611 (mdm608@northwestern.edu).

Accepted for Publication: February 8, 2021.

Author Contributions: Dr McDermott had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Conflict of Interest Disclosures: Dr McDermott reports receiving grant funding from Regeneron and research support from Mars Inc, Helixmith, Hershey, ArtAssist, ChromaDex, and ReserveAge consisting of interventions or measurement of biomarkers in ongoing randomized clinical trials. No other disclosures were reported.

Disclaimer: Dr McDermott, a Deputy Editor at JAMA, was not involved in any of the decisions regarding review of the manuscript or its acceptance.

Additional Contributions: We thank Corinne H. Miller, MLIS, clinical informationist at Galter Health Science Library, Northwestern University Feinberg School of Medicine, for her assistance performing literature searches for this article.

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