New ESC Guideline on Peripheral Arterial Disease

Liam Davenport

September 11, 2017

BARCELONA, SPAIN — Patients with peripheral arterial disease (PAD) should receive multidisciplinary management from a "vascular team" that involves specialties outside of cardiovascular medicine and surgery[1], say novel European guidelines on PAD that aim to reflect the complexities of patients with the condition.

PAD, which includes atherosclerosis of the extracranial carotid and vertebral, mesenteric, renal, upper- and lower-extremity arteries, affects 40 million Europeans, placing them at increased risk of fatal and nonfatal cerebrovascular events, MI, and cardiac death, the authors note.

The guidelines, which were unveiled at the European Society of Cardiology (ESC) 2017 Congress and published online in the European Heart Journal on August 26, 2017, were developed, for the first time, as a collaboration between cardiologists and vascular surgeons.

They look in detail at the use of antithrombic drugs in PAD, as well as make a series of novel and updated recommendations on the management of carotid artery disease (CAD), lower-extremity artery disease (LEAD), and renal artery disease, among others, since the previous version published in 2011.

In addition, there is a section on the management of patients with comorbid conditions commonly seen in PAD, such as heart failure, atrial fibrillation (AF), and valvular heart disease.

Victor Aboyans (CHU Limoges Hôpital Dupuytren, France) is ESC chairperson of the guideline task force.

He told theheart.org | Medscape Cardiology that the guidelines emphasize need for "the multidisciplinary management of these patients, and we propose the vascular team, comparable with what we have with the heart team for the management of coronary patients."

This reflects the reality that, "given the territory affected," there is often a need to involve specialties outside cardiovascular medicine and surgery. "For example, talking about the management of carotid disease, we also need the input of a neurologist; the same for nephrologists or gastroenterologists," Aboyans said.

"We cannot think any more about a patient at a consultation and the surgeon says: 'Okay, I'll operate on you, I'll fix the problem, and then it's over,' because this is just the beginning of another story, which is the long-term management and reassessment of these patients, as with coronary risk," he added.

Aboyans noted that many PAD patients, especially those with arterial disease of the extremities, have impaired walking, adding: "They may have heart failure, but they don't really complain about shortness of breath, just because they don't walk any more.

"So it is really mandatory that, if a patient comes to one specialty, to also have the call with other specialties, and this complementary approach is of benefit to the patients," he said.

"It is one thing to fix the local-territory issue, the other is the cardiovascular health of these patients and, in the end, the prognosis."

Comprehensive Review

To update the guidelines from the previous version published in 2011, a task force was selected from representatives of the ESC and the European Society for Vascular Surgery (ESVS), as well as the European Stroke Organisation (ESO).

They conducted a comprehensive review of the published literature on the management of PAD, performing a critical evaluation of the evidence for current diagnostic and therapeutic procedures, including a risk/benefit assessment.

The resulting recommendations were reviewed by the ESC Committee for Practice Guidelines (CPG) and external experts appointed by the ESVS and ESO, with the final document approved by the CPG and ESVS prior to publication.

Using the commonly accepted classes of recommendation and levels of evidence, the guidelines set out a series of changes since the previous 2011 guidelines and new recommendations for 2017, alongside which they set out several new or revised concepts in the way in which clinicians should approach their management of PAD.

For PAD in general, the guidelines state, for the first time, all patients should be screened for heart failure based on brain natriuretic peptide levels and transthoracic echocardiography, and patients with stable PAD and other conditions requiring anticoagulants, such as AF, should be given anticoagulation alone (both class IIa).

In CAD, the recommendation that embolic-protection devices should be used in asymptomatic patients with 60% to 99% carotid stenosis during carotid stenting has been strengthened from class IIb to IIa, while surgery should now be reserved for those with a high stroke risk, among other changes from the 2011 guidelines.

New for 2017 is that coronary angiography should be performed before elective carotid surgery in CAD patients. Also, although routine prophylactic revascularization should not be given to all CAD patients with asymptomatic carotid stenosis of 70% to 99% undergoing CABG (class III), it may be considered for those with 70% to 99% carotid stenosis in the presence of “one or more characteristics that may be associated with an increased risk of ipsilateral stroke in order to reduce stroke risk beyond the perioperative period” (class IIb) and in patients with bilateral 70% to 99% occlusions or 70% to 99% occlusion plus a contralateral occlusion (class IIb).

There are a number of changes and novel recommendations in the field of LEAD, such as refinements to the management of aorto-iliac and infrapopliteal lesions, and new class I recommendations to give statins to LEAD patients and to administer anticoagulation to LEAD patients with AF, if they have a CHA₂DS₂-VASc score >2.

Upper-extremity artery disease also sees changes, with the 2011 recommendation to perform revascularization for symptomatic subclavian artery stenosis weakened from class I to class IIa, and the previous class I recommendation to perform endovascular treatment first for subclavian stenosis revascularization switched to a class IIa recommendation to carry out stenting or surgery, among other changes.

Other recommendations added to the guidelines for the first time include the use of D-dimers to rule out acute mesenteric ischemia in patients with mesenteric artery disease (class IIb) and a class III recommendation not to delay renutrition in cases of symptomatic chronic mesenteric ischemia.

It is also recommended that renal artery disease patients with fibromuscular dysplasia receive balloon angioplasty without bailout stenting, which is a class IIa recommendation. There is less confidence in the use of stenting for renal-artery patients who have symptomatic atherosclerotic stenosis >60%, with the recommendation weakened from class IIb in 2011 to class III in the current version of the guidelines.

In terms of novel and revised concepts in patient management, the guidelines emphasize the importance of the "vascular team" in the multidisciplinary management of PAD patients, including initiatives to improve awareness of PAD and the use of the best pharmacological and nonpharmacological interventions to optimize outcomes.

Within CAD, the need for risk stratification for asymptomatic patients is highlighted, as well as the view that the revascularization of severe carotid stenosis in CABG patients should not be performed systematically but on a case-by-case basis.

The themes of the individualization of therapy and the use of the latest management strategies are also given weight in the treatment of LEAD patients, including the blanket prescription of statins and supervised exercise therapy in patients with claudication, even after revascularization.

Finally, it is underlined that PAD patients often have comorbid cardiac conditions, such as heart failure and AF, and vice versa.

Consequently, the guidelines recommend that patients considered for heart transplantation or cardiac assist device implantation undergo a full vascular assessment, while those having transcatheter aortic-valve implantation or other structural interventions should be screened for PAD.

The task force received its entire financial support from the ESC and ESVS without any involvement from the healthcare industry. Aboyans reports speaker fees, honoraria, consultancy fees, advisory board fees, investigator and committee member fees, and other remuneration from Sanofi, Novartis, Boehringer-Ingelheim, Bayer Healthcare, Pfizer/Bristol-Myers Squibb, and Amgen. Disclosures for the coauthors are listed in the paper.  

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