ACC

1. ACC/AHA 2006 guidelines on the management of PAD ACC/AHA 2006 Guidelines on the Management of PADACC/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 The American College of Cardiology/American Heart Association (ACC/AHA) 2006 guidelines for the management of patients with peripheral arterial disease are the first national guidelines on peripheral arterial disease (PAD). These guidelines were 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 These guidelines are 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 FoundationThe American College of Cardiology/American Heart Association (ACC/AHA) 2006 guidelines for the management of patients with peripheral arterial disease are the first national guidelines on peripheral arterial disease (PAD). These guidelines were 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 These guidelines are 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

3. ACC/AHA definition: Classification of recommendations 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 The ACC/AHA classifies their recommendations as follows: 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 harmfulThe ACC/AHA classifies their recommendations as follows: 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

4. ACC/AHA definition: Level of evidence 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 The ACC/AHA classifies their evidence as follows: 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 careThe ACC/AHA classifies their evidence as follows: 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

5. Patients at risk for PAD Individuals at risk for lower extremity PAD include the following patients: Less than 50 years of age, with diabetes and one other atherosclerotic risk factor (smoking, dyslipidemia, hypertension, hyperhomocysteinemia) 50–69 years of age and history of smoking or diabetes 70 years of age and older Leg symptoms with exertional (suggestive of claudication) or ischemic rest pain Abnormal lower extremity pulse examination Known atherosclerotic coronary, carotid, or renal artery diseaseIndividuals at risk for lower extremity PAD include the following patients: Less than 50 years of age, with diabetes and one other atherosclerotic risk factor (smoking, dyslipidemia, hypertension, hyperhomocysteinemia) 50–69 years of age and history of smoking or diabetes 70 years of age and older Leg symptoms with exertional (suggestive of claudication) or ischemic rest pain Abnormal lower extremity pulse examination Known atherosclerotic coronary, carotid, or renal artery disease

6. Varying presentations of patients with PAD The ACC/AHA 2006 guidelines for the management of patients with peripheral arterial disease summarized the different types of initial PAD patient presentations in a population 50 years of age and older. Patients with claudication, or the typical symptoms of PAD, comprise approximately 10%–35% of the initial presentations of PAD. Patients with atypical leg pain comprise approximately 40%–50% of the initial presentations of PAD. Patients who are asymptomatic comprise approximately 20%–50% of the initial presentations of PAD. The majority of PAD patients do not have the classical symptoms of claudication. The ACC/AHA 2006 guidelines for the management of patients with peripheral arterial disease summarized the different types of initial PAD patient presentations in a population 50 years of age and older. Patients with claudication, or the typical symptoms of PAD, comprise approximately 10%–35% of the initial presentations of PAD. Patients with atypical leg pain comprise approximately 40%–50% of the initial presentations of PAD. Patients who are asymptomatic comprise approximately 20%–50% of the initial presentations of PAD. The majority of PAD patients do not have the classical symptoms of claudication.

7. PAD patients are at increased risk for CV ischemic events PAD patients are at increased risk for CV ischemic events. Five-year outcomes for PAD patients 50 years of age or older include the following scenarios: 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%–30% 75% from CV causes Up to one-third of PAD patients will die within 5 years, 75% from CV causes. PAD patients are at increased risk for CV ischemic events. Five-year outcomes for PAD patients 50 years of age or older include the following scenarios: 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%–30% 75% from CV causes Up to one-third of PAD patients will die within 5 years, 75% from CV causes.

8. Class I recommendation:Use of the ankle-brachial index (ABI) 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 The ACC/AHA 2006 guidelines for the management of patients with peripheral arterial disease state that individuals with asymptomatic lower extremity PAD should be identified by examination and/or measurement of the ankle-brachial index (ABI) (Class I; Level of Evidence B). Patients with symptoms of intermittent claudication should undergo a vascular physical examination, including measurement of the ABI (Class I; Level of Evidence B). The ABI is the most cost-effective tool for lower extremity PAD detection. The ACC/AHA 2006 guidelines for the management of patients with peripheral arterial disease state that individuals with asymptomatic lower extremity PAD should be identified by examination and/or measurement of the ankle-brachial index (ABI) (Class I; Level of Evidence B). Patients with symptoms of intermittent claudication should undergo a vascular physical examination, including measurement of the ABI (Class I; Level of Evidence B). The ABI is the most cost-effective tool for lower extremity PAD detection.

9. Cardiovascular risk reduction vstreatment for claudication symptoms Management of patients with peripheral arterial disease includes separate management strategies for cardiovascular risk reduction and the pharmacologic treatment for claudication. For cardiovascular risk reduction, clopidogrel is indicated to reduce the risk of atherothrombotic events (recent MI, recent ischemic stroke, or vascular death) in individuals with established PAD. For the pharmacologic treatment of claudication, cilostazol is indicated to reduce symptoms of intermittent claudication, as indicated by an increased walking distance.Management of patients with peripheral arterial disease includes separate management strategies for cardiovascular risk reduction and the pharmacologic treatment for claudication. For cardiovascular risk reduction, clopidogrel is indicated to reduce the risk of atherothrombotic events (recent MI, recent ischemic stroke, or vascular death) in individuals with established PAD. For the pharmacologic treatment of claudication, cilostazol is indicated to reduce symptoms of intermittent claudication, as indicated by an increased walking distance.

10. 2006 ACC/AHA guidelines for the management of patients with lower extremity atherosclerotic PAD: Antiplatelet therapy* The 2006 ACC/AHA guidelines for the management of patients with lower extremity atherosclerotic PAD gave antiplatelet recommendations as follows: Antiplatelet therapy is indicated to reduce the risk of MI, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD (Level of Evidence A) Aspirin, in daily doses of 75–325 mg, is recommended as safe and effective antiplatelet therapy to reduce the risk of MI, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD (Level of Evidence A) Clopidogrel (75 mg per day) is recommended as an effective alternative antiplatelet therapy to aspirin to reduce the risk of MI, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD (Level of Evidence B) Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and/or effective. Level of Evidence A: Data are derived from multiple randomized clinical trials or meta-analyses. Level of Evidence B: Data are derived from a single randomized trial or non-randomized studies. The 2006 ACC/AHA guidelines for the management of patients with lower extremity atherosclerotic PAD gave antiplatelet recommendations as follows: Antiplatelet therapy is indicated to reduce the risk of MI, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD (Level of Evidence A) Aspirin, in daily doses of 75–325 mg, is recommended as safe and effective antiplatelet therapy to reduce the risk of MI, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD (Level of Evidence A) Clopidogrel (75 mg per day) is recommended as an effective alternative antiplatelet therapy to aspirin to reduce the risk of MI, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD (Level of Evidence B) Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and/or effective. Level of Evidence A: Data are derived from multiple randomized clinical trials or meta-analyses. Level of Evidence B: Data are derived from a single randomized trial or non-randomized studies.

11. ACC/AHA PAD guidelines recommend CV risk reduction and symptom relief The 2006 ACC/AHA PAD guidelines provide recommendations for cardiovascular risk reduction and symptom relief: Selected cardiovascular risk reduction: Antiplatelet therapy (Class I; Level of Evidence A) Antihypertensive therapy (Class I; Level of Evidence A) Smoking cessation (Class I; Level of Evidence B) Statin therapy (Class I; Level of Evidence B) Glucose control therapy (Class IIa; Level of Evidence C) Selected treatment for claudication: Supervised exercise training (Class I; Level of Evidence A) Cilostazol (Class I; Level of Evidence A) Surgical intervention in appropriate patients (Class I; Level of Evidence B) Endovascular procedures in appropriate patients (Class I; Level of Evidence A)The 2006 ACC/AHA PAD guidelines provide recommendations for cardiovascular risk reduction and symptom relief: Selected cardiovascular risk reduction: Antiplatelet therapy (Class I; Level of Evidence A) Antihypertensive therapy (Class I; Level of Evidence A) Smoking cessation (Class I; Level of Evidence B) Statin therapy (Class I; Level of Evidence B) Glucose control therapy (Class IIa; Level of Evidence C) Selected treatment for claudication: Supervised exercise training (Class I; Level of Evidence A) Cilostazol (Class I; Level of Evidence A) Surgical intervention in appropriate patients (Class I; Level of Evidence B) Endovascular procedures in appropriate patients (Class I; Level of Evidence A)