The American Heart Association and American College of Cardiology (AHA/ACC) has issued updated guidelines on the diagnosis and management of patients with lower extremity peripheral artery disease (PAD), emphasizing the importance of structured exercise programs in patients with PAD in order to improve functional status and reduce leg symptoms. Guideline highlights and recommendations include:

• Patients at increased risk of PAD (those aged ≥ 65 years) should undergo a comprehensive medical history and a review of symptoms to assess for exertional leg symptoms, including claudication or other walking impairment, ischemic rest pain, and nonhealing wounds.

• In patients with history or physical examination findings suggestive of PAD, the resting ABI, with or without segmental pressures and waveforms, is recommended to establish the diagnosis. In patients at high risk of PAD without history of PE findings suggestive of PAD, resting ABI is reasonable.

• Resting ABI results should be reported as abnormal (ABI ≤0.90), borderline (ABI 0.91 to 0.99), normal (1.00 to 1.40), or noncompressible (ABI >1.40)

• Platelet therapy with aspirin alone (range 75 to 325 mg per day) or clopidogrel alone (75 mg per day) is recommended to reduce MI, stroke, and vascular death in patients with symptomatic PAD.

• The use of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers can be effective to reduce the risk of cardiovascular ischemic events in patients with PAD.

• Statin is recommended for patients with PAD.

• Cilostazol is an effective therapy to improve symptoms and increase walking distance in patients with claudication.

• Supervised, structured exercise in a hospital or outpatient facility for a minimum of 30 to 45 minutes per session, at least 3 times a week, for a minimum of 12 weeks.

• Revascularization is a reasonable treatment option for the patient with lifestyle-limiting claudication with an inadequate response to exercise and medical therapy.

Citation: Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease. [Published online ahead of print November 13, 2016]. J Am Coll Cardiol. doi:10.1016/j.jacc.2016.11.007.

Commentary: This guideline offers a welcome, clear approach to PAD. Non-invasive testing is an accurate method to diagnose PAD, and an exercise program, with or without cilostazol to help with symptoms, is the clearly recommended initial approach. Careful risk factor management with control of blood pressure, cholesterol, diabetes and smoking cessation is important to prevent progression. For those still symptomatic after an exercise program, risk factor management and cilostazol, revascularization is an option. —Neil Skolnik, MD