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ACC/AHA 2006 guidelines
on the management of PAD
ACC/AHA 2006 guidelines
on the management of PAD
▪ First national guidelines on PAD
▪ Written in collaboration with:
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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:
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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.
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ACC/AHA definition:
Classification of recommendations
Class: I
IIa IIb III
▪ 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
Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.
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ACC/AHA definition:
Level of evidence
A
▪ Level of evidence A: Data derived from multiple
randomized clinical trials or meta-analyses
B
▪ Level of evidence B: Data derived from a single
randomized trial or nonrandomized studies
C
▪ Level of evidence C: Only consensus opinion of
experts, case studies, or standard of care
Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.
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2006 ACC/AHA PAD guidelines
Patients at risk for PAD
By specific age
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<50 years old
At any age
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diabetes and one other
atherosclerotic risk factor
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50–69 years old
or ischemic rest pain
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≥70 years old
with or without risk factors
Abnormal pulse
in lower extremity
history of smoking or diabetes
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Exertional leg symptoms
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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.
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Varying presentations of patients with PAD
The majority of PAD patients do not have
the classical symptoms of claudication
PAD patients
≥50 years
Initial presentation*
Claudication
Atypical leg pain
Asymptomatic
10%–35% of patients
40%–50% of patients
20%–50% of patients
* 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.
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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
CV morbidity
70%–80%
20%
Stable claudication
Nonfatal CV event
(MI or stroke)
10%–20%
Mortality
15% to 30%
▪ 75% from CV causes
Worsening claudication
1%–2%
Critical limb ischemia
* 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.
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Class I recommendation:
Use of the ankle-brachial index (ABI)
1. Asymptomatic patients
Individuals with asymptomatic lower
extremity PAD should be identified by
examination and/or measurement of the
ABI (Class I; Level B)
2. Symptomatic patients
Patients with symptoms of intermittent
claudication should undergo a vascular
physical examination, including
measurement of the ABI (Class I; Level B)
3. The most cost-effective tool for lower
extremity PAD detection is the ABI
Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.
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Cardiovascular risk reduction vs
treatment for claudication symptoms
Separate
management
strategies
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
Clopidogrel prescribing information.
Pharmacologic treatment
for claudication symptoms
Cilostazol: Indicated to reduce
symptoms of intermittent
claudication, as indicated by an
increased walking distance
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2006 ACC/AHA guidelines for the management of patients
with lower extremity atherosclerotic PAD: Antiplatelet therapy*
Patient type
Recommended therapy
Class/level of evidence
Peripheral
arterial disease
Antiplatelet therapy
Class I
level A
Aspirin (75–325 mg/day)
Class I
level A
Clopidogrel (75 mg/day)
Class I
level B
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.
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ACC/AHA PAD guidelines recommend
CV risk reduction and symptom relief
Evidence basis for selected treatment recommendations
CV risk reduction
Recommendations
Class
Treatment for claudication*
Evidence
Recommendations
Class
Evidence
Antiplatelet therapy
I
A
Supervised exercise training
I
A
Antihypertensive
therapy
I
A
Cilostazol
I
A
Smoking cessation
I
B
Surgical intervention
in appropriate patients
I
B
Statin therapy
I
B
Glucose control
therapy
IIa
C
Endovascular procedures
in appropriate patients
I
A
* 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.
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