Peripheral Arterial Disease Medical Therapy

The primary initial goals of medical therapy in patients with PAD are to treat the systemic atherosclerosis by risk modification and antiplatelet drugs in an attempt to reduce cardiovascular morbidity and mortality. Once that has been accomplished, the physician can then address the relief of symptoms and limb preservation.

Smoking Cessation
Several studies have suggested that smoking cessation will decrease the risk of critical leg ischemia and even reduce mortality in patients with PAD.

All patients with PAD should be referred to a smoking cessation program and prescribed nicotine replacement and antidepressants. Nicotine replacement therapies, in addition to behavior modification, are slightly more effective than behavior modification alone. A recent meta-analysis of several placebo-controlled trials revealed cessation rates of 23% to 27% over 6 to 12 months using a nicotine patch as compared to placebo, where the quit rates ranged from 13% to 18%. Also, in patients with medical diseases, transdermal nicotine patches have been shown to be safe even in high-risk populations. Thus, this is a strategy that should be considered for patients with PAD.

Diabetes
Patients with diabetes should first undergo intensive blood glucose control to target a hemoglobin A1C less than 7.0%. Obtaining this goal may have favorable effects on the risk of cardiovascular events in both type 1 and type 2 diabetes. However, intensive glycemic control had no effect on the risk of amputation from PAD. In addition to intensive blood sugar control, patients with atherosclerosis and diabetes also need aggressive risk factor modification; this may be particularly true in the treatment of hypertension when an angiotensin-converting enzyme (ACE) inhibitor may be a preferable agent. Given the lack of specific trials, drug therapy for patients with diabetes and PAD should follow general published recommendations.

{embed="vein/stat-menu1"}

Hyperlipidemia
Several effective therapies have been developed to treat patients with hyperlipidemia. Dietary restriction of cholesterol and saturated fats has only a modest effect on LDL cholesterol levels, but a more substantial decrease in triglyceride levels, important in the management of PAD. The statin drugs have become a well-established means of reducing LDL cholesterol levels. In addition to statin drugs, gemfibrozil has been shown to lower LDL cholesterol concentration, with the added benefit of increase in HDL cholesterol concentrations. Additional means to modify HDL cholesterol concentration is the use of niacin, which in a recent study was found to be safe in patients with PAD and diabetes.