PAD Quick Reference

Use this web-based quick guide to see information about diagnosing and managing PAD at a glance.

 

Download a print-friendly PDF of this guide.

 

Background

  • Peripheral Artery Disease (PAD) is atherosclerotic artery disease, most typically in lower extremity

  • PAD Guideline Directed Medical Therapy (GDTM) used only 30-40% due to clinical knowledge gaps

    • There is significant evidence that adherence to 4 recommended therapies reduces risk of adverse cardiovascular (36%) and limb events (44%)3

    • Examples of the 4 GDTMs include: aspirin, statin medications, ACE inhibitors, and smoking cessation

  • Only 10% of patients with PAD exhibit classic claudication

    • ~50% are asymptomatic

    • ~40% have atypical leg symptoms (i.e. knee pain, hip pain, etc)

  • African Americans have twice the risk compared with other races

  • High annual mortality of 5-7% in PAD patients without critical limb ischemia

 

Diagnosis

  • Risk Factors: Age > 65, tobacco use, DM, HTN, hyperlipidemia, AAA, known atherosclerotic disease, and family history of PAD

  • History Clues: Lower extremity pain, more specifically claudication, other non-joint related exertional leg symptoms, impaired walking

    • Claudication = reproducible discomfort (cramping, aching, pain) or fatigue in the muscles of the lower extremity occurring with exertion and relieved within 10 minutes of rest

  • Physical Exam: Diminished pulses, vascular bruits, pallor, rubor, non-healing wounds, any evidence of lower extremity gangrene

  • Differential diagnosis may be broad and includes:

    • Venous ulcer, symptomatic Baker’s cyst, local trauma, neuropathy, infection, small artery occlusion (microangiopathy), drug reaction/ toxicity, autoimmune injury, inflammatory disorder, spinal stenosis, nerve root compression, arthritis of hip, ankle or foot, chronic compartment syndrome

Testing and Assessment for Intervention

See also figure 1

Diagnosis and Assessment for PAD

Test to Order

Indication

Next Steps Based on Result

Diagnosis

Ankle Brachial Index (ABI): 1.0-1.39 (normal range)

If history and/or exam suggestive of PAD

 

Screening is reasonable if asymptomatic, but PAD risk factors present

ABI = 1.0-1.39: Look for other causes of symptoms/abnormal exam

ABI = 0.91-0.99: Possible PAD. Obtain exercise treadmill ABI or 6 MWT*

ABI <0.90: GDMT* if CLI* not present

ABI >1.40: Obtain Toe Brachial Index (TBI). TBI <0.70 indicates PAD

If CLI suspected and ABI non-compressible, obtain TBI with waveforms or toe perfusion pressure

Anatomical Assessment

CT Angiogram, or Magnetic Resonance Angiogram

Indicated if considering revascularization procedure or surgery

Revascularization should be considered for ALI, CLI, or symptomatic iliac disease, or infrainguinal disease that significantly impairs functional status/QoL* despite GDMT and exercise therapy

 

*6 MWT: 6 minute walk test
GDMT: Guideline directed medical therapy
ALI: acute limb ischemia
CLI: Critical leg ischemia
QoL: Quality of Life

 

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Management/Treatment Specifics

Goals

  • Eliminate/reduce claudication to improve mobility, functional status, and health-related QoL
  • Reduce risk of fatal ischemic cardiovascular events and limb loss

PAD Management Checklist for Front Line Providers

 

Management

Intervention

Frequency/Dosing

Considerations

Prior to any vascular intervention

Asymptomatic PAD (ABI < 0.9):
ASA or Clopidogrel1

ASA 81 mg daily or Plavix 75 mg daily

 
 

Symptomatic PAD:
ASA + Rivaroxaban,
OR, if increased risk of bleeding,
ASA OR Clopidogrel4,5

ASA 81 mg
Rivaroxaban 2.5 mg two times a day
OR, if increased risk of bleeding,
Aspirin 81 mg daily OR
Clopidogrel 75 mg daily

ASA and Rivaroxaban may improve CV outcomes, with modestly
increased risk of bleeding

If there is an increased risk of bleeding, ASA or Clopidogrel can be
used as a treatment method

Dual antiplatelet therapy (DAPT) generally not recommended for
symptomatic or asymptomatic PAD

Post-vascular intervention

ASA + Rivaroxaban
OR
ASA + Clopidogrel6,7

ASA 81 mg daily plus
Rivaroxaban 2.5 mg bid
OR ASA 81 mg daily plus
Clopidogrel 75 mg dailly

ASA and Rivaroxaban may reduce risk of adverse CV and limb
events after revascularization

If risk of bleeding is increased, DAPT with ASA and Clopidogrel may
be used

Cilostazol

Reduces claudication, increases walking

100 mg BID

Side effects: Headache, palpitations, and diarrhea

Contraindicated in presence of Heart Failure and/or EF <40%

Hypertension management

Target blood pressure: <130/<80

Monthly until controlled, then every 3-6 months

No preferred agent in absence of other disorders (DM, CKD, CHF)

Beta-blockers not associated with worsening claudication

First line is often ACE inhibitors

Diabetes management

HbA1c <7% (unless risk > benefit)

Controlled: q 6 months

Poorly controlled: q 3 months

Intensify medications to optimize control

Biannual foot exam with monofilament test

Lipid management

LDL target <70 mg/dl

Ongoing treatment

Moderate or high intensity statin therapy, indicated for all PAD
patients, regardless of cholesterol level, to reach LDL target

Ezetimibe ($) may be added to achieve LDL goal

PCSK-9 inhibitors ($$$) may reduce CV and adverse limb events
when added to statins, though expensive

Tobacco screening and cessation

Screen all patients annually with regular follow up to ensure cessation

Refer to smoking cessation program

Medication options include buproprion, varenicline, or nicotine replacement

Active smokers: address every visit

Provide a medication prescription even if patient not ready to fill, so
no wait when patient is ready

Detailed discussion on “what will happen to your health and limbs if
you continue smoking”

Exercise program

Supervised or home-based

Materials to share with your patients

3-5 sessions per week

Home Based Exercise performed 3-5x/week, beginning possibly
with 10 minutes of walking exercise per session

Increasing walking per session by 5 min per week, until patient
walking 45-50 min per session (excluding rest periods)

Treadmill-based exercise therapy program for patients with PAD:
30 to 60 minute exercise sessions, three times a week, for minimum
of 12 weeks, with additional 36 sessions, if warranted

Revascularization

Claudication severity, presence of iliac disease, and QoL drives revascularization decision

<10-15% progress to CLI over 5 years

Note: 0.15 increase in ABI is considered significant post-procedure

Performed in conjunction with GDMT and exercise therapy

Iliac disease: Generally treated with revascularization

Below Iliac disease: Generally, GDMT + Exercise Therapy are initial
therapies

When CLI present, endovascular and/or surgical procedures used
to provide in-line blood flow to 1 patent artery

Surgical patency rates higher than endovascular procedures, but
with more complications

Post-procedure follow-up with periodic ABI measurements and, in
some patients, Doppler ultrasound is warranted

 

NOAC: Novel Oral Anticoagulant, CLI: Critical leg ischemia, QoL: Quality of Life, GDTM: Guideline Directed Medical Therapy

 

When to Refer to a Vascular Specialist

  • Debilitating claudication

  • Lifestyle limiting activity

  • Diabetes and foot wound

  • Non-healing foot wounds

  • Known PAD and foot wound

Additional Management Considerations

Supervised/Home Exercise Program

  • Effectively reduce claudication and atypical symptoms, improve both functioning and QoL, alone or in conjunction with revascularization

  • Other exercise strategies include upper-body ergometry and cycling for patients with leg amputations

Foot Care for Patients with Diabetes

  • Biannual foot exams including pulses/perfusion, use 10 g monofilament and either temp, pinprick, vibration, or ankle reflexes to detect neuropathy

  • Refer patients with PAD to podiatrist

  • If foot ulcer present, refer to vascular specialist

Minimizing Risk of Tissue Loss

  • Prevention: patient education regarding healthy foot behaviors (e.g., daily feet inspection; foot care and hygiene, including safe toenail cutting strategies; avoidance of barefoot walking, proper shoes)

  • Prompt diagnosis and treatment of infections and other foot disorders

    • Suspect if patient has local pain, tenderness; inflamatory reaction around wound, pretibial edema; discharge or odor, or signs of a systemic inflammatory response

    • Treatment of deep soft-tissue infections typically requires prompt surgical drainage; vascular imaging and timely revascularization

  • Goal: complete wound healing

Acute Limb Ischemia is a medical emergency typically requiring prompt anticoagulation, emergency consultation with vascular specialist, and thrombolysis or thrombectomy for viable limbs.

 

PAD: Clinical Integrated Care Considerations and Information

Refer to Vascular Medicine/Cardiology

  • Assistance in managing coexisting PAD risk factors, such as HTN, lipid disorders

  • Pre-operative assessment of high risk patients

  • Confirm diagnosis of PAD when symptoms atypical and/or normal/borderline noninvasive tests

  • Phone number: 212-241-9454 to request appointment with Dr. Olin at The Lauder Family Cardiovascular Ambulatory Center

Refer to Surgery (i.e. Vascular Specialist)

  • Determine the most appropriate diagnostic testing and arrangement

  • Revascularization in patients with refractory symptoms despite GDMT

  • Manage acute and critical limb ischemia

  • Treatment of non-healing skin and soft tissue infections and non-healing wounds

  • Diagnostic Testing Available by Location

    • All Locations: ABI Testing, Exercise ABI, Toe Brachial Index (with waveforms), Toe Perfusion Pressure

    • Mount Sinai West and Mount Sinai Downtown Only: Transcutaneous 02 pressure

 

Hospital

Location of Vascular Surgery/Outpatient Wound Care

Vascular Surgery Phone Numbers

The Mount Sinai Hospital

17 East 102nd Street, 4th Floor, New York, NY 10029

1190 Fifth Avenue, 1st Floor, GP-1 Center, New York, NY 10029

212-659-8554

212-241-5315

Mount Sinai Morningside

440 West 114th Street, Ambulatory Care Center, New York NY 10025

CVI 2nd Floor Suite 220 OR ACC 1-1st Floor

212-523-3360

Mount Sinai West

425 West 59th Street, 7th Floor, New York, NY 10019

212-523-4797

Mount Sinai Queens

Mount Sinai Queens Pavilion

25-20 30th Avenue, 5th Floor, Astoria, NY 11102

718-808-7777

Mount Sinai Downtown

10 Union Square East, 2nd Floor, Suite 2N, New York NY 10003

212-844-5559

Mount Sinai Brooklyn

MS Outpatient Vascular Office

3131 Kings Hwy, Room LL07

718-677-0109

Mount Sinai South Nassau

1420 Broadway, 2nd Floor, Hewlett, NY 11557

516-374-8682

Wound Care: 516-764-4325

** Wound Care is offered at all locations, except MS-South Nassau sees patients at their Wound Care Center

 

Refer to Interventional Radiology

  • Diagnostic angiography and therapeutic catheter-based interventions in symptomatic PAD

 

Hospital

Location

Phone Numbers

Mount Sinai West

1000 Tenth Avenue, 2nd Floor, New York NY 10019

212-241-4046 (Press 1)

Mount Sinai East

5 East 98th Street, 12th Floor, New York, NY 10029

212-241-4046 (Press 1)

Mount Sinai Queens

25-20 30th Avenue, 5th Floor, Astoria, NY 11102

347-408-8234

See website for other locations.

Exercise Program

Supervised Office-Based

  • Offered by Cardiac Rehabilitation @ Mount Sinai Hospital Phone: 212-427-1540

  • Physical Therapy @ Mount Sinai Downtown Union Square, use Epic "PT" referral or Phone: 212-844-8750

Home-Based Exercise

Behavioral Health

  • The prevalence of depression or depressive symptoms in PAD patients is 11-48%, with high rates in female patients, African Americans, and those with advanced disease

  • Annual screening with PHQ2/9 is recommended, with treatment by PCP or behavioral health provider

Care Management Referral

  • Patients who would benefit from nursing education: medication education, diabetic foot care, disease management, or self-management

  • Indicated for patients needing care coordination, history of treatment non-adherence, complex psychosocial needs, and/or avoidable Emergency Room or Inpatient admissions

  • Use “MSHP Care Management” Referral in Epic, email mshpcmreferral@mountsinai.org or phone: 212-241-7228

Home Health Care Referral

  • Home-based care may be arranged using "Consult to Visiting Nurse Services" order in Epic for the following, but are not limited to:

    • Home-based wound care

    • Home-based visiting physical therapist

    • Home-based nursing education and visits

References

1. Gerhard-Hermann MD et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease.
J Am Coll Cardiology 2017:69:1465-1508
2. Cambia U. et al, Peripheral Arterial Disease: Past Present and Future. Am J Med 2019;132:1133-41
3. Armstrong E et al. J Am Heart Assoc 2014;3:e000697.
4. Eikelboom JW et al. N Engl J Med. 2017 Oct 5;377(14):1319-1330,
5. Anand SS et al. Lancet. 2018 Jan 20;391(10117):219-229.
6. Bonaca MP et al. N Engl J Med. 2020;382:1994-2004
7. Mount Sinai Health System Experts: Dr. Jeffrey Olin, Dr. Peter Faries, Dr. Soma Brahmanandam

 

Next Steps

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