Jacksonville Family Medicine Residency Program, Naval Hospital Jacksonville, FL ; Uniformed Services University of the Health Sciences, Bethesda, MD ; Naval Hospital Naples, Italy dustinksmith@yahoo.com
The authors reported no potential conflict of interest relevant to this article.
The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Uniformed Services University of the Health Sciences, Department of Defense, or the United States government.
Smoking cessation. As with other atherosclerotic diseases, PAD progression is strongly correlated with smoking. A trial involving 204 active smokers with PAD showed that 5-year mortality and amputation rates dropped by more than half in those who quit smoking within a year, with numbers needed to treat (NNT) of 6 for mortality and 5 for amputation.19 Because of this dramatic effect, American College of Cardiology/American Heart Association (ACC/AHA) guidelines encourage providers to address smoking at every visit and use cessation programs and medication to increase quit rates.13
Exercise may be the most important intervention for PAD. A 2017 Cochrane review found that supervised, structured exercise programs increase pain-free and maximal walking distances by at least 20% and also improve physical and mental quality of life.20 In a trial involving 111 patients with aortoiliac PAD, supervised exercise plus medical care led to greater functional improvement than either revascularization plus medical care or medical care alone.21 In a 2018 Cochrane review, neither revascularization or revascularization added to supervised exercise were better than supervised exercise alone.22 ACC/AHA guidelines recommend supervised exercise programs for claudication prior to considering revascularization.13TABLE 313 outlines the components of a structured exercise program.
Unfortunately, the benefit of these programs has been difficult to reproduce without supervision. Another 2018 Cochrane review demonstrated significant improvement with supervised exercise and no clear improvement in patients given home exercise or advice to walk.23 A recent study examined the effect of having patients use a wearable fitness tracker for home exercise and demonstrated no benefit over usual care.24
Diet. There is some evidence that dietary interventions can prevent and possibly improve PAD. A large randomized controlled trial showed that a Mediterranean diet lowered rates of PAD over 1 year compared to a low-fat diet, with an NNT of 336 if supplemented with extra-virgin olive oil and 448 if supplemented with nuts.25 A small trial of 25 patients who consumed non-soy legumes daily for 8 weeks showed average ABI improvement of 6%, although there was no control group.26
Medical therapy to address peripheral and cardiovascular events
Standard medical therapy for coronary artery disease (CAD) is recommended for patients with PAD to reduce cardiovascular and limb events. For example, treatment of hypertension reduces cardiovascular and cerebrovascular events, and studies verify that lowering blood pressure does not worsen claudication or limb perfusion.
A trial involving 204 active smokers with PAD showed that 5-year mortality and amputation rates dropped by more than half in those who quit smoking within a year.
13TABLE 413,27-30 outlines the options for medical therapy.
