The UK’s National Institute for Health and Clinical Excellence (NICE) has published guidelines relating to peripheral artery disease (PAD), which aim to resolve what it calls the considerable uncertainty and variations in practice that currently exist in this area and in so doing improve outcomes for patients.
According to a summary of the NICE report, PAD is a common condition affecting 3% to 7% of people in the general population and 20% of people over the age of 60, the main cause of vessel stenosis being atherosclerosis, the build up of fatty deposits on the arterial walls.
Pain on walking which stops after resting (intermittent claudication) is the most common initial symptom of peripheral arterial disease and is the result of the narrowed arteries not delivering adequate blood to leg muscles. As well as having a detrimental impact on quality of life, intermittent claudication also indicates that there is an increased risk of heart attack and stroke compared with patients with peripheral arterial disease who do not have the symptom. Even when asymptomatic, peripheral arterial disease is a marker for an increased risk of potentially preventable cardiovascular events.
NICE Guidance in summary is to offer all people with peripheral arterial disease information, advice, support and treatment regarding the secondary prevention of cardiovascular disease, in line with published NICE guidance on:
– smoking cessation
– diet, weight management and exercise
– lipid modification and statin therapy
– the prevention, diagnosis and management of diabetes
– the prevention, diagnosis and management of high blood pressure
– antiplatelet therapy.
People with suspected peripheral arterial disease should be assessed by:
– asking about the presence and severity of possible symptoms of intermittent claudication and critical limb ischaemia
– examining the legs and feet for evidence of critical limb ischaemia, for example ulceration
– examining the femoral, popliteal and foot pulses
– measuring the ankle brachial pressure index (ratio of blood pressure in the lower leg to that in the arm)
People with PAD who need further imaging (after duplex ultrasound) should be offered contrast-enhanced magnetic resonance angiography before considering revascularisation.
Intermittent claudicators should be offered a supervised exercise programme.
People with critical limb ischaemia should be assessed by a vascular multi-disciplinary team before treatment decisions are made.
Major amputation should not be “offered” to people with critical limb ischaemia unless all options for revascularisation have been considered by a vascular multi-disciplinary team.