ACC calls for better management of peripheral artery disease in diabetic patients
Peripheral artery disease (PAD) has gained a lot of attention in recent years due to the high rates of adverse limb outcomes, including approximately 400 amputations per days in the U.S. But adverse issues related to PAD are further amplified in patients with diabetes.
While the 2024 American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines on Lower Peripheral Artery Disease offers a general overview of PAD diagnosis and management, its discussion around diabetic patients was brief. For this reason, the ACC just released an additional scientific statement to expand clinicians’ understanding of the epidemiology, pathobiology, diagnosis and management of diabetic patients with PAD.
The scientific statement offers additional recommendations on how to best manage these patients based on current clinical evidence. In total, it includes 18 clinical recommendations beyond what is states in the 2024 guidelines. It also outlines major issues in terms of health equity and awareness that need to be addressed.
"PAD in people with diabetes is common, under recognized, and drives higher rates of major adverse limb events and major adverse cardiovascular events. Women, several racial and ethnic groups and people with lower socioeconomic status face greater lifetime risk of complications, underscoring an equity imperative. Lack of awareness and underdiagnosis need to be addressed," wrote statement chair Sandeep R. Das, MD, a professor of medicine, at UT Southwestern Medical Center, and the writing committee.
The authors said there is a consensus that risk-based screening for PAD in diabetic patients is a standard of care and that systematic pulse and foot examinations with appropriate physiologic testing should be done. They also recommend patients seriously consider smoking cessation, increased physical activity and nutrition counseling to improve outcomes.
Diabetic patients or caregivers should perform daily foot inspections, and they should have at least one annual comprehensive foot evaluation by a qualified clinician to better detect PAD at earlier stages when it is easier to treat.
Recommendations for preventive therapy should include high-intensity statins, reinforced by ezetimibe, PCSK9 inhibitors or bempedoic acid as needed to reduce cardiovascular and limb risk. Low-dose rivaroxaban plus aspirin is recommended in high-risk patients without indications for full anticoagulation or dual antiplatelet therapy. The authors noted that evidence for dual antiplatelet therapy to improve PAD outcomes is lacking. SGLT2 inhibitors and GLP-1RA are also appropriate for most diabetics at elevated cardiovascular and PAD risk. Semaglutide also has data showing it can improve function and quality-of-life gains in PAD patients.
Diabetes increases the complexity of coronary and peripheral artery disease, so the statement also recommends use of multidisciplinary care teams when clinically indicated. These PAD care teams should include cardiology, endocrinology, podiatry, primary care, vascular medicine and vascular surgery in case review and shared decision making. Before amputation, the writing committee said every person with diabetes and chronic limb-threatening ischemia (CLTI) should be evaluated by a limb salvage team.
It is recommended that revascularization should be performed on an urgent basis in patients with diabetes and PAD who have evidence of foot infection and tissue loss.
Optimal periprocedural blood glucose management and effective infection treatment is also essential to maximizing outcomes based on current evidence.
The authors of the statement said certain knowledge gaps remain. Also, much more research into the cost effectiveness of screenings and different treatment options is needed to better align incentives.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]