Lower Extremity Peripheral Artery Disease: Contemporary Epidemiology, Management Gaps, and Future Directions: A Scientific Statement From the American Heart Association

Abstract

Lower extremity peripheral artery disease (PAD) affects >230 million adults worldwide and is associated with increased risk of various adverse clinical outcomes (other cardiovascular diseases such as coronary heart disease and stroke and leg outcomes such as amputation). Despite its prevalence and clinical importance, PAD has been historically underappreciated by health care professionals and patients. This underappreciation seems multifactorial (eg, limited availability of the first-line diagnostic test, the ankle-brachial index, in clinics; incorrect perceptions that a leg vascular disease is not fatal and that the diagnosis of PAD would not necessarily change clinical practice). In the past several years, a body of evidence has indicated that these perceptions are incorrect. Several studies have consistently demonstrated that many patients with PAD are not receiving evidence-based therapies. Thus, this scientific statement provides an update for health care professionals regarding contemporary epidemiology (eg, prevalence, temporal trends, risk factors, and complications) of PAD, the present status of diagnosis (physiological tests and imaging modalities), and the major gaps in the management of PAD (eg, medications, exercise therapy, and revascularization). The statement also lists key gaps in research, clinical practice, and implementation related to PAD. Orchestrated efforts among different parties (eg, health care providers, researchers, expert organizations, and health care organizations) will be needed to increase the awareness and understanding of PAD and improve the diagnostic approaches, management, and prognosis of PAD.

Keywords: AHA Scientific Statements; diagnosis; epidemiology; peripheral artery disease; prognosis; risk factors.

Conflict of interest statement

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

Figures

Figure 1.. Prevalence of peripheral artery disease by age in men (A and B) and women (C and D) in high-income countries (A and C) and low- and middle-income countries (B and D).

Reprinted from Fowkes et al. Copyright ©2013, with permission from Elsevier.

Figure 2.. Adjusted hazard ratio of 3 major atherosclerotic diseases according to time since quitting smoking.

A, Peripheral artery disease (PAD). B, Coronary heart disease (CHD). C, Stroke. Reprinted from Ding et al. Copyright ©2019, with permission from the American College of Cardiology Foundation.

Figure 3.. Hazard ratio (HR) of major atherosclerotic subtypes according to the presence versus absence of any retinopathy.

CHD indicates coronary heart disease; CLI, critical limb ischemia; and PAD, peripheral artery disease.

Figure 4.. Cumulative incidence of major adverse cardiovascular events in the placebo group according to CVD status at baseline.

CVD indicates cardiovascular disease; MI, myocardial infarction; and PAD, peripheral artery disease.