Medical management of peripheral arterial disease: a therapeutic algorithm

Over half of the people with peripheral arterial disease (PAD) may be asymptomatic. The most common symptom of mild-to-moderate PAD is intermittent claudication, present in about one third of symptomatic patients. Patients with intermittent claudication often have severely impaired functional status. Despite the high prevalence of the disease and the strong association with cardiovascular morbidity and mortality, patients with PAD are less likely to receive appropriate treatment for their atherosclerotic risk factors than are those being treated for coronary artery disease. The goals of treatment are to prevent progression of systemic atherosclerosis and its associated morbidity and mortality, to prevent limb loss, and to improve functional capacity for symptomatic patients. For claudicating patients, medical management includes symptomatic treatment with cilostazol or pentoxifylline. For all patients, it is equally important to pursue risk reduction through exercise programs and promotion of smoking cessation, as well as with the use of statins, antiplatelet therapies, antithrombotic strategies, angiotensin-converting-enzyme inhibitors, beta-blockers, and attention to homocysteine levels. Because not all patients are symptomatic, medical management of peripheral arterial disease may proceed along an algorithmic pathway that recognizes 3 types of patients: those requiring risk reduction only, symptomatic patients with minimal lifestyle limitation, and symptomatic patients with significant lifestyle impairment.