New ESC Guidelines on diagnosis and treatment of peripheral artery disease

For cardiologists, coronary artery disease is the most important presentation of atherosclerosis. Patients with coronary artery disease may also have symptomatic or asymptomatic atherosclerosis in other vascular areas (peripheral artery disease).

The presence of atherosclerotic disease at one vascular site increases the likelihood of the disease at another site. In the elderly, who constitute the dominant part of patient population, the overlap of coronary artery disease, cerebrovascular disease and lower extremity artery disease is particularly high. In consequence, increasing numbers of patients with heart disease need  to be assessed for problems in other vascular sites. On the other hand, a substantial proportion of patients with peripheral artery diseases will die from coronary artery disease.

The Guidelines on peripheral artery disease (PAD) are the first document produced by the ESC to address all aspects - with the exception of the aorta - of peripheral atherosclerotic disease, including disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. They are the result of close collaboration between physicians from many different areas of expertise: cardiology, neurology, radiology, vascular surgery, and vascular medicine.

The document covers general issues such as epidemiology, risk factors, diagnostic approaches, and general rules for treatment. The detailed clinical presentations are then discussed in specific sections for each vascular site. Particular emphasis is placed on multisite artery disease, such as patients with coronary artery disease and disease in another vascular bed. The document ends with a list of significant gaps in evidence, which will hopefully stimulate new research.

The section on treatment modalities in patients with carotid artery disease covers medical therapy, surgery, and endovascular techniques. The Guidelines clearly differentiate management of symptomatic and asymptomatic patients. In patients with symptomatic disease, neurological assessment and appropriate treatment should be proposed as soon as possible after the index event.

The document also addresses clinical presentation, diagnostic modalities, prognosis and treatment in patients with upper extremity, mesenteric and renal artery disease.

The Guidelines extensively cover diagnosis (with an emphasis on the importance of the ankle-brachial index) and treatment, with endovascular or surgical techniques, in patients with lower extremity artery disease (LEAD), differentiating between those suffering from claudication and those with critical limb ischaemia. The document emphasises the importance of an adequate balance between supervised exercise and best medical therapy as compared to revascularization in patients with LEAD, taking into account the level of disability and the localisation of disease.

 A very important section of these Guidelines concerns the management of patients with multisite artery disease. Indeed, although patients with multisite artery disease are encountered regularly in clinical practice, no randomized trials have been designed to compare different treatment strategies. From a clinical perspective, this document emphasises the need for an increased awareness of the possibility of atherosclerotic disease occurring at sites other than the presenting one. The document also emphasises that, when dealing with a patient with multisite artery disease, the physician must focus attention not only on lesion sites and inherent technical difficulties related to specific treatment options, but also on the overall clinical status of the patient, taking into account the presence of all cardiovascular risk factors and comorbidities.

In conclusion, the new ESC Guidelines on the diagnosis and treatment of peripheral artery disease will help physicians manage most common aspects of PAD from a variety of complex clinical scenarios encountered in clinical practice. These Guidelines emphasise that the management of patients with PAD should always be decided after multidisciplinary discussion, also including specialists beyond the area of cardiovascular medicine, for example neurologists or nephrologists. This was also the way in which current Guidelines were created.

The Guidelines will be formally introduced at a special session of the ESC Congress 2011 in Paris on 29th August.