Lower Extremity Peripheral Artery Disease: Contemporary Epidemiology, Management Gaps, and Future Directions
A Scientific Statement From the American Heart Association
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.
Lower extremity peripheral artery disease (PAD) is atherosclerotic disease of the arteries supplying the legs.1 Despite its prevalence and impact on adverse clinical outcomes, impaired physical function, and reduced physical activity, PAD has been understudied and underrecognized compared with other atherosclerotic diseases such as myocardial infarction and stroke.2 The lack of awareness has led to underdiagnosis and undertreatment of PAD in the United States and around the world.2
There appear to be several reasons for this underrecognition of PAD. For example, the first-line method to diagnose PAD, the ankle-brachial index (ABI), is not readily available in most clinics in the United States. Also, many people think that leg diseases cannot be fatal, whereas myocardial infarction has been recognized as a leading cause of sudden cardiac death for a long time. Similarly, PAD is not widely recognized as a disabling condition, whereas stroke is established as the leading cause of disability. Difficulty walking, a hallmark of PAD-related disability, may be considered normal aging by clinicians, and the protean nature of ischemic leg symptoms can be mistaken for other diseases like arthritis or spinal degenerative disease. Also, some experts think that the specific investigation of PAD is not important, because evidence from myocardial infarction and stroke can be extrapolated to PAD.
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