2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines
2016; Lippincott Williams & Wilkins; Volume: 135; Issue: 12 Linguagem: Inglês
10.1161/cir.0000000000000471
ISSN1524-4539
AutoresMarie Gerhard‐Herman, Heather L. Gornik, Coletta Barrett, Neal R. Barshes, Matthew A. Corriere, Douglas E. Drachman, Lee A. Fleisher, F. Gerry R. Fowkes, Naomi M. Hamburg, Scott Kinlay, R. Lookstein, Sanjay Misra, Leila Mureebe, Jeffrey W. Olin, Rajan A.G. Patel, Judith G. Regensteiner, Andres Schanzer, Mehdi H. Shishehbor, Kerry J. Stewart, Diane Treat‐Jacobson, M. Eileen Walsh,
Tópico(s)Cardiac, Anesthesia and Surgical Outcomes
ResumoHomeCirculationVol. 135, No. 122016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessReview ArticlePDF/EPUB2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Marie D. Gerhard-Herman, MD, FACC, FAHA, Chair, Heather L. Gornik, MD, FACC, FAHA, FSVM, Vice Chair, Coletta Barrett, RN, Neal R. Barshes, MD, MPH, Matthew A. Corriere, MD, MS, FAHA, Douglas E. Drachman, MD, FACC, FSCAI, Lee A. Fleisher, MD, FACC, FAHA, Francis Gerry R. Fowkes, MD, FAHA, Naomi M. Hamburg, MD, FACC, FAHA, Scott Kinlay, MBBS, PhD, FACC, FAHA, FSVM, FSCAI, Robert Lookstein, MD, FAHA, FSIR, Sanjay Misra, MD, FAHA, FSIR, Leila Mureebe, MD, MPH, RPVI, Jeffrey W. Olin, DO, FACC, FAHA, Rajan A.G. Patel, MD, FACC, FAHA, FSCAI, Judith G. Regensteiner, PhD, FAHA, Andres Schanzer, MD, Mehdi H. Shishehbor, DO, MPH, PhD, FACC, FAHA, FSCAI, Kerry J. Stewart, EdD, FAHA, MAACVPR, Diane Treat-Jacobson, PhD, RN, FAHA and M. Eileen Walsh, PhD, APN, RN-BC, FAHA Marie D. Gerhard-HermanMarie D. Gerhard-Herman , Heather L. GornikHeather L. Gornik *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Coletta BarrettColetta Barrett *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Neal R. BarshesNeal R. Barshes *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Matthew A. CorriereMatthew A. Corriere *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Douglas E. DrachmanDouglas E. Drachman *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Lee A. FleisherLee A. Fleisher *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Francis Gerry R. FowkesFrancis Gerry R. Fowkes *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Naomi M. HamburgNaomi M. Hamburg *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Scott KinlayScott Kinlay *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Robert LooksteinRobert Lookstein *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Sanjay MisraSanjay Misra *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Leila MureebeLeila Mureebe *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Jeffrey W. OlinJeffrey W. Olin *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Rajan A.G. PatelRajan A.G. Patel *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Judith G. RegensteinerJudith G. Regensteiner *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Andres SchanzerAndres Schanzer *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Mehdi H. ShishehborMehdi H. Shishehbor *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Kerry J. StewartKerry J. Stewart *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ , Diane Treat-JacobsonDiane Treat-Jacobson *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ and M. Eileen WalshM. Eileen Walsh *, †, ‡, §, ‖, ¶, #, **, ††, ‡‡, §§, ‖‖, ¶¶ Originally published13 Nov 2016https://doi.org/10.1161/CIR.0000000000000471Circulation. 2017;135:e726–e779is corrected byCorrection to: 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice GuidelinesOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2016: Previous Version 1 Table of ContentsPreamblee 727Introduction e7281.1. Methodology and Evidence Review e7281.2. Organization of the Writing Committee e7301.3. Document Review and Approval e7301.4. Scope of Guideline e731Clinical Assessment for PAD e7332.1. History and Physical Examination: Recommendations e733Diagnostic Testing for the Patient With Suspected Lower Extremity PAD (Claudication or CLI) e7353.1. Resting ABI for Diagnosing PAD: Recommendations e7353.2. Physiological Testing: Recommendations e7353.3. Imaging for Anatomic Assessment: Recommendations e739Screening for Atherosclerotic Disease in Other Vascular Beds for the Patient With PAD e7404.1. Abdominal Aortic Aneurysm: Recommendation e7404.2. Screening for Asymptomatic Atherosclerosis in Other Arterial Beds (Coronary, Carotid, and Renal Arteries) e740Medical Therapy for the Patient With PAD e7405.1. Antiplatelet Agents: Recommendations e7415.2. Statin Agents: Recommendation e7425.3. Antihypertensive Agents: Recommendations e7425.4. Smoking Cessation: Recommendations e7435.5. Glycemic Control: Recommendations e7435.6. Oral Anticoagulation: Recommendations e7445.7. Cilostazol: Recommendation e7445.8. Pentoxifylline: Recommendation e7455.9. Chelation Therapy: Recommendation e7455.10. Homocysteine Lowering: Recommendation e7455.11. Influenza Vaccination: Recommendation e745Structured Exercise Therapy: Recommendations e745Minimizing Tissue Loss in Patients With PAD: Recommendations e747Revascularization for Claudication e7488.1. Revascularization for Claudication: Recommendation e7488.1.1. Endovascular Revascularization for Claudication: Recommendations e7498.1.2. Surgical Revascularization for Claudication: Recommendations e750Management of CLI e7509.1. Revascularization for CLI: Recommendations e7519.1.1. Endovascular Revascularization for CLI: Recommendations e7519.1.2. Surgical Revascularization for CLI: Recommendations e7529.2. Wound Healing Therapies for CLI: Recommendations e753Management of ALI e75410.1. Clinical Presentation of ALI: Recommendations e75410.2. Medical Therapy for ALI: Recommendations e75510.3. Revascularization for ALI: Recommendations e75510.4. Diagnostic Evaluation of the Cause of ALI: Recommendations e756Longitudinal Follow-Up: Recommendations e757Evidence Gaps and Future Research Directions e758Advocacy Priorities e758Referencese 759Appendix 1. Author Relationships With Industry and Other Entities (Relevant) e771Appendix 2. Reviewer Relationships With Industry and Other Entities (Comprehensive) e774Appendix 3. Abbreviationse 779PreambleSince 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care.In response to reports from the Institute of Medicine1,2 and a mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) modified its methodology.3–5 The relationships among guidelines, data standards, appropriate use criteria, and performance measures are addressed elsewhere.5Intended UsePractice guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease. The focus is on medical practice in the United States, but guidelines developed in collaboration with other organizations may have a broader target. Although guidelines may be used to inform regulatory or payer decisions, the intent is to improve quality of care and align with patients' interests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances, and should not replace clinical judgment. Guidelines are reviewed annually by the Task Force and are official policy of the ACC and AHA. Each guideline is considered current until it is updated, revised, or superseded by published addenda, statements of clarification, focused updates, or revised full-text guidelines. To ensure that guidelines remain current, new data are reviewed biannually to determine whether recommendations should be modified. In general, full revisions are posted in 5-year cycles.3–6ModernizationProcesses have evolved to support the evolution of guidelines as "living documents" that can be dynamically updated. This process delineates a recommendation to address a specific clinical question, followed by concise text (ideally 1 drug, strategy, or therapy exists within the same COR and LOE and no comparative data are available, options are listed alphabetically.Table 1. ACC/AHA Recommendation System: Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015)Table 1. ACC/AHA Recommendation System: Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015)Relationships With Industry and Other EntitiesThe ACC and AHA sponsor the guidelines without commercial support, and members volunteer their time. The Task Force zealously avoids actual, potential, or perceived conflicts of interest that might arise through relationships with industry or other entities (RWI). All writing committee members and reviewers are required to disclose current industry relationships or personal interests, from 12 months before initiation of the writing effort. Management of RWI involves selecting a balanced writing committee and assuring that the chair and a majority of committee members have no relevant RWI (Appendix 1). Members are restricted with regard to writing or voting on sections to which their RWI apply. For transparency, members' comprehensive disclosure information is available online. Comprehensive disclosure information for the Task Force is also available online.The Task Force strives to avoid bias by selecting experts from a broad array of backgrounds representing different geographic regions, sexes, ethnicities, intellectual perspectives/biases, and scopes of clinical practice, and by inviting organizations and professional societies with related interests and expertise to participate as partners or collaborators.Individualizing Care in Patients With Associated Conditions and ComorbiditiesManaging patients with multiple conditions can be complex, especially when recommendations applicable to coexisting illnesses are discordant or interacting.8 The guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances. The recommendations should not replace clinical judgment.Clinical ImplementationManagement in accordance with guideline recommendations is effective only when followed. Adherence to recommendations can be enhanced by shared decision making between clinicians and patients, with patient engagement in selecting interventions on the basis of individual values, preferences, and associated conditions and comorbidities. Consequently, circumstances may arise in which deviations from these guidelines are appropriate.Jonathan L. Halperin, MD, FACC, FAHAChair, ACC/AHA Task Force on Clinical Practice Guidelines1. Introduction1.1. Methodology and Evidence ReviewThe recommendations listed in this guideline are, whenever possible, evidence based. An initial extensive evidence review, which included literature derived from research involving human subjects, published in English, and indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline, was conducted from January through September 2015. Key search words included but were not limited to the following: acute limb ischemia, angioplasty, ankle-brachial index, anticoagulation, antiplatelet therapy, atypical leg symptoms, blood pressure lowering/hypertension, bypass graft/bypass grafting/surgical bypass, cilostazol, claudication/intermittent claudication, critical limb ischemia/severe limb ischemia, diabetes, diagnostic testing, endovascular therapy, exercise rehabilitation/exercise therapy/exercise training/supervised exercise, lower extremity/foot wound/ulcer, peripheral artery disease/peripheral arterial disease/peripheral vascular disease/lower extremity arterial disease, smoking/smoking cessation, statin, stenting, and vascular surgery. Additional relevant studies published through September 2016, during the guideline writing process, were also considered by the writing committee, and added to the evidence tables when appropriate. The final evidence tables included in the Online Data Supplement summarize the evidence utilized by the writing committee to formulate recommendations. Additionally, the writing committee reviewed documents related to lower extremity peripheral artery disease (PAD) previously published by the ACC and AHA.9,10 References selected and published in this document are representative and not all-inclusive.As stated in the Preamble, the ACC/AHA guideline methodology provides for commissioning an independent ERC to address systematic review questions (PICOTS format) to inform recommendations developed by the writing committee. All other guideline recommendations (not based on the systematic review questions) were also subjected to an extensive evidence review process. For this guideline, the writing committee in conjunction with the Task Force and ERC Chair identified the following systematic review questions: 1) Is antiplatelet therapy beneficial for prevention of cardiovascular events in the patient with symptomatic or asymptomatic lower extremity PAD? 2) What is the effect of revascularization, compared with optimal medical therapy and exercise training, on functional outcome and quality of life (QoL) among patients with claudication? Each question has been the subject of recently published, systematic evidence reviews.11–13 The quality of these evidence reviews was appraised by the ACC/AHA methodologist and a vendor contracted to support this process (Doctor Evidence [Santa Monica, CA]). Few substantive randomized or nonrandomized studies had been published after the end date of the literature searches used for the existing evidence reviews, so the ERC concluded that no additional systematic review was necessary to address either of these critical questions.A third systematic review question was then identified: 3) Is one revascularization strategy (endovascular or surgical) associated with improved cardiovascular and limb-related outcomes in patients with critical limb ischemia (CLI)? This question had also been the subject of a high-quality systematic review that synthesized evidence from observational data and an RCT14; additional RCTs addressing this question are ongoing.15–17 The writing committee and the Task Force decided to expand the survey to include more relevant randomized and observational studies. Based on evaluation of this additional evidence the ERC decided that further systematic review was not needed to inform the writing committee on this question. Hence, the ERC and writing committee concluded that available systematic reviews could be used to inform the development of recommendations addressing each of the 3 systematic review questions specified above. The members of the Task Force and writing committee thank the members of the ERC that began this process and their willingness to participate in this volunteer effort. They include Aruna Pradhan, MD, MPH (ERC Chair); Natalie Evans, MD; Peter Henke, MD; Dharam J. Kumbhani, MD, SM, FACC; and Tamar Polonsky, MD.1.2. Organization of the Writing CommitteeThe writing committee consisted of clinicians, including noninvasive and interventional cardiologists, exercise physiologists, internists, interventional radiologists, vascular nurses, vascular medicine specialists, and vascular surgeons, as well as clinical researchers in the field of vascular disease, a nurse (in the role of patient representative), and members with experience in epidemiology and/or health services research. The writing committee included representatives from the ACC and AHA, American Association of Cardiovascular and Pulmonary Rehabilitation, Inter-Society Consensus for the Management of Peripheral Arterial Disease, Society for Cardiovascular Angiography and Interventions, Society for Clinical Vascular Surgery, Society of Interventional Radiology, Society for Vascular Medicine, Society for Vascular Nursing, Society for Vascular Surgery, and Vascular and Endovascular Surgery Society.1.3. Document Review and ApprovalThis document was reviewed by 2 official reviewers nominated by the ACC and AHA; 1 to 2 reviewers each from the American Association of Cardiovascular and Pulmonary Rehabilitation, Inter-Society Consensus for the Management of Peripheral Arterial Disease, Society for Cardiovascular Angiography and Interventions, Society for Clinical Vascular Surgery, Society of Interventional Radiology, Society for Vascular Medicine, Society for Vascular Nursing, Society for Vascular Surgery, and Vascular and Endovascular Surgery Society; and 16 additional individual content reviewers. Reviewers' RWI information was distributed to the writing committee and is published in this document (Appendix 2).This document was approved for publication by the governing bodies of the ACC and the AHA and endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, Inter-Society Consensus for the Management of Peripheral Arterial Disease, Society for Cardiovascular Angiography and Interventions, Society for Clinical Vascular Surgery, Society of Interventional Radiology, Society for Vascular Medicine, Society for Vascular Nursing, Society for Vascular Surgery, and Vascular and Endovascular Surgery Society.1.4. Scope of GuidelineLower extremity PAD is a common cardiovascular disease that is estimated to affect approximately 8.5 million Americans above the age of 40 years and is associated with significant morbidity, mortality, and QoL impairment.18 It has been estimated that 202 million people worldwide have PAD.19 The purpose of this document is to provide a contemporary guideline for diagnosis and management of patients with lower extremity PAD. This document supersedes recommendations related to lower extremity PAD in the "ACC/AHA 2005 Guidelines for the Management of Patients With Peripheral Arterial Disease"9 and the "2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease."10 The scope of this guideline is limited to atherosclerotic disease of the lower extremity arteries (PAD) and includes disease of the aortoiliac, femoropopliteal, and infrapopliteal arterial segments. It does not address nonatherosclerotic causes of lower extremity arterial disease, such as vasculitis, fibromuscular dysplasia, physiological entrapment syndromes, cystic adventitial disease, and other entities. Future guidelines will address aneurysmal disease of the abdominal aorta and lower extremity arteries and diseases of the renal and mesenteric arteries.In developing the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease," the writing committee reviewed the evidence to support recommendations in the relevant ACC/AHA guidelines noted in Table 2 and affirms the ongoing validity of the related recommendations, thus obviating the need to repeat existing guideline recommendations in the current guideline. Table 2 also contains a list of other statements that may be of interest to the reader. Table 3 includes definitions for PAD key terms used throughout the guideline.Table 2. Important Guideline PolicyTitleOrganizationPublication Year (Reference)ACC/AHA Guideline policy relevant to the management of lower extremity PAD Duration of dual antiplatelet therapy in patients with coronary artery diseaseACC/AHA201620 Perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgeryACC/AHA201421 Lifestyle management to reduce cardiovascular riskAHA/ACC201322 Assessment of cardiovascular riskACC/AHA201323 Blood cholesterol to reduce atherosclerotic cardiovascular risk in adultsACC/AHA201324 PAD (lower extremity, renal, mesenteric, and abdominal aortic)ACC/AHA20059 and 201110 Secondary prevention and risk-reduction therapy for patients with coronary and other atherosclerotic vascular diseaseAHA/ACC201125Other related publications Atherosclerotic occlusive disease of the lower extremities guidelineSVS201526 Measurement and interpretation of the ankle-brachial indexAHA201227 Cardiac disease evaluation and management among kidney and liver transplantation candidatesAHA/ACC201228 Intensive glycemic control and the prevention of cardiovascular eventsADA/ACC/AHA200929 Influenza vaccination as secondary prevention for cardiovascular diseaseAHA/ACC200630 Indications for renal arteriography at the time of coronary arteriographyAHA/CLCD/CVRI/KCVD200631 Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)*NHLBI200332*A revision to the current document is being prepared, with publication expected in 2017. The new title is expected to be "ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Detection, Evaluation, Prevention and Management of High Blood Pressure."AAPA indicates American Academy of Physician Assistants; ABC, Association of Black Cardiologists; ACC, American College of Cardiology; ACPM, American College of Preventive Medicine; ADA, American Diabetes Association; AGS, American Geriatrics Society; AHA, American Heart Association; APhA, American Pharmacists Association; ASH, American Society of Hypertension; ASPC, American Society for Preventive Cardiology; CLCD, Council on Clinical Cardiology; CVRI, Council on Cardiovascular Radiology and Intervention; KCVD, Council on the Kidney in Cardiovascular Disease; NHLBI, National Heart, Lung, and Blood Institute; NMA, National Medical Association; PAD, peripheral artery disease; PCNA, Preventive Cardiovascular Nurses Association; and SVS, Society for Vascular Surgery.Table 3. Definition of PAD Key TermsTermDefinitionClaudicationFatigue, discomfort, cramping, or pain of vascular origin in the muscles of the lower extremities that is consistently induced by exercise and consistently relieved by rest (within 10 min).Acute limb ischemia (ALI)Acute (<2 wk), severe hypoperfusion of the limb characterized by these features: pain, pallor, pulselessness, poikilothermia (cold), paresthesias, and paralysis. One of these categories of ALI is assigned (Section 10):Viable—Limb is not immediately threatened; no sensory loss; no muscle weakness; audible arterial and venous Doppler.Threatened—Mild-to-moderate sensory or motor loss; inaudible arterial Doppler; audible venous Doppler; may be further divided into IIa (marginally threatened) or IIb (immediately threatened).Irreversible—Major tissue loss or permanent nerve damage inevitable; profound sensory loss, anesthetic; profound muscle weakness or paralysis (rigor); inaudible arterial and venous Doppler.33,34Tissue lossType of tissue loss:Minor—nonhealing ulcer, focal gangrene with diffuse pedal ischemia.Major—extending above transmetatarsal level; functional foot no longer salvageable.33Critical limb ischemia (CLI)A condition characterized by chronic (≥2 wk) ischemic rest pain, nonhealing wound/ulcers, or gangrene in 1 or both legs attributable to objectively proven arterial occlusive disease. The diagnosis of CLI is a constellation of both symptoms and signs. Arterial disease can be proved objectively with ABI, TBI, TcPO2, or skin perfusion pressure. Supplementary parameters, such as absolute ankle and toe pressures and pulse volume recordings, may also be used to assess for significant arterial occlusive disease. However, a very low ABI or TBI does not necessarily mean the patient has CLI. The term CLI implies chronicity and is to be distinguished from ALI.35In-line blood flowDirect arterial flow to the foot, excluding collaterals.Functional statusPatient's ability to perform normal daily activities required to meet basic needs, fulfill usual roles, and maintain health and well-being. Walking ability is a component of functional status.Nonviable limbCondition of extremity (or portion of extremity) in which loss of motor function, neurological function, and tissue integrity cannot be restored with treatment.Salvageable limbCondition of extremity with potential to secure viability and preserve motor function to the weight-bearing portion of the foot if treated.Structured exercise programPlanned program that provides individualized recommendations for type, frequency, intensity, and duration of exercise. Program provides recommendations for exercise progression to assure that the body is consistently challenged to increase exercise intensity and levels as functional status improves over time. There are 2 types of structured exercise program for patients with PAD:Supervised exercise programStructured community- or home-based exercise programSupervised exercise programStructured exercise program that takes place in a hospital or outpatient facility in which intermittent walking exercise is used as the treatment modality. Program can be standalone or can be made available within a cardiac rehabilitation program. Program is directly supervised by qualified healthcare provider(s). Training is performed for a minimum of 30 to 45 min per session, in sessions performed at least 3 times/wk for a minimum of 12 wk.36–46 Patients may not initially achieve these targets, and a treatment goal is to progress to these levels over time. Training involves intermittent bouts of walking to moderate-to-maximum claudication, alternating with periods of rest. Warm-up and cool-down periods precede and follow each session of walking.Structured community- or home-based exercise programStructured exercise program that takes place in the personal setting of the patient rather than in a clinical setting.41,47–51 Program is self-directed with the guidance of healthcare providers who prescribe an exercise regimen similar to that of a supervised program. Patient counseling ensures that patients understand how to begin the program, how to maintain the program, and how to progress the difficulty of the walking (by increasing distance or speed). Program may incorporate behavioral change techniques, such as health coaching and/or use of activity monitors.Emergency versus urgent An emergency procedure is one in which life or limb is threatened if the patient is not in the operating room or interventional suite and/or where there is time for no or very limited clinical evaluation, typically within <6 h. An urgent procedure is one in which there may be time for a limited clinical evaluation, usually when life or limb is threatened if the patient is not in the operating room or interventional suite, typically between 6 and 24 h.Interdisciplinary care teamA team of professionals representing different disciplines to assist in the evaluation and management of the patient with PAD. For the care of patients with CLI, the interdisciplinary care team should include individuals who are skilled in endovascular revascularization, surgical revascularization, wound healing therapies and foot surgery, and medical evaluation and care. Interdisciplinary care team members may include:Vascular medical and surgical specialists (ie, vascular medicine, vascular surgery, interventional radiology, interventional cardiology)NursesOrthopedic surge
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