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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 June 11, 2024 e1335

and functional decline, in older patients may obscure symptoms associated with PAD until it reaches an advanced state. The physical examination identifies signs of previously unrecognized PAD, with opportunities to provide appropriate clinical evaluation (see Section 2, “Clinical Assessment for PAD”) and care. Older patients with PAD have a much higher prevalence of multimorbidity and polypharmacy.18,19 The concomitant presence of other comorbidities or age-related degenerative processes may accentuate the impact of PAD in the older population and requires nuanced attention and care. Specifically, the presence of geriatric syndromes, including frailty and sarcopenia, confers a greater risk for MACE, MALE, and death (Table 10). Older patients with PAD who have ≥1 of these geriatric syndromes have worse outcomes with revascularization or amputation; decisions for invasive treatment merit specific consideration in this cohort.

Recommendation-Specific Supportive Text 1.	 Geriatric syndromes, including frailty, sarcopenia,

malnutrition, and mobility impairment, frequently complicate the care of patients with PAD. Clinical tools have been evaluated to assess for frailty in the context of PAD, such as the Clinical Frailty Scale, the modified Frailty Index, the Risk Analysis Index, and others.11,12 The impact of these conditions on the treatment of patients with PAD is listed in Table 10. In retrospective cohorts of patients with PAD, morbidity, functional status, prescription of GDMT, and overall mortality were significantly worse after

Table 10.  Geriatric Syndromes and Considerations in the Management of PAD in Older Patients Consideration Description and Characterization Frailty Can be assessed among patients with PAD using measures such as the Clinical Frailty Scale, the modified Frailty Index, the Risk Analysis Index, and others.11,12

Elevated rates of MACE associated with frailty and claudication.12 2-y survival rate was reduced depending on degree of frailty in patients undergoing revascularization for CLTI.11 Frailty is highly predictive of 30-d mortality rate for all PAD revascularization procedures.10

Sarcopenia Age-related loss of muscle mass.7,9,22,23

Sarcopenia was 10 times more prevalent in those with PAD than age-matched controls without PAD.22 Sarcopenia is associated with lower survival rate8,9 and higher risk of MACE9 and MALE.7 Patients with sarcopenia are at increased risk for muscle mass loss in the lower extremities.23

Malnutrition Common in older patients with PAD, affecting up to 50% of individuals.13

5-y survival rate in those with PAD is directly related to GNRI stratification of nutritional risk.6 In patients with CLTI, 30-d mortality was 5 times higher in those with severe malnutrition compared with those with moderate or no malnutrition.5 5-y amputation-free survival rate in patients undergoing surgical revascularization for CLTI was worsened relative to poorer nutritional status.4

Mobility impairment The presence of PAD was associated with poor physical function compared with those without PAD.3

Ambulatory patients >75 y of age with PAD were 13.51-fold more likely to experience functionally limiting pain than those without PAD.2 Patients >65 y of age with PAD had a more rapid decline in life-space mobility and a higher mortality rate than those without PAD.1

Revascularization considerations Age >80 y was associated with an increased mortality rate after endovascular or surgical revascularization for infrainguinal PAD.14,15

Among patients ≥70 y of age with CLTI, those with dependent functional status had a higher mortality rate than those with independent functional status after infrainguinal bypass surgery.20 Older patients were less likely to be prescribed GDMT (including antiplatelet therapy, statin, and ACE inhibitor/ARB) than those 10 y younger after endovascular revascularization.21 In patients >70 y of age with CLTI and <2-y predicted survival, a comparison of treatment with medical therapy, endovascular, or surgical revascularization showed no difference in QOL or health status outcomes.24

Impact of amputation Morbidity and mortality rates associated with amputation in older patients are exceptionally high, and mortality rates increased by approximately 4% for every year of age.25

In older patients with CLTI at high risk for surgery, infrainguinal bypass conferred lower risk of a 30-d mortality rate than amputation.26 In patients >70 y of age treated for CLTI, 46 of 200 patients underwent amputation within 1 y (23%),27 with significant improvement in QOL at 6 and 12 mo but no difference in objective measures of health status.

Polypharmacy Typically described as prescribing ≥5 medications.

Increasingly common in older patients (24% of older patients in 2000 and 39% of older adults in 2012).18,19 Tailoring of medical therapies and shared decision-making are strategies to minimize impact of polypharmacy in older patients with PAD.

ACE indicates angiotensin-enzyme converting; ARB, angiotensin-receptor blocker; CLTI, chronic limb-threatening ischemia; GDMT, guideline-directed management and therapy; GNRI, Geriatric Nutritional Risk Index; MACE, major adverse cardiovascular events; MALE, major adverse limb events; PAD, peripheral artery disease; and QOL, quality of life.

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