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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 June 11, 2024 e1349

and QOL (Figure 4). Mechanisms of improvement in walking performance resulting from exercise training in those with chronic symptomatic PAD are multifactorial and not fully understood.1,2 Predominant mechanisms include improvements in skeletal muscle strength and endurance (eg, mitochondrial density and activity, muscle fiber adaptations), capabilities that are known to occur in most healthy and chronic diseased individuals. There is also evidence of improvements in endothelial function, potential angiogenesis, improved blood distribution efficiency leading to potential calf blood flow increases, and a reduced local inflammatory response. Evidence does not show an increase in either microvascular or macrovascular blood flow after exercise training despite significant functional improvement.3,4 Although some evidence suggests local inflammatory adverse effects related to ischemia reperfusion injury, the evidence is strong that intermittent walking to mild or moderate pain is required to maximize the aforementioned adaptations to maximally improve walking performance.5 Although the evidence base is strongest for supervised exercise therapy (SET), other forms of structured community-based exercise programs, including homebased exercise, have been developed, and recent studies support their use in this patient population.5–15 The types of structured exercise programs for PAD are defined in Table 14. Recommendations for Exercise Therapy for PAD Referenced studies that support the recommendations are summarized in the Online Data Supplement.

COR LOE Recommendations

1 A 1 In patients with chronic symptomatic PAD, SET is

recommended to improve walking performance, functional status, and QOL.7,16–28

1 A 2.	 In patients with chronic symptomatic PAD,

a structured community-based exercise program with behavioral change techniques is effective to improve walking performance, functional status, and QOL.5–15

1 A 3 In patients who have undergone revascularization

for chronic symptomatic PAD, SET after revascularization is effective to improve walking performance, functional status, and QOL.29–39

1 B-R 4.	 In patients with functionally limiting claudication,

SET or a structured community-based exercise program should be offered as an initial treatment option.17,18,25,40

2a A 5 In patients with chronic symptomatic PAD, alterna-

tive programs of nonwalking structured exercise therapy (eg, arm ergometry, recumbent stepping) can be beneficial to improve walking performance, functional status, and QOL.19,20,41–47

2b B-R 6 In patients with chronic symptomatic PAD, the use-

fulness of structured walking exercise therapy that avoids moderate to severe ischemic symptoms is uncertain.5,45,46

2b B-R 7 In patients with chronic symptomatic PAD, the

usefulness of unstructured exercise to improve walking performance, functional status, and QOL is uncertain.10,12,28

Table 14.  Structured Exercise Programs for PAD Supervised Exercise Therapy5,7,16–28,42,52,53 Primarily focuses on intermittent walking exercise on a treadmill, interspersed with rest periods when pain becomes moderate or severe. Program takes place in a hospital or outpatient facility and is often placed within a cardiac rehabilitation program setting; can be standalone if necessary. Program is directly supervised by qualified health care professional(s); generally clinical exercise physiologists or nurses with exercise training experience. Training is performed for a minimum of 30-45 min per 60-min session. Supervised sessions are performed at least 3 times/wk for a minimum of 12 wk. Training involves intermittent bouts of walking to moderate-to-maximum claudication pain or discomfort, alternating with periods of rest, with incremental increases as function and symptoms improve. Goal is to progress to 30-45 min of active walking exercise during each session. Nontreadmill modalities (eg, stationary bicycle) can used when appropriate and continually assessed to determine when or if the patient can use a treadmill. Supervised exercise therapy is a covered benefit by Medicare and most commercial insurances. Structured Community-Based Exercise Program5,6,8,9,12,15,19,57,63–66 Program takes place in the personal setting (eg, home, community, neighborhood) of the patient rather than in a clinical setting. Qualified health care professional(s) prescribe an exercise regimen similar to that of a supervised program. Program is self-directed with the guidance of qualified health care professional(s) and is generally walking-based. Patient counseling ensures understanding of how to begin and maintain the program and how to progress the difficulty of the walking (by increasing distance or speed). Program may incorporate behavioral change techniques, delivered by in-person or virtual health coaching or the use of activity monitors. Program may include periodic supervised exercise sessions to assess progress, reinforce adherence, and make exercise prescription alterations when appropriate. Modified with permission from Gerhard-Herman et al.67 Copyright 2017 American Heart Association, Inc., and American College of Cardiology Foundation. Structured exercise programs are planned by qualified health care professional(s) and provide recommendations for exercise training with a goal of improving functional status over time. Structured exercise programs for PAD are classified as supervised exercise therapy or a structured community-based exercise program. Structured community-based exercise programs include home-based programs.

PAD indicates peripheral artery disease.

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