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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 June 11, 2024 e1351 PAD and found that high-intensity community-based walking showed greater improvement in the 6MWT than low-intensity exercise or control groups. The MOSAIC (Motivating Structured Walking Activity in People With Intermittent Claudication) trial compared a 3-month structured home-based walking program that involved minimal counseling (2 in-person sessions in week 1 and 2 20-minute telephone interventions at weeks 6 and 12) versus usual care with no exercise counseling.15 The exercise group showed significantly greater improvement in 6MWT distance than the usual care group.15 This evidence supports structured community-based exercise programs, including home-based programs, to improve functional status for patients with chronic symptomatic PAD. 3. A 3-month RCT that compared percutaneous transluminal angioplasty (PTA), SET, and combined treatment for patients with claudication caused by femoropopliteal disease found that both SET and PTA improved clinical and QOL outcomes, whereas PTA in combination with SET produced greater benefits than either therapy alone.39 The ERASE (Endovascular Revascularization and Supervised Exercise) study randomized participants with claudication to endovascular revascularization plus SET or SET alone.32 After 1 year, patients in both groups had significant improvements in walking distances and health-related QOL, with greater improvements in the combinedtherapy group.32 This finding of greater improvement in the combined-therapy group compared with SET or PTA alone has been reported in several other highquality randomized trials and systematic reviews and meta-analyses.29–36,38 Collectively, these studies support the continued provision of SET to patients with claudication, whether as a monotherapy or combined with revascularization. However, the combination of revascularization and SET provides the greatest improvements in functional status. The combination of revascularization with structured community-based exercise programs, including home-based programs, for patients with chronic symptomatic PAD is an area in need of further study. 4. The CLEVER (Claudication: Exercise Versus Endoluminal Revascularization) trial randomized patients with symptomatic aortoiliac PAD and showed comparable benefits for SET and endovascular revascularization at 6 and 18 months, with each therapy being superior to optimal medical care.17,18 A Cochrane review of 10 RCTs with 1087 participants assessed the outcomes of endovascular revascularization and SET on functional outcome and reported that the former did not provide significant benefit compared with SET alone for functional improvement or QOL.40 An RCT that compared the 7-year effectiveness of SET or endovascular revascularization in patients with stable claudication with iliac or femoropopliteal disease found no differences in improved walking and QOL outcomes.25 Although more secondary interventions occurred in the exercise group, the total number of interventions was greater in the endovascular revascularization group. Collectively, these studies provide strong support for initially offering SET to patients with limiting claudication and no evidence of CLTI, both for reducing claudication symptoms and for improving functional status and QOL. When SET is unavailable, a structured community-based exercise program should be offered (see Recommendation 2). 5. Exercise therapy protocols for PAD have traditionally recommended bouts of intermittent walking to moderate or higher pain levels interspersed with short periods of rest. Some patients may be reluctant to engage in exercise that causes moderate to severe ischemic symptoms. More recently, an increasing number of studies have shown that programs that incorporate alternative regimens of exercise can achieve health benefits comparable to walking at moderate or higher levels of claudication pain.19,41,42,44,59 These alternative regimens avoid claudication and include nonwalking modalities of exercise, such as arm or leg cycling and recumbent stepping.19,41,42,44,59,60 Two 2015 metaanalyses provide evidence that alternative forms of exercise improve walking performance and QOL in patients with PAD.19,20 Resistance training, particularly if done at high intensity, has also been shown to improve outcomes in patients with PAD in some, but not all, studies.41,61 6 Studies examining the effects of low-intensity treadmill walking to onset of pain have demonstrated improvements in treadmill performance similar to that of exercise programs that induce moderate to severe symptoms.45,46,62 However, 1 clinical trial has recently shown that a year-long program of low-intensity community-based walking exercise did not improve 6MWT distances compared with a control group.5 It should be noted that the studies that performed treadmill-based exercise therapy evaluated outcomes with a graded treadmill test while the community-based walking trial evaluated change in walking performance with both a graded treadmill test and a 6MWT, and neither of them showed improvement in the low-intensity group compared with the control group.5,46,62 7 Although a very strong evidence base supports SET and structured community-based exercise programs for patients with chronic symptomatic PAD, no compelling evidence shows that unstructured exercise, such as patient self-directed efforts or advice from a health care professional to “go out and walk,” can improve walking performance or QOL. Walking advice and general educational Downloaded from http://ahajournals.org by on October 7, 2026