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CLINICAL STATEMENTS AND GUIDELINES

June 11, 2024 Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 e1374

of atrial fibrillation (30%) as well as abnormalities on echocardiography (84 patients imaged), including any valvular disease (61%), intracardiac thrombus (11%), and mitral stenosis (4%). A presumed major cardioembolic cause (atrial fibrillation, mitral stenosis, or intracardiac thrombus) was identified in 44% of patients with presumed cardioembolic ALI.4 Beyond cardiac evaluation, additional testing, such as imaging of the aorta (ie, for thrombus or aneurysm) or evaluation for hypercoagulable states, is determined based on the initial clinical evaluation and suggestive findings in the history, physical examination, or those identified during treatment for ALI (ie, findings on catheter angiography obtained at the time of revascularization).

12 LONGITUDINAL FOLLOW-UP OF PAD

Recommendations for Longitudinal Follow-Up of PAD Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations General Principles

1 C-EO 1.	 In patients with PAD, with or without revascularization,

longitudinal follow-up with routine clinical evaluation, including assessment of limb symptoms and functional status, lower extremity pulse and foot assessment, and progress of risk factor management, is recommended.

1 C-EO 2 In patients with PAD, coordination of care among

clinicians to improve the management of PAD and comorbid conditions and to optimize patient outcomes is recommended.

Functional Status and QOL

1 B-NR 3 In patients with PAD, with or without

revascularization, periodic assessment of functional status as well as overall health-related QOL as a component of longitudinal follow-up is recommended.1–6

Medical Therapy

1 A 4.	 In patients with PAD, long-term use of GDMT to

prevent MACE and MALE is recommended.7–12

Postrevascularization Follow-Up

1 C-LD 5 In patients with PAD who have undergone lower

extremity revascularization (ie, surgical and/or endovascular), longitudinal follow-up that includes periodic clinical evaluation of lower extremity symptoms and pulse and foot assessment is recommended.13–16

1 C-LD 6 In patients with PAD who have undergone lower

extremity revascularization (ie, surgical, endovascular, or both) with new lower extremity signs or symptoms, ABI and arterial duplex ultrasound is recommended.14,17–20

2a B-R 7 In patients with PAD who have undergone infrain-

guinal, autogenous vein bypass graft(s) without new lower extremity signs or symptoms, it is reasonable to perform ABI and arterial duplex ultrasound surveillance within the first 1 to 3 months postprocedure, then repeat at 6 and 12 months, and then annually.13,14,20–22 2a C-LD 8 In patients with PAD who have undergone

endovascular procedures without new lower extremity signs or symptoms, it is reasonable to perform ABI and arterial duplex ultrasound surveillance within the first 1 to 3 months postprocedure, then repeat at 6 and 12 months, and then annually.17,19,20

2b B-NR 9 In patients with PAD who have undergone infrain-

guinal, prosthetic bypass graft(s) without new lower extremity signs or symptoms, the effectiveness of ABI and arterial duplex ultrasound surveillance is uncertain.14,20,23,24

Telehealth

2a C-LD 10.	 For patients with PAD, telehealth can be an alternative mode for vascular evaluation and management and longitudinal follow-up, but the use of these visits should be consistent with the urgency of presenting symptoms.25–28

Synopsis PAD is a chronic medical condition. A comprehensive care plan for patients with PAD includes periodic clinical evaluation by a health care professional with experience in the care of patients with vascular disease and coordination of care among other clinicians. Ongoing care focuses on cardiovascular and limb risk reduction (ie, prevention of MACE and MALE) with medical therapy, optimizing functional status and QOL with structured exercise and, when indicated, revascularization. Patients with PAD who have undergone revascularization need ongoing surveillance, although the optimal frequency of surveillance after revascularization has yet to be determined.

Recommendation-Specific Supportive Text

1 Because patients with PAD are at risk for MACE

(including MI, stroke, and death) and because traditional cardiovascular risk factors are strongly associated with the development and progression of PAD, aggressive risk factor management is an important component of longitudinal care (see Section 5, “Medical Therapy and Preventive Foot Care for the Patient With PAD”). GDMT and risk factor management seek to slow the progression of PAD and prevent MACE and MALE (see Section 5, “Medical Therapy and Preventive Foot Care for the Patient With PAD”). Beyond risk factor management, monitoring limb symptoms and functional status allows for assessment of the degree of functional impairment, participation in a structured exercise program (see Section 6, “Exercise Therapy for PAD”), and worsening of symptoms that would warrant evaluation for revascularization. Longitudinal followup care also includes lower extremity pulse and

Recommendations for Longitudinal Follow-Up of PAD (Continued) COR LOE Recommendations

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