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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 June 11, 2024 e1375

foot assessment and opportunities for education regarding good foot care and awareness of signs of worsening PAD, including CLTI. Specific timing, intervals, or both of routine follow-up visits is tailored to the patient-specific clinical context, including severity of disease and degree of functional limitation, history, and timing of previous revascularization procedures, and need for adjustment of medications to optimize GDMT and control risk factors. 2.	 Because of the complexity of PAD, a multispecialty care team approach promotes collaboration and avoids potential duplication of care.13,14,29–32 Coordination of care is particularly important for risk factor management (ie, diabetes, hypertension, smoking, dyslipidemia) to optimize outcomes for these patients. Saratzis et al33 estimated that management of cardiovascular risk factors in patients with PAD, including optimal LDL-C, good blood pressure control, smoking cessation, and antiplatelet therapy, could lead to an average of 6.3 MACEfree years gained in a population of patients observed longitudinally for medical management of PAD. 3.	 In a chronic disease such as PAD, assessment of

functional status and QOL provides a meaningful way to determine the impact of therapies.34 In patients with PAD, the perception of walking capacity, pain, and social and emotional implications of living with PAD are all important QOL measures. Although assessment of functional status and QOL can inform and be incorporated into the clinical assessment, validated questionnaires have been developed and can be administered via patient electronic health records or via a computer in the waiting area, thus eliminating the need for data entry by health care personnel. These assessments can be incorporated into clinical follow-up visits. A scientific statement on patient-reported health status measures for PAD has been published.35 Examples of validated QOL tools for PAD include: •	 VasculQoL-6,1 a shortened version of the PAD-specific instrument VascuQOL, which was found to be a valid and responsive instrument for the measurement of health-related QOL in PAD. •	 PADQOL, a PAD-specific QOL measure, which measures the impact of PAD and the patient’s subjective experience.2 •	 PAQ, a PAD-specific health status measure. The PAQ Summary Score has been correlated to the ABI, and a lower PAQ Summary Score has been found to be associated with an increased likelihood of PAD among patients with suspected PAD symptoms.3–5 Simple tools to screen for depression, such as the

Patient Health Questionnaire-9, can also be implemented.36 Depression has been recognized as prevalent among patients with PAD and has been recognized as a risk amplifier (see Section 4.1, “Amplifiers of Cardiovascular and Limb-Related Risk in Patients With PAD”) that is associated with adverse outcomes.37–39 Functional status can be assessed informally (ie, by

asking about subjective pain-free and maximal walking distances and ability to walk in daily life and participate in vocational and recreational activities), or through objective functional assessments (exercise treadmill ABI testing or 6MWT). The 6MWT assesses the distance a patient can walk in a 6-minute period and is a submaximal test of endurance capacity, aerobic capacity, or both. The 6MWT is simple and easy to perform at a low cost and can be done by those who are deconditioned, elderly, or frail.6

4 GDMT for PAD and evidence-based recommenda-

tions for specific elements of GDMT are discussed in Section 5, “Medical Therapy and Preventive Foot Care for the Patient With PAD” (Figure 4). Maintaining patient-specific GDMT to prevent MACE and MALE is an important element of longitudinal care for patients with PAD. Lipid-lowering therapies reduce the risk of MACE and MALE events in patients with PAD.7,8,40,41 Statin therapy postoperatively is associated with improved survival in patients who undergo lower extremity bypass surgery for CLTI.42 Antiplatelet and antithrombotic therapies are fundamental to prevent MACE, including MI, ischemic stroke, and death, but have also shown to be important in reducing limb events in stable PAD and postrevascularization.9–11,43–48 Management of diabetes and hypertension are both important components of care for patients with PAD, and glycemic control is especially important for patients with CLTI and nonhealing wounds.12,49–51 Maintenance of smoking cessation is critical for patients with PAD (see Section 5.4, “Smoking Cessation for PAD”). 5-9.	 Both endovascular and surgical revascularization

can be complicated by restenosis caused by neointimal hyperplasia as well as other complications. Neointimal hyperplasia involves thickening of the tunica intima of an artery and involves the proliferation and migration of medial smooth muscle cells into a region as it becomes stenotic in response to revascularization.15,16 The goal of routine surveillance after revascularization is to identify intervention sites with significant restenosis that are at risk for failure, even in the absence of signs or symptoms (ie, to maintain patency). A reduction in the ABI of >0.15 from a previous value has been proposed to detect revascularization failure, but ABIs should be used in combination with duplex ultrasound to improve sensitivity

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