Essence of this article
Coronary artery disease and peripheral artery disease management may be complex owing to common comorbidities, which may also require treatment (e.g. diabetes, hyperlipidaemia, obesity and hypertension). Management can be improved with increased physician and patient education and use of the latest guidelines.
Management of coronary and peripheral artery disease
Management of coronary artery disease (CAD) and peripheral artery disease (PAD) can be challenging owing to differences in treatment strategies. Patients with both diseases concurrently show increased rates of morbidity and mortality, and aggressive treatment is recommended.431 Patients with both CAD and PAD have been shown to receive suboptimal treatment, frequently displaying poorer hospital outcomes compared with patients with CAD alone.432 The European Society of Cardiology (ESC) guidelines state that management should include lifestyle advice, patient education, pharmacological therapy and/or revascularization.433
Lifestyle advice can reduce several risk factors for cardiovascular disease and includes not smoking, taking regular exercise, maintaining a healthy weight and eating a balanced diet.431, 433 Patients should be advised to have a diet low in saturated fats and salt, high in fruit and vegetables and to include a moderate intake of oily fish.431, 433
Pharmacological management of CAD includes short-acting nitrates, beta blockers and/or calcium channel blockers as first-line therapy for angina/ischaemia relief (Figure 1).433 Low-dose acetylsalicylic acid and statins are also recommended, adding an angiotensin-converting-enzyme inhibitor if comorbidities are present (e.g. diabetes, heart failure, hypertension).433 However, even with appropriate therapies, patients with comorbidities may still be at an increased risk of cardiovascular events. For example, patients with diabetes had a 2.9-fold higher risk of cardiovascular events despite receiving patient education on reducing their risk of secondary events and drug prescription after acute coronary syndrome versus patients with CAD alone (18-month follow-up).434
Figure 1. Medical management of stable CAD433
ACEI, angiotensin-converting-enzyme inhibitor; ARB, angiotensin receptor blocker; CABG, coronary artery bypass grafting; CAD, coronary artery disease; CCB, calcium channel blocker; CCS, Canadian Cardiovascular Society; DHP, dihydropyridine; PCI, percutaneous coronary intervention.
aData for diabetics; bif intolerance, consider clopidogrel
Coronary artery bypass grafting and percutaneous coronary intervention (PCI) are the two main forms of revascularization procedures. Revascularization decisions are based on the presence of significant obstructive coronary artery stenosis and related ischaemia (e.g. post-myocardial infarction, left ventricular dysfunction), current symptoms and expected benefit.433 If the procedure has an acceptable level of risk and a good life expectancy, it may be considered first-line treatment.433, 435 Revascularization is recommended if the patient has any significant stenosis (>50%) or a large area of ischemia.436 PCI is associated with a low mortality risk of <0.5% in stable CAD patients;433 however, poorer outcomes are expected if lower-extremity PAD is also present.431 Patients with stable CAD undergoing PCI are also recommended to have anticoagulant and antiplatelet therapy.436