July 28, 2025 • 32 mins
Join us as we welcome back our most popular guest, Dr. Heather Gornik, co-director of the Vascular Center at University Hospitals of Cleveland, as we discuss her role as the lead author of the 2024 ACC/AHA Guideline for the Management of Lower Extremity Peripheral Artery Disease, including a review of key points from the guidelines.
For more information, see:
2024 ACC/AHA Guideline for the Management of Lower Extremity Peripheral Artery Disease, including ACC Guideline Hub and Guidelines At-a-Glance with top 10 takeaways.
AHA guideline hub, including slide set
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Kanny (00:09):
So welcome back to the Cardio Ohio podcast.
This is Kenny Gral coming to youfrom Columbus as always.
And also as always, I'd like towelcome my co-host from
Cleveland, Ellen, SEIC, thecurrent governor of the State of
Ohio chapter.
Alan, welcome.
Ellen (00:25):
Thank you can.
I'm so excited for today becausewe have an opportunity to speak
to Dr.
Heather Gornick, who you allprobably remember gave us a
wonderful discussion offibromuscular dysplasia and
spontaneous coronary arterydissections.
She is the co-director ofUniversity Hospital's Vascular
(00:45):
Center, as well as the Directorof Fibromuscular Dysplasia
program, a professor of Case,Western Reserve School of
Medicine, and now the head ofour, women's Heart Center.
But today we have her speakingto us about the.
Updated guidelines formanagement of lower extremity,
peripheral arterial disease.
(01:07):
And we are doing this becauseshe is actually the senior
author of this document.
So Heather, welcome so much.
We're so happy to have you back.
Heather (01:17):
Thank you, Ellen.
I'm so glad to be back with youand Ka and I'm really looking
forward to this discussion.
Ellen (01:23):
So, before we get into these guidelines, we use
guidelines in medical practiceall the time, and I think it's
important to consider who'sinvolved in creating these types
of documents.
Can you discuss with us.
Who's involved in this process?
Is it vascular medicine?
Is it surgeons, cardiologists,podiatrists?
And, and how does this processactually work?
Heather (01:46):
Sure.
Well, I think the PAD guidelinesreally took a village.
I think most guidelines do takea village, but I think this
village was very large androbust, and it was actually a
four year process to bring theseguidelines.
Through the whole process fromthe work with the guideline
writing committee, through thepeer review, and then
(02:06):
endorsement by all theorganizations, and I will just
say the, the document wasspearheaded, of course, by the
Joint Guideline Committee of aCC and a HA, but we actually had
nine.
Partnering organizations withus, and as you alluded to really
reflect the, the broad spectrumof multidisciplinary engagement
(02:28):
in the field of peripheralvascular disease.
So we, among those nineorganizations, we have
represented not only of course,cardiology.
Vascular medicine,interventional cardiology,
interventional radiology,vascular surgery with a few
organizations cardiovascularrehabilitation, vascular
(02:49):
nursing, and podiatry, just toname a few.
We also had some patients on theguideline writing committee
giving.
Their perspectives.
And also for the first time onthis document, we had two new
organizations partnering withus, which I was really excited
about.
The A PMA, the AmericanPodiatric Medical Association
(03:13):
was a partner on this documentfor the first time.
And then we worked with theAssociation of Black
Cardiologists.
So it was, it was a lot of funand very interesting in GE
aging, this whole village,reviewing the data together.
Coming up with the consensusrecommendations, voting,
hearing, diverse perspectives.
(03:33):
It was a really interestingprocess and I learned a lot by
spearheading the writingcommittee.
Kanny (03:39):
So Heather, well, one question I have is when you,
when you took this process on,you mentioned how you started,
you know, several years ago.
Are you trying to start fromscratch or are you using the
previous edition of theguidelines?
I think they were, you know,2016.
Are you using them as a, as aframework to move forward, or
are you trying to kind of, startfrom scratch
Heather (03:59):
yeah, I think it was a hybrid of both.
And actually this is, I thinkthe fourth time there's been a
comprehensive PAD guideline.
The first one was actuallyspearheaded by Dr.
The late wonderful Dr.
Allen Hirsh.
In 2005 was the first time thatthe.
The PAD guidelines came out,although that wasn't just lower
(04:19):
extremity PAD, it was also, itwas really all vascular disease
below the diaphragm.
Back in 2005 there was another.
Guideline update done in 2011,which is was a brief guideline
update that focused on PAD aswell as AAA and I believe renal
artery disease.
(04:40):
And then the, the mostcomprehensive reboot of just
lower extremity, PPAD guideline,as you mentioned, was the 2016
guideline.
I had a chance to be involvedwith.
And as we move forward to this2024 edition, we did look at
that prior guideline and whatwas its scope, but there was a
(05:00):
lot of new material and newthings and new concepts we
wanted to add it in.
So it was sort of a springboard.
And this document is meant tofully replace the 2016 document.
Kanny (05:13):
Well, that sounds wonderful.
Before we kind of get into someof the specific
recommendations,, obviously mostcardiac practitioners are now
very well aware of the crossoverbetween, peripheral arterial
disease and coronary arterialdisease.
But what is the currentunderstanding of the overall,
you know, prevalence of PAD?
(05:34):
I know your document also talksabout specific populations.
Heather (05:38):
For sure.
I, in, in our.
Document.
We talk about the prevalence ofPAD in the US estimated to be
about 10 to 12 millionindividuals in the United
States, and then the globalprevalence is estimated to be as
high as 236 million peopleliving with PAD.
So this is a really common.
(05:58):
Cardiovascular disease.
Actually there was some workdone many years ago, again led
by Dr.
Allen Hirsch, a study called thePartners Trial, where they went
out in primary care practices.
This is one of the firstattempts at looking at the
prevalence of PAD.
So they went to primary carepractices and they patients ages
(06:18):
70 or above.
Or 50 to 69 who hadatherosclerotic risk factors.
And in that population theyactually found a 29% prevalence
of an abnormal a BI estimates ofthe co prevalence of.
PA, D and CAD vary, but it'svery clear that patients who
(06:40):
have CAD are at greatlyincreased risk of having PAD.
And the flip side is verydefinitely true.
If someone has lower extremityatherosclerotic, PAD, their
likelihood of having somecoronary disease is extremely
high.
Ellen (06:59):
Wonderful.
So, so Heather, for cardiaccaregivers, who should we think
about assessing for PAD?
You know, we see a lot ofpatients with coronary disease,
but we see other cardiacconditions as well.
What are the red flags or theclues to a problem that we
should.
Should look at for our patients?
Heather (07:17):
Yeah, and I think if you go into the guideline
document, our group made somenice very digestible and helpful
tables, and one of the tablesis.
Who are the patients atincreased risk for PAD?
Because these are the folkswhere we give a class one
recommendation that they need tohave, be asked about
(07:38):
claudication.
They need to be asked aboutwalking impairment.
They need a physical exam, andthey, if they have signs or
symptoms of PAD, they need an aBI.
So the people at increased riskare older patients.
This is our Medicare population,ages 65 plus younger patients
who have atherosclerotic riskfactors.
Special of the usual stuff,diabetes, smoking,
(08:01):
hyperlipidemia, hypertension,but also CKD and family history
of PAD.
Anyone who's less than 50 but isa type one diabetic and has
another risk factor foratherosclerosis.
And then really importantly,people at increased risk for PAD
are the people seeing thecardiologist for their CAD.
(08:23):
So if you are following apatient who had an MI or.
A stent years ago for worseningangina.
You need to think about couldthis patient have PAD Ask them
about do they have leg pain withwalking that goes away with
rest?
Are they limited in theirwalking?
And most importantly, this is mysoapbox.
(08:44):
I get on every time I get achance to talk to more general
cardiologists.
You gotta take off their socksand shoes at the office visit.
Please and look at the feet forulcers, assess for perfusion,
feel the pulses, and if there'sany suspicion for PAD, move on
to the next test, which isusually the a BI in the vascular
(09:07):
lab.
Kanny (09:08):
I, I assume many ABIs are ordered by general
cardiologists.
Is there any nuance to when weorder arresting a BI versus
arresting and exercise?
Because I think that's allsometimes a question that comes
up from our nurse practitionersand others who are ordering
these screening tests.
Heather (09:23):
Yeah, I think for sure.
I think if a patient has wounds.
So if you take off the socks atthe office visit and there's a,
a foot ulcer and they'rediabetic, that person does not
need an exercise.
A BII think there you can goright to the resting a BI and
not only, I think you wanna doit in a vascular lab where not
only they're gonna do a BI.
(09:44):
They're gonna do other perfusionassessment.
They're gonna do pulse volumerecordings, toe brachial index
doppler, because sometimes,especially in diabetics,
patients with kidney disease,patients with wounds, the a BI
doesn't tell the full story.
And you can have a normal orslightly elevated a BI due to
vascular calcification, butstill have PAD.
(10:05):
So that's why really sendingthose folks to the vascular lab
for a comprehensive assessment.
I think if your patient has anyfunctional limitation.
Or leg pain.
I think in my practice I wouldgo right away to the exercise a,
BI, of course, if they're safelyable to walk on a treadmill, if
you're at all worried abouttheir cardiac status, I would
(10:26):
not do the exercise a, BI,because exercise, ABIs are often
performed at a pretty steepincline and in most facilities
without cardiac monitoring.
So unless there's a cardiaccontraindication, if the patient
has any.
Exertional symptoms, functionalimpairment, I think you can do
the exercise a BI.
(10:46):
They'll get the a, BI at rest,they'll get the waveforms and
pulse volume recordings, andthen they'll do the exercise and
repeat the study after exercise.
Kanny (10:57):
That's great.
Your document which I wasreviewing, really goes very
nicely into a summary of the,medical therapy.
I think, a lot of clinicianskind of associate PVD with,
vascular intervention and wedon't always give as much
thought to, medical therapy theway we would similarly do for,
(11:18):
coronary disease where there'sso many outcome trials.
But it feels like that'schanging.
And you now have some excellenttrials, given an evidence base
for medical therapy.
Do you wanna just touch on maybesome of the updated
recommendations for medicaltherapy that you address in, in
this document?
Heather (11:38):
Yeah, for sure.
I think for most patients withPAD, medical therapy is all they
need.
And in fact, one of theemphasis.
The emphasis of this document isthat everybody needs medical
therapy across the spectrum ofPAD.
And as you mentioned, Kenny,there's been a lot of new
developments.
So we still have thefoundational aspects.
(12:01):
Patients have to quit smoking.
They need lipid loweringtherapy.
But in addition to highintensity statin, we now have
options for more aggressivelipid lowering therapy with
either PCSK nine.
Or Ezetimibe.
There's been a lot ofadvancement in the field of
antithrombotic and anti-platelettherapy for PAD.
(12:23):
And in the PAD space, we had tworeally pivotal RCTs that were
published within a few years ofthis guideline that heavily
influenced the guidelinerecommendation regarding the use
of low-dose rivaroxaban, 2.5milligrams twice daily atop
low-dose aspirin.
And this is based on two trials.
(12:43):
One was called the CompassTrial, patients who were
medically managed and one wascalled the Voyager trial.
Patients with PAD who underwentintervention, but the
combination of those twomedications compared to
antiplatelet alone was.
Associated with significantreductions in cardiovascular
events in patients with PAD andalso for one of the first times
(13:05):
we have a medical therapy thatactually prevented limb events,
so prevented repeatrevascularization, acute limb
ischemia, amputation.
So I think in the PAD space.
A lot of excitement aboutlow-dose aspirin and
rivaroxaban.
The guidelines also for thefirst time include SGLT two
inhibitors and GLP one agonistsfor patients with PAD and
(13:30):
diabetes Since.
These were published.
There's actually been anothertrial or two that further
support especially the GLP onesfor patients with PAD to prevent
cardiovascular events, butagain, to prevent limb events.
So that's really exciting for usin the PAD space.
One thing that was also new thatmaybe isn't so sexy is the other
(13:51):
things, but ACE inhibitors andARBs got an upgrade to a Class
one recommendation for patientswith PAD.
Who have hypertension to preventcardiovascular events.
That was previously a Class twoA recommendation.
And then the other aspect I'mkind of excited about in terms
(14:12):
of medical therapy is I thinkheavily influenced by the
engagement of our podiatriccolleagues.
On this document, we have asection emphasizing the
importance of.
Preventive foot care forpatients with PAD.
So a lot of exciting medicaltherapies.
Ellen (14:31):
So Heather, that is wonderful.
One question for you, it's afollow up I guess, regarding
medical therapies.
There are so many new thingscoming out, right?
So you've got your aspirin,you've got your rivaroxaban,
your statin therapy, your otheradditional lipid lowering
therapies.
Is this like heart failure,where now we have the four
pillars and everybody with anysort of heart failure gets
(14:53):
started on all four medications?
Or is it a matter of, well, youmight start with the basics,
aspirin, statins, and a fewthings, and then if they have
future events or furthersymptoms, you escalate, at what
point do you add therivaroxaban?
Heather (15:09):
Yeah, I think a lot of the implementation science in
PAD is forthcoming, so I don'thave firm answers for that.
I, I do think we need to do alittle bit better in, in all of
cardiovascular medicine and inPAD with a little bit of
treatment inertia, and I'mguilty of this as anyone.
I'm the chair of the guidelines.
(15:30):
If I have a patient with PADwho's been stable on their
aspirin, their high dose.
It statin.
They're not smoking and they'vebeen stable for many years.
I, I think I have been trying toreally reboot things and as
patients come back to mypractice, I say, listen I know
(15:50):
you've been doing well and thisis just our annual visit, but.
There's some new guidelines thatcame out last year that
suggested that the addition ofthis other medication I'm
referring to, rivaroxaban, mayprevent events in your case down
the road and at least have theconversation with the patient
that there's some new dataoffering them, you know, a new
treatment.
But I think sometimes I'mcurious what you both have to
(16:13):
say.
I think sometimes there istreatment inertia.
When a patient is doing well andnew guidelines come out and new
therapies and it's hard to knowhow aggressive to be
Kanny (16:24):
I mean, it's a very similar situation to when you
have a patient with stablecoronary disease and you at
their annual checkup, theirlipids are not quite a target,
but they're doing so well thatyou have some inertia to wanting
to, advance their statin or adda second agent.
you did allude to exercise and Ithink, it might be a good time
to just remind our listenersabout the adjunctive benefits of
(16:46):
exercise and then maybe eventouch on the role of cardiac
rehab in some patients.
Heather (16:50):
Sure and actually can to your prior point.
The one other thing I will add,and I know there may be some of
our Cardiovascular care teammembers our apps, listening to
this podcast, I will say theapps do an amazing job of
guideline directed medicaltherapy and kind of getting
patients there incrementally.
I'm always really impressed withour A PP colleagues really
(17:14):
pushing the cocktail ofmedicines that are recommended
by guidelines and supported bytrials.
Okay, so onto exercise.
So I think for patients withPAD, structured exercise really
is a cornerstone of therapy.
It is really a wonder treatmentfor many patients with stable
symptomatic PADA, a structuredprogram of exercise, either in a
(17:38):
rehab or other structured formsof exercise if done properly.
Can result in dramaticimprovements in functional
capacity, how long patients canwalk without having pain, and
how long they can walk in total.
So exercise has been shown overand over again to work.
I think in this document, acouple of new things to
(17:59):
highlight.
Is that in addition tosupervised exercise, which is,
has been recognized by CMS andcovered for a number of years
now for our Medicare patients,but is woefully underutilized.
In addition to that supervisedexercise, there's now another
class one recommended therapy,which is a, a structured
(18:22):
community-based exerciseprogram.
So that might be a program thatis, unfortunately there's not
enough of them in the UnitedStates, but it's.
Maybe not fully conducted in asupervised rehab.
There may be a coach, there maybe use of trackable wearable
devices, accelerometersmonitoring and accountability.
But that sort of program hasbeen shown to be as effective or
(18:44):
nearly as effective assupervised exercise where people
come into the medical center.
So in this document, it's alsogiven a Class one
recommendation.
And I think the other nice thingthat the document highlights is
a recommendation that.
Exercise is indicated forpatients with chronic
symptomatic PAD.
(19:05):
Even after they get, if they endup getting revascularization for
very limiting symptoms, you cando exercise with that
revascularization to get furtherimprovements in a synergistic
way on functional outcomes.
Ellen (19:21):
That's wonderful, Heather.
'cause.
A lot of times the same thingwith cardiac rehab, right?
We might do an intervention, wemight give them medications, but
that cardiac rehab, thatexercise portion is a real key
piece of the puzzle as well.
So it's nice that it holds truefor PAD as well.
So you're talking to a group ofcardiovascular caregivers and we
(19:44):
obviously can do a lot of thistesting and, and medical
treatment.
But at what point should werefer our patients to a vascular
medicine specialist or aninterventionalist?
At what point do we say, okay,we need some additional
expertise in this field.
Heather (20:01):
Yeah, I think general cardiovascular practitioners can
do a lot for PAD, and I thinkthat's one of the important
reasons why we're excited aboutthis guideline, and we want to
broadly disseminate thisguideline because we want
general cardiovascularpractitioners.
Internal medicine specialists,other specialists to be able to
(20:24):
recognize PAD, diagnose PAD, andmanage potentially a lot of the
patients.
I mean, you're already managingsevere coronary disease and
heart failure, and you'recomfortable with your your,
your.
Lipid lowering agents and bloodpressure lowering agents.
And now our new diabetes agents.
I, I think throw in some goodcareful foot inspection and
(20:47):
exercise, and I think PAD can bevery well managed by the
cardiovascular specialist.
I think if patients are notresponding to usual.
Medical therapy if, if theyremain functionally limited, if
they can't do their job, iftheir quality of life is poor
because they have leg pain withwalking and they have PAD and
(21:08):
they've tried exercise andthey've tried they're on a good
medical regimen.
Those are people who should beseen by a vascular specialist.
And of course any patient withPAD who you think might have
what we now call CLTI, chroniclimb threatening ischemia, that
used to be CLI.
(21:29):
It's got a new name.
And that would be ischemic restpain.
Ulcers or gangrene.
Those are folks who need to seea vascular specialist urgently.
But I don't think every patientwith PAD needs to see a vascular
specialist.
I think a lot of them can bemanaged in cardiovascular
medicine practice.
And I hope these guidelines givea blueprint for people to feel
(21:52):
comfortable doing that.
Ellen (21:54):
I guess since you brought up the difference between
chronic.
Limb, well, chronic limbthreatening ischemia.
Can you discuss the hallmarksand the treatment differences
between the chronic versus acutelimb ischemia?
'cause obviously the sort ofrapidity with which.
Things need to be managed mightbe a bit different.
Heather (22:14):
Yes, for sure.
The CLTI, that's a patient who'sgenerally had symptoms for two
weeks or more, and as mentionedit's a chronic wound, it's rest,
pain, it's an ulcer.
And those people, it is avascular urgency for limb
salvage for them to beevaluated, for revascularization
(22:36):
to prevent, potentially managetheir wounds.
Restore blood flow to the legand salvage as much of the leg
and foot as possible.
The acute limb ischemia, that'sthe six Ps.
You know, the pulseless, pale,polar, parasitic I forget my
other.
I'm laughing and painful.
(22:57):
I'm maybe missing one of thePEA's leg That is acute onset
symptoms.
Those are often embolic events,or they may be.
Thrombotic events on top ofexisting plaque or maybe an
occlusion of a revascularizationsite.
Those are the people who need tocome to the emergency room, get
(23:18):
on IV heparin immediately, andbe evaluated for emergency
revascularization.
Kanny (23:26):
So on that topic Heather, you know, as a general
cardiologist, we're often thefirst one being called by the
emergency room for, for a phoneconsult.
Obviously when we hear thatstory about the acute ischemic
limb, I think, we all understandwe have to, get in touch with,
with one of our vascularcolleagues on an immersion basis
(23:47):
and get that patient in.
Are there any other situationsthat you kind of consider red
flags for the generalpractitioner where, rather than
just electively getting aconsult, we may need to do that
emergently or at least discuss acase with you.
Is, is the acute ischemia themain one or are there any other
clinical scenarios where, thealarm should be getting raised?
Heather (24:09):
I think the CLTI patient is almost at that level.
That's, that group has just avery poor natural history with
high, Likelihood of moving on toamputation or even death.
And I think unfortunately thosepatients, you would think they
would be recognized, but oftenare not.
(24:30):
So there's often a lag in their,in their care.
I think the acute limb ischemia,the patients writhing in pain,
the foot's white, you know, it'skind of obvious.
I think sometimes the CLTIpatient that can be more
indolent and sometimes peopledon't put two and two together.
I think also sometimes peopledon't think if you have a
(24:52):
diabetic patient with a footulcer, that it could be PAD.
A lot of diabetic foot ulcersare PAD related and not just
related to diabetes.
So we actually have, it's beenwell documented that patients
may be.
Getting cared for wounds ormaybe actually may undergo an
amputation without havingvascular assessment to see if
(25:16):
they have PAD and couldpotentially be revascularized.
So I think that that CLTI groupis, is a pretty, is a very high
risk group that's often notmanaged as quickly as they
should be because their symptomsare not as dramatic.
Kanny (25:37):
That's very helpful.
One other topic I wanted to talkabout was kind of you, I think
you alluded at the beginning toteam-based care and we still
have, of course, the moreserious cases that do need
revascularization.
You know, in some settings,they're being done predominantly
by vascular surgeons and othersby, peripheral vascular
cardiology based practitionersas well.
(25:58):
And then of course you have somany well-trained vascular
medicine specialists likeyourself.
There's been a move towardsteam-based care in other areas
of cardiology.
Valvular disease.
We have our heart teamconferences every week.
Interventional cardiology aswell.
You have collaboration betweensurgeons and interventional
cardiologists.
With the more complicated cases,do you see vascular medicine
(26:20):
moving towards a team-based kindof approach?
Because I, you know, in mypractice, I, I still see
especially patients beingreferred from some outlying
hospitals, patients who weremaybe saw a vascular surgeon and
told that, there was absolutelyno option for them.
For definitive surgery.
And then, once they're assessedby an interventional vascular
doc, they actually are a verygood candidate to get,
(26:44):
percutaneous revascularization.
So do you still see some turfbattles like that out there, or
do you think the vascularcommunities also kind of moving
towards, team-based care,mirroring what's happening in,
in the cardiac areas?
Heather (26:57):
Yeah, I think in my 20 years since I left my
fellowship, I've seen greatprogress in this space in terms
of partnership.
I think in this document weemphasize the tremendous
importance of what we call themulti-specialty PAD care team,
and that team includes.
Expertise in vascular surgery,expertise in endovascular care,
(27:20):
expertise in wound care,expertise in risk factor
management.
You know, a lot of expertise phypeople who are experts in
orthotics and prosthetics,infectious disease, et cetera.
And actually our, especially forour CLTI section, we have a
class one recommendation thatpatients with CLTI.
(27:43):
Should be managed by aMultispecialty PAD care team.
Just recognizing that there's alot we can do when we put the
patient at the center and havedifferent perspectives putting
together a care plan and tobuild on your other point.
We actually have arecommendation in the guideline
that for patients with CLTI whorequire amputation, those
(28:08):
patients should be evaluated bythe multi-specialty care team to
assess for the most distal levelof amputation and to make sure
there's no.
Further revascularizationoptions.
So this document stronglyendorses Multispecialty, PAD
care.
I think our multispecialtyguideline writing committee,
(28:30):
which was very collaborative,really reflects great progress
in terms of partnership of allthe different groups and less
competition because.
You know, as I started thisconversation, you have 236
million estimated people in theworld.
With PAD there is plenty of workfor everyone to do, and actually
(28:52):
a lot of patients don't get anyvascular care, so I, I.
I do think we need to partner toincrease the reach of our all
specialties to identify patientswith PAD, treat them properly,
and then for patients withsevere PAD like CLTI really work
together, put the patient at thecenter and come up with the best
(29:13):
care plan that optimizesoutcome.
Ellen (29:17):
Wow, Heather, this has really been quite an eye-opening
discussion and we're learning somuch.
What are the few most importanttakeaways that all cardiac
caregivers should know abouttaking care of their patients
who may have PAD?
Like what are the, the keyaspects from the guidelines that
we just all need to know as, asa summary.
Heather (29:38):
All right.
These may be a combination ofthe guidelines and Heather
Gornick's takeaways, if that'sokay.
That
Ellen (29:44):
is perfect.
Heather (29:46):
I think number one, you are seeing patients with PAD
every day in your cardiovascularmedicine practice.
You just need to decide ifyou're gonna recognize it and
find it or not.
Number two, take off those socksand shoes.
Look at the feet, evaluate thepulses.
Ask about leg symptoms as partof your office visit.
(30:09):
Number three, embrace all ofthese wonderful medical
therapies we now have to preventlimb loss, heart attack, stroke,
and death in these patients.
And I think probably the mostexciting one is the the low-dose
rivaroxaban on top of low-doseaspirin.
And I think number four is ifyour patient has.
(30:29):
Severe PAD, especially the CLTI.
Obviously acute limb ischemia oreven just stable, symptomatic
PAD that's not responding, andthe patient still remains really
limited.
Get them to your trustedvascular specialist for
revascularization andexploration of other options.
Kanny (30:52):
Well, that's, that's a, a concise and awesome summary of a
very broad topic.
So as we always have, weappreciate your insight.
I, I do wanna put one plug,Heather.
You know, obviously we're gonnaput the link to our guidelines
in our podcast notes.
But on acc.org there's also agreat summary document,
(31:13):
guidelines at a glance wherethey summarize, the 10 takeaway
points from your guidelines, butalso have a really nice chart
comparing the differences.
In medical therapy between theseguidelines and the prior edition
as well as the Europeanguidelines.
So it's a very concise way tolook at the key differences
that, of course, most of whichyou've outlined in our
(31:35):
discussion today.
So, thanks again for yourservice to the cardiovascular
community and, and for yourclinical work as well, and also
for being our most downloadedpodcast guests.
Heather (31:47):
Thank you Kenny and Ellen.
It's been a lot of fun talkingto you.
Thank you for joining today'spodcast.
For more information about thespeakers or the topics, please
go to Ohio acc.org,
So welcome back to the Cardio Ohio podcast.
This is Kenny Gral coming to youfrom Columbus as always.
And also as always, I'd like towelcome my co-host from
Cleveland, Ellen, SEIC, thecurrent governor of the State of
Ohio chapter.
Alan, welcome.
Ellen (00:25):
Thank you can.
I'm so excited for today becausewe have an opportunity to speak
to Dr.
Heather Gornick, who you allprobably remember gave us a
wonderful discussion offibromuscular dysplasia and
spontaneous coronary arterydissections.
She is the co-director ofUniversity Hospital's Vascular
(00:45):
Center, as well as the Directorof Fibromuscular Dysplasia
program, a professor of Case,Western Reserve School of
Medicine, and now the head ofour, women's Heart Center.
But today we have her speakingto us about the.
Updated guidelines formanagement of lower extremity,
peripheral arterial disease.
(01:07):
And we are doing this becauseshe is actually the senior
author of this document.
So Heather, welcome so much.
We're so happy to have you back.
Heather (01:17):
Thank you, Ellen.
I'm so glad to be back with youand Ka and I'm really looking
forward to this discussion.
Ellen (01:23):
So, before we get into these guidelines, we use
guidelines in medical practiceall the time, and I think it's
important to consider who'sinvolved in creating these types
of documents.
Can you discuss with us.
Who's involved in this process?
Is it vascular medicine?
Is it surgeons, cardiologists,podiatrists?
And, and how does this processactually work?
Heather (01:46):
Sure.
Well, I think the PAD guidelinesreally took a village.
I think most guidelines do takea village, but I think this
village was very large androbust, and it was actually a
four year process to bring theseguidelines.
Through the whole process fromthe work with the guideline
writing committee, through thepeer review, and then
(02:06):
endorsement by all theorganizations, and I will just
say the, the document wasspearheaded, of course, by the
Joint Guideline Committee of aCC and a HA, but we actually had
nine.
Partnering organizations withus, and as you alluded to really
reflect the, the broad spectrumof multidisciplinary engagement
(02:28):
in the field of peripheralvascular disease.
So we, among those nineorganizations, we have
represented not only of course,cardiology.
Vascular medicine,interventional cardiology,
interventional radiology,vascular surgery with a few
organizations cardiovascularrehabilitation, vascular
(02:49):
nursing, and podiatry, just toname a few.
We also had some patients on theguideline writing committee
giving.
Their perspectives.
And also for the first time onthis document, we had two new
organizations partnering withus, which I was really excited
about.
The A PMA, the AmericanPodiatric Medical Association
(03:13):
was a partner on this documentfor the first time.
And then we worked with theAssociation of Black
Cardiologists.
So it was, it was a lot of funand very interesting in GE
aging, this whole village,reviewing the data together.
Coming up with the consensusrecommendations, voting,
hearing, diverse perspectives.
(03:33):
It was a really interestingprocess and I learned a lot by
spearheading the writingcommittee.
Kanny (03:39):
So Heather, well, one question I have is when you,
when you took this process on,you mentioned how you started,
you know, several years ago.
Are you trying to start fromscratch or are you using the
previous edition of theguidelines?
I think they were, you know,2016.
Are you using them as a, as aframework to move forward, or
are you trying to kind of, startfrom scratch
Heather (03:59):
yeah, I think it was a hybrid of both.
And actually this is, I thinkthe fourth time there's been a
comprehensive PAD guideline.
The first one was actuallyspearheaded by Dr.
The late wonderful Dr.
Allen Hirsh.
In 2005 was the first time thatthe.
The PAD guidelines came out,although that wasn't just lower
(04:19):
extremity PAD, it was also, itwas really all vascular disease
below the diaphragm.
Back in 2005 there was another.
Guideline update done in 2011,which is was a brief guideline
update that focused on PAD aswell as AAA and I believe renal
artery disease.
(04:40):
And then the, the mostcomprehensive reboot of just
lower extremity, PPAD guideline,as you mentioned, was the 2016
guideline.
I had a chance to be involvedwith.
And as we move forward to this2024 edition, we did look at
that prior guideline and whatwas its scope, but there was a
(05:00):
lot of new material and newthings and new concepts we
wanted to add it in.
So it was sort of a springboard.
And this document is meant tofully replace the 2016 document.
Kanny (05:13):
Well, that sounds wonderful.
Before we kind of get into someof the specific
recommendations,, obviously mostcardiac practitioners are now
very well aware of the crossoverbetween, peripheral arterial
disease and coronary arterialdisease.
But what is the currentunderstanding of the overall,
you know, prevalence of PAD?
(05:34):
I know your document also talksabout specific populations.
Heather (05:38):
For sure.
I, in, in our.
Document.
We talk about the prevalence ofPAD in the US estimated to be
about 10 to 12 millionindividuals in the United
States, and then the globalprevalence is estimated to be as
high as 236 million peopleliving with PAD.
So this is a really common.
(05:58):
Cardiovascular disease.
Actually there was some workdone many years ago, again led
by Dr.
Allen Hirsch, a study called thePartners Trial, where they went
out in primary care practices.
This is one of the firstattempts at looking at the
prevalence of PAD.
So they went to primary carepractices and they patients ages
(06:18):
70 or above.
Or 50 to 69 who hadatherosclerotic risk factors.
And in that population theyactually found a 29% prevalence
of an abnormal a BI estimates ofthe co prevalence of.
PA, D and CAD vary, but it'svery clear that patients who
(06:40):
have CAD are at greatlyincreased risk of having PAD.
And the flip side is verydefinitely true.
If someone has lower extremityatherosclerotic, PAD, their
likelihood of having somecoronary disease is extremely
high.
Ellen (06:59):
Wonderful.
So, so Heather, for cardiaccaregivers, who should we think
about assessing for PAD?
You know, we see a lot ofpatients with coronary disease,
but we see other cardiacconditions as well.
What are the red flags or theclues to a problem that we
should.
Should look at for our patients?
Heather (07:17):
Yeah, and I think if you go into the guideline
document, our group made somenice very digestible and helpful
tables, and one of the tablesis.
Who are the patients atincreased risk for PAD?
Because these are the folkswhere we give a class one
recommendation that they need tohave, be asked about
(07:38):
claudication.
They need to be asked aboutwalking impairment.
They need a physical exam, andthey, if they have signs or
symptoms of PAD, they need an aBI.
So the people at increased riskare older patients.
This is our Medicare population,ages 65 plus younger patients
who have atherosclerotic riskfactors.
Special of the usual stuff,diabetes, smoking,
(08:01):
hyperlipidemia, hypertension,but also CKD and family history
of PAD.
Anyone who's less than 50 but isa type one diabetic and has
another risk factor foratherosclerosis.
And then really importantly,people at increased risk for PAD
are the people seeing thecardiologist for their CAD.
(08:23):
So if you are following apatient who had an MI or.
A stent years ago for worseningangina.
You need to think about couldthis patient have PAD Ask them
about do they have leg pain withwalking that goes away with
rest?
Are they limited in theirwalking?
And most importantly, this is mysoapbox.
(08:44):
I get on every time I get achance to talk to more general
cardiologists.
You gotta take off their socksand shoes at the office visit.
Please and look at the feet forulcers, assess for perfusion,
feel the pulses, and if there'sany suspicion for PAD, move on
to the next test, which isusually the a BI in the vascular
(09:07):
lab.
Kanny (09:08):
I, I assume many ABIs are ordered by general
cardiologists.
Is there any nuance to when weorder arresting a BI versus
arresting and exercise?
Because I think that's allsometimes a question that comes
up from our nurse practitionersand others who are ordering
these screening tests.
Heather (09:23):
Yeah, I think for sure.
I think if a patient has wounds.
So if you take off the socks atthe office visit and there's a,
a foot ulcer and they'rediabetic, that person does not
need an exercise.
A BII think there you can goright to the resting a BI and
not only, I think you wanna doit in a vascular lab where not
only they're gonna do a BI.
(09:44):
They're gonna do other perfusionassessment.
They're gonna do pulse volumerecordings, toe brachial index
doppler, because sometimes,especially in diabetics,
patients with kidney disease,patients with wounds, the a BI
doesn't tell the full story.
And you can have a normal orslightly elevated a BI due to
vascular calcification, butstill have PAD.
(10:05):
So that's why really sendingthose folks to the vascular lab
for a comprehensive assessment.
I think if your patient has anyfunctional limitation.
Or leg pain.
I think in my practice I wouldgo right away to the exercise a,
BI, of course, if they're safelyable to walk on a treadmill, if
you're at all worried abouttheir cardiac status, I would
(10:26):
not do the exercise a, BI,because exercise, ABIs are often
performed at a pretty steepincline and in most facilities
without cardiac monitoring.
So unless there's a cardiaccontraindication, if the patient
has any.
Exertional symptoms, functionalimpairment, I think you can do
the exercise a BI.
(10:46):
They'll get the a, BI at rest,they'll get the waveforms and
pulse volume recordings, andthen they'll do the exercise and
repeat the study after exercise.
Kanny (10:57):
That's great.
Your document which I wasreviewing, really goes very
nicely into a summary of the,medical therapy.
I think, a lot of clinicianskind of associate PVD with,
vascular intervention and wedon't always give as much
thought to, medical therapy theway we would similarly do for,
(11:18):
coronary disease where there'sso many outcome trials.
But it feels like that'schanging.
And you now have some excellenttrials, given an evidence base
for medical therapy.
Do you wanna just touch on maybesome of the updated
recommendations for medicaltherapy that you address in, in
this document?
Heather (11:38):
Yeah, for sure.
I think for most patients withPAD, medical therapy is all they
need.
And in fact, one of theemphasis.
The emphasis of this document isthat everybody needs medical
therapy across the spectrum ofPAD.
And as you mentioned, Kenny,there's been a lot of new
developments.
So we still have thefoundational aspects.
(12:01):
Patients have to quit smoking.
They need lipid loweringtherapy.
But in addition to highintensity statin, we now have
options for more aggressivelipid lowering therapy with
either PCSK nine.
Or Ezetimibe.
There's been a lot ofadvancement in the field of
antithrombotic and anti-platelettherapy for PAD.
(12:23):
And in the PAD space, we had tworeally pivotal RCTs that were
published within a few years ofthis guideline that heavily
influenced the guidelinerecommendation regarding the use
of low-dose rivaroxaban, 2.5milligrams twice daily atop
low-dose aspirin.
And this is based on two trials.
(12:43):
One was called the CompassTrial, patients who were
medically managed and one wascalled the Voyager trial.
Patients with PAD who underwentintervention, but the
combination of those twomedications compared to
antiplatelet alone was.
Associated with significantreductions in cardiovascular
events in patients with PAD andalso for one of the first times
(13:05):
we have a medical therapy thatactually prevented limb events,
so prevented repeatrevascularization, acute limb
ischemia, amputation.
So I think in the PAD space.
A lot of excitement aboutlow-dose aspirin and
rivaroxaban.
The guidelines also for thefirst time include SGLT two
inhibitors and GLP one agonistsfor patients with PAD and
(13:30):
diabetes Since.
These were published.
There's actually been anothertrial or two that further
support especially the GLP onesfor patients with PAD to prevent
cardiovascular events, butagain, to prevent limb events.
So that's really exciting for usin the PAD space.
One thing that was also new thatmaybe isn't so sexy is the other
(13:51):
things, but ACE inhibitors andARBs got an upgrade to a Class
one recommendation for patientswith PAD.
Who have hypertension to preventcardiovascular events.
That was previously a Class twoA recommendation.
And then the other aspect I'mkind of excited about in terms
(14:12):
of medical therapy is I thinkheavily influenced by the
engagement of our podiatriccolleagues.
On this document, we have asection emphasizing the
importance of.
Preventive foot care forpatients with PAD.
So a lot of exciting medicaltherapies.
Ellen (14:31):
So Heather, that is wonderful.
One question for you, it's afollow up I guess, regarding
medical therapies.
There are so many new thingscoming out, right?
So you've got your aspirin,you've got your rivaroxaban,
your statin therapy, your otheradditional lipid lowering
therapies.
Is this like heart failure,where now we have the four
pillars and everybody with anysort of heart failure gets
(14:53):
started on all four medications?
Or is it a matter of, well, youmight start with the basics,
aspirin, statins, and a fewthings, and then if they have
future events or furthersymptoms, you escalate, at what
point do you add therivaroxaban?
Heather (15:09):
Yeah, I think a lot of the implementation science in
PAD is forthcoming, so I don'thave firm answers for that.
I, I do think we need to do alittle bit better in, in all of
cardiovascular medicine and inPAD with a little bit of
treatment inertia, and I'mguilty of this as anyone.
I'm the chair of the guidelines.
(15:30):
If I have a patient with PADwho's been stable on their
aspirin, their high dose.
It statin.
They're not smoking and they'vebeen stable for many years.
I, I think I have been trying toreally reboot things and as
patients come back to mypractice, I say, listen I know
(15:50):
you've been doing well and thisis just our annual visit, but.
There's some new guidelines thatcame out last year that
suggested that the addition ofthis other medication I'm
referring to, rivaroxaban, mayprevent events in your case down
the road and at least have theconversation with the patient
that there's some new dataoffering them, you know, a new
treatment.
But I think sometimes I'mcurious what you both have to
(16:13):
say.
I think sometimes there istreatment inertia.
When a patient is doing well andnew guidelines come out and new
therapies and it's hard to knowhow aggressive to be
Kanny (16:24):
I mean, it's a very similar situation to when you
have a patient with stablecoronary disease and you at
their annual checkup, theirlipids are not quite a target,
but they're doing so well thatyou have some inertia to wanting
to, advance their statin or adda second agent.
you did allude to exercise and Ithink, it might be a good time
to just remind our listenersabout the adjunctive benefits of
(16:46):
exercise and then maybe eventouch on the role of cardiac
rehab in some patients.
Heather (16:50):
Sure and actually can to your prior point.
The one other thing I will add,and I know there may be some of
our Cardiovascular care teammembers our apps, listening to
this podcast, I will say theapps do an amazing job of
guideline directed medicaltherapy and kind of getting
patients there incrementally.
I'm always really impressed withour A PP colleagues really
(17:14):
pushing the cocktail ofmedicines that are recommended
by guidelines and supported bytrials.
Okay, so onto exercise.
So I think for patients withPAD, structured exercise really
is a cornerstone of therapy.
It is really a wonder treatmentfor many patients with stable
symptomatic PADA, a structuredprogram of exercise, either in a
(17:38):
rehab or other structured formsof exercise if done properly.
Can result in dramaticimprovements in functional
capacity, how long patients canwalk without having pain, and
how long they can walk in total.
So exercise has been shown overand over again to work.
I think in this document, acouple of new things to
(17:59):
highlight.
Is that in addition tosupervised exercise, which is,
has been recognized by CMS andcovered for a number of years
now for our Medicare patients,but is woefully underutilized.
In addition to that supervisedexercise, there's now another
class one recommended therapy,which is a, a structured
(18:22):
community-based exerciseprogram.
So that might be a program thatis, unfortunately there's not
enough of them in the UnitedStates, but it's.
Maybe not fully conducted in asupervised rehab.
There may be a coach, there maybe use of trackable wearable
devices, accelerometersmonitoring and accountability.
But that sort of program hasbeen shown to be as effective or
(18:44):
nearly as effective assupervised exercise where people
come into the medical center.
So in this document, it's alsogiven a Class one
recommendation.
And I think the other nice thingthat the document highlights is
a recommendation that.
Exercise is indicated forpatients with chronic
symptomatic PAD.
(19:05):
Even after they get, if they endup getting revascularization for
very limiting symptoms, you cando exercise with that
revascularization to get furtherimprovements in a synergistic
way on functional outcomes.
Ellen (19:21):
That's wonderful, Heather.
'cause.
A lot of times the same thingwith cardiac rehab, right?
We might do an intervention, wemight give them medications, but
that cardiac rehab, thatexercise portion is a real key
piece of the puzzle as well.
So it's nice that it holds truefor PAD as well.
So you're talking to a group ofcardiovascular caregivers and we
(19:44):
obviously can do a lot of thistesting and, and medical
treatment.
But at what point should werefer our patients to a vascular
medicine specialist or aninterventionalist?
At what point do we say, okay,we need some additional
expertise in this field.
Heather (20:01):
Yeah, I think general cardiovascular practitioners can
do a lot for PAD, and I thinkthat's one of the important
reasons why we're excited aboutthis guideline, and we want to
broadly disseminate thisguideline because we want
general cardiovascularpractitioners.
Internal medicine specialists,other specialists to be able to
(20:24):
recognize PAD, diagnose PAD, andmanage potentially a lot of the
patients.
I mean, you're already managingsevere coronary disease and
heart failure, and you'recomfortable with your your,
your.
Lipid lowering agents and bloodpressure lowering agents.
And now our new diabetes agents.
I, I think throw in some goodcareful foot inspection and
(20:47):
exercise, and I think PAD can bevery well managed by the
cardiovascular specialist.
I think if patients are notresponding to usual.
Medical therapy if, if theyremain functionally limited, if
they can't do their job, iftheir quality of life is poor
because they have leg pain withwalking and they have PAD and
(21:08):
they've tried exercise andthey've tried they're on a good
medical regimen.
Those are people who should beseen by a vascular specialist.
And of course any patient withPAD who you think might have
what we now call CLTI, chroniclimb threatening ischemia, that
used to be CLI.
(21:29):
It's got a new name.
And that would be ischemic restpain.
Ulcers or gangrene.
Those are folks who need to seea vascular specialist urgently.
But I don't think every patientwith PAD needs to see a vascular
specialist.
I think a lot of them can bemanaged in cardiovascular
medicine practice.
And I hope these guidelines givea blueprint for people to feel
(21:52):
comfortable doing that.
Ellen (21:54):
I guess since you brought up the difference between
chronic.
Limb, well, chronic limbthreatening ischemia.
Can you discuss the hallmarksand the treatment differences
between the chronic versus acutelimb ischemia?
'cause obviously the sort ofrapidity with which.
Things need to be managed mightbe a bit different.
Heather (22:14):
Yes, for sure.
The CLTI, that's a patient who'sgenerally had symptoms for two
weeks or more, and as mentionedit's a chronic wound, it's rest,
pain, it's an ulcer.
And those people, it is avascular urgency for limb
salvage for them to beevaluated, for revascularization
(22:36):
to prevent, potentially managetheir wounds.
Restore blood flow to the legand salvage as much of the leg
and foot as possible.
The acute limb ischemia, that'sthe six Ps.
You know, the pulseless, pale,polar, parasitic I forget my
other.
I'm laughing and painful.
(22:57):
I'm maybe missing one of thePEA's leg That is acute onset
symptoms.
Those are often embolic events,or they may be.
Thrombotic events on top ofexisting plaque or maybe an
occlusion of a revascularizationsite.
Those are the people who need tocome to the emergency room, get
(23:18):
on IV heparin immediately, andbe evaluated for emergency
revascularization.
Kanny (23:26):
So on that topic Heather, you know, as a general
cardiologist, we're often thefirst one being called by the
emergency room for, for a phoneconsult.
Obviously when we hear thatstory about the acute ischemic
limb, I think, we all understandwe have to, get in touch with,
with one of our vascularcolleagues on an immersion basis
(23:47):
and get that patient in.
Are there any other situationsthat you kind of consider red
flags for the generalpractitioner where, rather than
just electively getting aconsult, we may need to do that
emergently or at least discuss acase with you.
Is, is the acute ischemia themain one or are there any other
clinical scenarios where, thealarm should be getting raised?
Heather (24:09):
I think the CLTI patient is almost at that level.
That's, that group has just avery poor natural history with
high, Likelihood of moving on toamputation or even death.
And I think unfortunately thosepatients, you would think they
would be recognized, but oftenare not.
(24:30):
So there's often a lag in their,in their care.
I think the acute limb ischemia,the patients writhing in pain,
the foot's white, you know, it'skind of obvious.
I think sometimes the CLTIpatient that can be more
indolent and sometimes peopledon't put two and two together.
I think also sometimes peopledon't think if you have a
(24:52):
diabetic patient with a footulcer, that it could be PAD.
A lot of diabetic foot ulcersare PAD related and not just
related to diabetes.
So we actually have, it's beenwell documented that patients
may be.
Getting cared for wounds ormaybe actually may undergo an
amputation without havingvascular assessment to see if
(25:16):
they have PAD and couldpotentially be revascularized.
So I think that that CLTI groupis, is a pretty, is a very high
risk group that's often notmanaged as quickly as they
should be because their symptomsare not as dramatic.
Kanny (25:37):
That's very helpful.
One other topic I wanted to talkabout was kind of you, I think
you alluded at the beginning toteam-based care and we still
have, of course, the moreserious cases that do need
revascularization.
You know, in some settings,they're being done predominantly
by vascular surgeons and othersby, peripheral vascular
cardiology based practitionersas well.
(25:58):
And then of course you have somany well-trained vascular
medicine specialists likeyourself.
There's been a move towardsteam-based care in other areas
of cardiology.
Valvular disease.
We have our heart teamconferences every week.
Interventional cardiology aswell.
You have collaboration betweensurgeons and interventional
cardiologists.
With the more complicated cases,do you see vascular medicine
(26:20):
moving towards a team-based kindof approach?
Because I, you know, in mypractice, I, I still see
especially patients beingreferred from some outlying
hospitals, patients who weremaybe saw a vascular surgeon and
told that, there was absolutelyno option for them.
For definitive surgery.
And then, once they're assessedby an interventional vascular
doc, they actually are a verygood candidate to get,
(26:44):
percutaneous revascularization.
So do you still see some turfbattles like that out there, or
do you think the vascularcommunities also kind of moving
towards, team-based care,mirroring what's happening in,
in the cardiac areas?
Heather (26:57):
Yeah, I think in my 20 years since I left my
fellowship, I've seen greatprogress in this space in terms
of partnership.
I think in this document weemphasize the tremendous
importance of what we call themulti-specialty PAD care team,
and that team includes.
Expertise in vascular surgery,expertise in endovascular care,
(27:20):
expertise in wound care,expertise in risk factor
management.
You know, a lot of expertise phypeople who are experts in
orthotics and prosthetics,infectious disease, et cetera.
And actually our, especially forour CLTI section, we have a
class one recommendation thatpatients with CLTI.
(27:43):
Should be managed by aMultispecialty PAD care team.
Just recognizing that there's alot we can do when we put the
patient at the center and havedifferent perspectives putting
together a care plan and tobuild on your other point.
We actually have arecommendation in the guideline
that for patients with CLTI whorequire amputation, those
(28:08):
patients should be evaluated bythe multi-specialty care team to
assess for the most distal levelof amputation and to make sure
there's no.
Further revascularizationoptions.
So this document stronglyendorses Multispecialty, PAD
care.
I think our multispecialtyguideline writing committee,
(28:30):
which was very collaborative,really reflects great progress
in terms of partnership of allthe different groups and less
competition because.
You know, as I started thisconversation, you have 236
million estimated people in theworld.
With PAD there is plenty of workfor everyone to do, and actually
(28:52):
a lot of patients don't get anyvascular care, so I, I.
I do think we need to partner toincrease the reach of our all
specialties to identify patientswith PAD, treat them properly,
and then for patients withsevere PAD like CLTI really work
together, put the patient at thecenter and come up with the best
(29:13):
care plan that optimizesoutcome.
Ellen (29:17):
Wow, Heather, this has really been quite an eye-opening
discussion and we're learning somuch.
What are the few most importanttakeaways that all cardiac
caregivers should know abouttaking care of their patients
who may have PAD?
Like what are the, the keyaspects from the guidelines that
we just all need to know as, asa summary.
Heather (29:38):
All right.
These may be a combination ofthe guidelines and Heather
Gornick's takeaways, if that'sokay.
That
Ellen (29:44):
is perfect.
Heather (29:46):
I think number one, you are seeing patients with PAD
every day in your cardiovascularmedicine practice.
You just need to decide ifyou're gonna recognize it and
find it or not.
Number two, take off those socksand shoes.
Look at the feet, evaluate thepulses.
Ask about leg symptoms as partof your office visit.
(30:09):
Number three, embrace all ofthese wonderful medical
therapies we now have to preventlimb loss, heart attack, stroke,
and death in these patients.
And I think probably the mostexciting one is the the low-dose
rivaroxaban on top of low-doseaspirin.
And I think number four is ifyour patient has.
(30:29):
Severe PAD, especially the CLTI.
Obviously acute limb ischemia oreven just stable, symptomatic
PAD that's not responding, andthe patient still remains really
limited.
Get them to your trustedvascular specialist for
revascularization andexploration of other options.
Kanny (30:52):
Well, that's, that's a, a concise and awesome summary of a
very broad topic.
So as we always have, weappreciate your insight.
I, I do wanna put one plug,Heather.
You know, obviously we're gonnaput the link to our guidelines
in our podcast notes.
But on acc.org there's also agreat summary document,
(31:13):
guidelines at a glance wherethey summarize, the 10 takeaway
points from your guidelines, butalso have a really nice chart
comparing the differences.
In medical therapy between theseguidelines and the prior edition
as well as the Europeanguidelines.
So it's a very concise way tolook at the key differences
that, of course, most of whichyou've outlined in our
(31:35):
discussion today.
So, thanks again for yourservice to the cardiovascular
community and, and for yourclinical work as well, and also
for being our most downloadedpodcast guests.
Heather (31:47):
Thank you Kenny and Ellen.
It's been a lot of fun talkingto you.
Thank you for joining today'spodcast.
For more information about thespeakers or the topics, please
go to Ohio acc.org,
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