Interconnectivity of whole arterial system combining peripheral arterial and aortic diseases emphasized for first time in ESC guidelines

The 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases (PAAD) evaluate these vascular diseases together as part of same cardiovascular system, appreciating that patients with aortic diseases are at risk of having peripheral vascular diseases and vice versa. The Guidelines are aimed at cardiologists, but were coordinated for alignment with guidelines for surgeons by EACTS and endorsed by VASCERN and ESVM.

“These updated guidelines have been introduced now due to significant advancements and shifts in our understanding and management of aortic and peripheral artery diseases (PAD), including new treatment modalities, since the last guidelines were published in 2014 and 2017, respectively,” says ESC Guidelines co-chair Professor Jose Fernando Rodriguez Palomares, University Hospital Vall d'Hebron, Barcelona, Spain.

“The decision to integrate these guidelines is based on several key factors. The aorta and peripheral arteries are integral components of the same arterial system. Disorders in one part of this system often have implications for the other,” adds co-chair Professor Lucia Mazzolai of Lausanne University Hospital, Switzerland. “Combining the guidelines provides consistent and standardised recommendations for the management of arterial diseases as a whole. This ensures that patients receive cohesive and coordinated care across different vascular conditions, reducing fragmentation and improving overall treatment outcomes.”

PAAD is estimated to affect around 113 million people aged 40 and over globally, of whom nearly half (43%) are in low- and middle-income countries. The global prevalence is 1.5% and increases with age, affecting 15-20% of those aged 70 years and over and 20-30% of those aged 80 years and older. Prevalence increased by 72% from 1990 to 2019, despite the global population growing only 45%.

PAD is a common circulatory problem in which narrowed arteries reduce blood flow to the limbs, more frequently the legs. It is primarily caused by atherosclerosis, where fatty deposits build up on the artery walls. “This condition can lead to a range of symptoms and complications, significantly affecting both patients and their families,” explains Prof Mazzolai. “Disease manifests in patients with pain, cramping, or fatigue in the legs during physical activity, which subsides with rest. This induces mobility issues affecting daily tasks and quality of life. If not well treated the disease can evolve to severe forms of PAD potentially leading to pain present at rest, non-healing ulcers and risk of amputation. Moreover, presence of PAD significantly increases the risk of cardiac and cerebral events.”

“The burden such diseases place on families is substantial, with patients requiring support in all sorts of ways including the activities of daily life. The whole family may need to adopt lifestyle changes to support the patient, such as healthier eating and exercise,” explains Professor Rodriguez Palomares.

The authors say the most important recommendations in the new 2024 Guidelines are those addressing the chronic nature of PAAD, the importance of screening, and the necessity of comprehensive treatment strategies – and awareness that this a chronic disease that needs lifetime follow-up.

“A significant proportion of patients are asymptomatic and therefore PAAD screening is crucial, based on age, the presence of cardiovascular risk factors, family history and/or presence of syndromic features. PAAD diagnosis can be easily achieved with a non-interventional vascular test/imaging,” says Professor Rodriguez Palomares. The guidelines highlight that optimal pharmacological treatment (antithrombotic, lipid-lowering, antihypertensive, antidiabetic) and emphasis on exercise and lifestyle changes are mandatory and effective in reducing burden of disease. Patients with PAAD have a very high cardiovascular risk and require optimal management of risk factors such as hypertension, hyperlipidemia, and diabetes to prevent serious complications.

Finally, the authors emphasise gender aspects and that PAAD comprises chronic diseases requiring continued attention. They conclude: “PAAD is a chronic disease necessitating lifelong follow-up by vascular specialists, cardiologists, and a multidisciplinary team. Women often present with atypical or asymptomatic disease, warranting special attention during screening. Exercise and lifestyle changes are crucial before considering interventional management in chronic PAAD.” 

Reference:

Lucia Mazzolai, Gisela Teixido-Tura, Stefano Lanzi, Vinko Boc, Eduardo Bossone, Jose F Rodriguez-Palomares, ESC Scientific Document Group , 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases: Developed by the task force on the management of peripheral arterial and aortic diseases of the European Society of Cardiology (ESC) Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS), the European Reference Network on Rare Multisystemic Vascular Diseases (VASCERN), and the European Society of Vascular Medicine (ESVM), European Heart Journal, 2024;, ehae179, https://doi.org/10.1093/eurheartj/ehae179.