Parvar Saman L, Fitridge Robert, Dawson Joseph, Nicholls Stephen J
Vascular Research Centre, Heart Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Department of Medicine, The University of Adelaide, Adelaide, South Australia, Australia.
Vascular Research Centre, Heart Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Department of Medicine, The University of Adelaide, Adelaide, South Australia, Australia; Department of Vascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
J Vasc Surg. 2018 Nov;68(5):1595-1606. doi: 10.1016/j.jvs.2018.07.027.
Peripheral arterial disease (PAD) is a global health issue associated with impaired functional capacity and elevated risk of major adverse cardiovascular events (MACEs). With changing risk factor profiles and an aging population, the burden of disease is expected to increase. This review considers evidence for the noninvasive management of PAD and makes clinical recommendations accordingly.
A comprehensive literature review was performed to examine the evidence for smoking cessation, exercise therapy, antiplatelet therapy, anticoagulant therapy, antihypertensive therapy, lipid-lowering therapy, and glycemic control in diabetes for patients with PAD.
Nicotine replacement, bupropion, and varenicline are safe and more effective than placebo in achieving smoking abstinence. Wherever it is practical and available, supervised exercise therapy is ideal treatment for intermittent claudication. Alternatively, step-monitored exercise can increase walking performance and the participant's compliance with less staff supervision. Clopidogrel is preferable to aspirin alone for all patients. However, small studies support the use of dual antiplatelet therapy after revascularization to improve limb outcomes. More recently, the addition of low-dose rivaroxaban to aspirin alone was proven to be more effective in reducing MACEs without a significant increase in major bleeding. However, the exact role of direct oral anticoagulant therapy in the management of PAD is still being understood. Evidence is emerging for more intensive blood pressure and lipid-lowering therapy than traditional targets. Whereas research in PAD is limited, there is clinical scope for an individualized approach to these risk factors. The management of diabetes remains challenging as glycemic control has not been demonstrated to improve macrovascular outcomes. Any potential impact of glycemic control on microvascular disease needs to be weighed against the risks of hypoglycemia. Sodium-glucose cotransporter 2 inhibitors appear to reduce MACEs, although caution is advised, given the increased incidence of lower limb amputation in clinical trials of canagliflozin.
Medical and lifestyle management of PAD should aim to improve functional outcomes and to reduce MACEs. Smoking cessation counseling or pharmacotherapy is recommended, although new strategies are needed. Whereas supervised exercise therapy is ideal, there can be barriers to clinical implementation. Other initiatives are being used as an alternative to walking-based supervised exercise therapy. More studies are required to investigate the role of intensive glycemic, blood pressure, and dyslipidemia control in patients with PAD. Overall, a multifactorial approach is recommended to alter the natural history of this condition.
外周动脉疾病（PAD）是一个全球性健康问题，与功能能力受损及主要不良心血管事件（MACE）风险升高相关。随着危险因素分布的变化和人口老龄化，疾病负担预计将会增加。本综述探讨PAD非侵入性管理的证据并据此提出临床建议。
进行全面的文献综述，以研究PAD患者戒烟、运动疗法、抗血小板治疗、抗凝治疗、降压治疗、降脂治疗以及糖尿病血糖控制方面的证据。
尼古丁替代疗法、安非他酮和伐尼克兰在实现戒烟方面比安慰剂更安全且更有效。只要可行且具备条件，监督下的运动疗法是间歇性跛行的理想治疗方法。另外，步数监测运动在较少人员监督的情况下也可提高步行能力和参与者的依从性。对所有患者而言，氯吡格雷比单用阿司匹林更可取。不过，小型研究支持血管重建术后使用双重抗血小板治疗以改善肢体预后。最近，在单用阿司匹林基础上加用低剂量利伐沙班被证明在降低MACE方面更有效，且大出血无显著增加。然而，直接口服抗凝治疗在PAD管理中的确切作用仍有待明确。有证据表明，与传统目标相比，更强化的血压和降脂治疗是有必要的。尽管PAD方面的研究有限，但针对这些危险因素采取个体化方法在临床上是可行的。糖尿病的管理仍然具有挑战性，因为血糖控制尚未被证明能改善大血管结局。血糖控制对微血管疾病的任何潜在影响都需要与低血糖风险相权衡。钠-葡萄糖协同转运蛋白2抑制剂似乎能降低MACE，不过鉴于卡格列净临床试验中下肢截肢发生率增加，建议谨慎使用。
PAD的药物和生活方式管理应旨在改善功能结局并降低MACE。建议进行戒烟咨询或药物治疗，不过还需要新的策略。虽然监督下的运动疗法是理想选择，但临床实施可能存在障碍。其他举措正被用作基于步行的监督运动疗法的替代方法。需要更多研究来调查强化血糖、血压和血脂控制在PAD患者中的作用。总体而言，建议采用多因素方法来改变这种疾病的自然病程。
