Guidelines for the management of peripheral artery and aortic diseases

The 2024 Guidelines for the management of peripheral arterial and aortic diseases were developed by the task force of the ESC [1–3]. This groundbreaking document combines the management of peripheral arterial and aortic disease for the first time, emphasising a holistic multidisciplinary approach to vascular health.

The new guidelines recommend multidisciplinary management by an experienced team. The prevalence of peripheral arterial and aortic diseases is high: 113 million people ≥40 years are affected. Of those ages 80–84 years, nearly 15% have peripheral arterial and aortic disease [1].

PAD: Underdiagnosed and undertreated

Despite the high prevalence, particularly in women, peripheral arterial disease (PAD) is still too often overlooked. “The disease is often asymptomatic,” Prof. Lucia Mazzolai (University Hospital Centre Vaudois, Switzerland) emphasised [2]. Thus, screening is necessary, as early PAD diagnosis is crucial for better outcomes. This is particularly true in women, because typical symptoms, such as intermittent claudication, are less common than in men, while atypical symptoms are more common.

The ankle-brachial index (ABI) is the recommended initial diagnostic test for PAD screening and diagnosis. An ABI ≤0.90 is chosen as a diagnostic criterion. “Duplex ultrasound is the recommended first-line imaging method to confirm PAD, especially in women,” Prof. Mazzolai said. PAD is categorised according to clinical presentation and may or may not be associated with limb wounds.

The new guideline recognises the broad therapeutic aims of PAD management. As patients with PAD have a 4 to 5-time increased risk of CV events compared with patients without PAD, the goals of treatment are to reduce the risk of cardiac disease, cerebrovascular disease, and lower limb disease and to improve the quality-of-life of patients. This goal can best be achieved by an optimal multimodal medical treatment consisting of pharmacological treatment, supervised exercise training, and lifestyle behaviour.

A new recommendation is that revascularisation is not recommended in asymptomatic PAD. “Revascularisation is only recommended in symptomatic PAD patients following a period of optimal medical treatment and exercise and needs to be discussed in a multidisciplinary setting,” Prof. Mazzolai said.

Another new recommendation is given for antithrombotic treatment following revascularisation. In these patients, a treatment combining rivaroxaban (2.5 mg twice daily) and aspirin (100 mg once daily) should be considered when a patient has a non-high bleeding risk (class IIa recommendation). There is also a new class I recommendation for aggressive lipid-lowering therapy with an LDL-C goal of <55 mg/dL (1.4 mmol/L). Regardless of revascularisation, supervised exercise training is recommended in patients with symptomatic PAD (class I). Walking should be recommended as the first-line training modality with a frequency and duration of 3x/week for 30 minutes.

A regular follow-up of patients with PAD is recommended, at least once a year (class I recommendation). “These patients need constant and lifelong follow-up. This is a chronic disease, we often forget this,” Prof. Mazzolai concluded.

Standardisation in aortic nomenclature and measurement

“It is important for us to use the same nomenclature to be able to communicate properly,” Prof. José Rodríguez Palomares (University Hospital Vall d’Hebron, Spain) pointed out [2]. Therefore, the new guidelines recommend (class I) a standardisation in aortic nomenclature and measurements. A transthoracic echocardiogram (TTE) is recommended as the first-line imaging technique in evaluating thoracic aortic diseases. A second recommendation is the evaluation of risk factors for aneurysm rupture. Aortic diameters are measured at prespecified anatomical landmarks. Aortic diameter is the most important predictor of aneurysm rupture, but not as a sole predictor. “It has to be coupled with other morphological criteria like aortic length and the aortic phenotype,” explained Prof. Alessandro Della Corte (University of Campania Luigi Vanvitelli, Italy) [3]. Especially for body sizes at the lower end of the normal distribution index in aortic diameter to body surface area (BSA), nomograms, z-scores, or other indexing methods should additionally be considered for a more accurate assessment of aortic size (class IIa recommendation).

Surgery is now recommended in all patients with dilatation of the aortic root or ascending aorta with a tricuspid aortic valve and a maximum diameter of ≥55 mm. Valve-sparing aortic root replacement is recommended if the technique is feasible. In patients with low predicted risk, surgery is even advocated at smaller diameters.

The new guidelines provide an algorithm for the surveillance of patients with non-heritable thoracic aortic disease with different surgical options based on individual patients. Moreover, a new algorithm is introduced for genetic and imaging screening in patients with thoracic aortic disease. “If the patient is younger than 60 years and presents with acute aortic syndrome or aortic dilatation without CV risk factors, we should refer this patient to a specialised centre,” Prof. Palomares said [2]. In case of a positive genetic test, genetic testing of at-risk biological relatives is recommended.

Another new algorithm aims to prevent delay of diagnosis in patients with acute aortic syndrome (AAS) that advocates immediate cardiovascular CT in high-risk patients. The novel algorithm for medical management of AAS is based on 3 steps. The first step consists of rate/pressure control titrated to a heart rate of 60 bpm. Second comes pain control with intravenous opiates. Step 3 follows when systolic BP remains ≥120 mmHg and entails intravenous vasodilators with the goal of the lowest possible BP that maintains adequate organ perfusion.

Finally, the guidelines contain an interventional treatment algorithm for (AAD) [1]. A new recommendation for endovascular repair is given in the subacute phase of uncomplicated type B AAD in patients with risk factors, if feasible (see Figure). The main problem in these conditions continues to be a delay in diagnoses or transferring patients to an aortic centre.

Figure: Interventional treatment algorithm for patients with uncomplicated type B acute aortic dissection (AAD). Modified from [1]

AAD, acute aortic dissection; Ao, Aorta; CCT, cardiovascular computed tomography; CMR, cardiovascular magnetic resonance; FL, false lumen; OMT, optimal medical therapy, TEVAR, thoracic endovascular aortic repair.

1. 
   
   1. Mazzolai L, et al. Eur Heart J 2024;45(36):3538-3700.
   2. Presentations in Session ‘2024 ESC Guidelines Overview’ ESC Congress 2024, 30 Aug–02 Sept, London, UK.
   3. Presentations in Session ‘2024 ESC Guidelines for the management of peripheral arterial and aortic diseases,’ ESC Congress 2024, 30 Aug–02 Sept, London, UK.

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Posted on 7 November 20247 November 2024