Primary prevention
The most important preventive actions involve combined dietary and lifestyle modifications (stopping smoking; increasing physical activity; losing weight; increasing consumption of fish, fruits, vegetables, fibre, and nuts; reducing salt intake).[39]
Smoking is a leading preventable cause of disease, disability, and death; even low levels of smoking increase risk of atherosclerotic cardiovascular disease (ASCVD).[39][40] Support programmes, medications, and alternative therapies are available. In adults who use tobacco, a combination of behavioural interventions plus pharmacotherapy is recommended.[39] Secondhand smoke exposure should be avoided.[39]
Routine and/or opportunistic assessment of cardiovascular risk factors with calculation of 10-year risk of ASCVD should be used to guide decisions on treatment with preventive therapies (e.g., statins).[39][41] ACC: ASCVD risk estimator plus Opens in new window
The US Preventive Services Task Force recommends that adults aged 40-75 years without ASCVD but who have one or more cardiovascular risk factors (i.e., dyslipidaemia, diabetes, hypertension, or smoking), and an estimated 10-year cardiovascular disease risk of 10% or greater, should be started on a statin for primary prevention. Those with 10-year risk between 7.5% and 10.0% may selectively be offered a statin. For patients who are 76 years or older there is insufficient evidence to recommend for or against starting a statin for primary prevention.[42]
Aspirin is no longer routinely recommended for primary prevention but may be considered in selected patients for whom the absolute cardiovascular benefit outweighs the absolute risk of increased bleeding.[43]
Secondary prevention
Patients with peripheral arterial disease (PAD) have significantly increased risk of cardiovascular mortality and morbidity, and it is crucial to modify their cardiovascular risk factors. All patients should have aggressive risk factor modification, regardless of their symptoms.[2] This should include: control of blood pressure; guideline-directed management for patients with diabetes; lipid-lowering therapy; cessation of smoking; dietary advice to reduce cardiovascular disease risk and control weight; and increased exercise.[1][2] Additionally, the presence of specific comorbidities and risk factors increases the risk for major adverse cardiovascular events and major adverse limb events in those with PAD. Multisociety US guidelines recommend that patients with PAD should be assessed for these risk amplifiers when developing patient-focused treatment recommendations.[2] These risk amplifiers include (in addition to hypertension, dyslipidaemia, and diabetes) chronic kidney disease, depression, atherosclerotic disease in more than one vascular bed, microvascular disease (retinopathy, neuropathy, nephropathy), and older age and geriatric syndromes (frailty, mobility impairment, sarcopenia, malnutrition). Co-ordination of care across multispeciality teams is important for management of these patients.
Most patients with established peripheral arterial disease will benefit from preventive antiplatelet therapy. Although studies have investigated multiple agents (e.g., aspirin, clopidogrel, other antiplatelet agents, and low-dose anticoagulants [rivaroxaban]) alone and in combination, optimal therapy across the spectrum of disease (symptomatic or asymptomatic, pre- or post-intervention) remains uncertain.[111][112]
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