Management of peripheral arterial disease in older persons

Patients with peripheral arterial disease (PAD) are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from coronary artery disease (CAD). Smoking should be stopped, and hypertension, dyslipidemia, diabetes mellitus, and hypothyroidism treated. Statins reduce the incidence of intermittent claudication, improve exercise duration until the onset of intermittent claudication in patients with PAD and hypercholesterolemia, and reduce cardiovascular events and mortality. High-dose statins should be used to treat PAD. Antiplatelet drugs such as aspirin or clopidogrel and angiotensin-converting enzyme (ACE) inhibitors should be given to patients with PAD. Beta-blockers should be given if CAD is present. Cilostazol improves exercise time until intermittent claudication. Exercise rehabilitation programs should be used. Revascularization should be performed if indicated. Patients with an infrarenal or juxtarenal abdominal aortic aneurysm (AAA) measuring 5.5 cm or larger should undergo repair to eliminate the risk of rupture. Patients with an infrarenal or juxtarenal AAA measuring 4.0–5.4 cm in diameter should be monitored by ultrasound or computed tomographic scans every 6–12 months to detect expansion. Patients with an AAA should undergo intensive risk factor modification; be treated with ACE inhibitors, statins, and beta-blockers; and undergo surgery if indicated.