Chapter III: Management of Cardiovascular Risk Factors and Medical Therapy

Abstract

Critical limb ischaemia (CLI) is a particularly severe manifestation of lower limb atherosclerosis posing a major threat to both limb and life of affected patients. Besides arterial revascularisation, risk-factor modification and administration of antiplatelet therapy is a major goal in the treatment of CLI patients. Key elements of cardiovascular risk management are smoking cessation and treatment of hyperlipidaemia with dietary modification or statins. Moreover, arterial hypertension and diabetes mellitus should be adequately treated. In CLI patients not suitable for arterial revascularisation or subsequent to unsuccessful revascularisation, parenteral prostanoids may be considered. CLI patients undergoing surgical revascularisation should be treated with beta blockers. At present, neither gene nor stem-cell therapy can be recommended outside clinical trials. Of note, walking exercise is contraindicated in CLI patients due to the risk of worsening pre-existing or causing new ischaemic wounds. CLI patients are oftentimes medically frail and exhibit significant comorbidities. Co-existing coronary heart and carotid as well as renal artery disease should be managed according to current guidelines. Considering the above-mentioned treatment goals, interdisciplinary treatment approaches for CLI patients are warranted. Aim of the present manuscript is to discuss currently existing evidence for both the management of cardiovascular risk factors and treatment of co-existing disease and to deduct specific treatment recommendations.

Critical Limb Ischemia: Current Trends and Future Directions

“…Since then, several international guidelines have been published that include secondary prevention in PAD, such as smoking cessation, management of hypertension and diabetes, lipid lowering, and antiplatelet therapies 7, 22, 34, 35. All PAD and CLI guidelines consider the effectiveness of statins, antiplatelet therapy, and ACE inhibitors to reduce cardiovascular events and mortality proven in the PAD population 7, 22, 34, 35. Recommendations for CLI are often, as a result of lacking CLI‐specific evidence,35, 36 extrapolated from other populations.…”

“…All PAD and CLI guidelines consider the effectiveness of statins, antiplatelet therapy, and ACE inhibitors to reduce cardiovascular events and mortality proven in the PAD population 7, 22, 34, 35. Recommendations for CLI are often, as a result of lacking CLI‐specific evidence,35, 36 extrapolated from other populations.…”

“…High‐level evidence, typically level I, to guide evidence‐based clinical decision making in CLI is limited in contrast to coronary artery, carotid artery, and aortic aneurysm disease 7, 18, 35, 36, 62. Well‐designed prospective studies and RCTs in CLI patients are sparse 80.…”

Role and Management of Coagulation Disorders in Peripheral Arterial Disease

“…Overweight is not usually the most common risk factor, but diabetes is (16). Cigarette smoking is, as about 90% of the patients with PAD used to be cigarette smokers 25 years ago, but fortunately this share is decreasing (17).…”

“…Smoking increases adrenergic activation and fibrinogen levels in addition to its several toxic components injuring vascular wall. the most important evidence-based recommendations for the conservative management of PAOD, are presented by the American College of Chest Physicians Evidence-Based Clinical Practice guidelines (8th Edition) (18) and the guidelines by the European Society of Vascular Surgery (16). Lifelong antiplatelet therapy in comparison with no antiplatelet therapy in PAD patients with or without clinically manifest coronary or cerebrovascular disease is strongly recommended (grade 1A).…”