Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Cardiovascular Risk Reduction
Smoking Cessation
D - Patients with peripheral arterial disease should be actively discouraged from smoking.
Cholesterol Lowering
A - Lipid lowering therapy with a statin is recommended for patients with peripheral arterial disease and total cholesterol level >3.5 mmol/L.
Glycaemic Control
B - Optimal glycaemic control is recommended for patients with peripheral arterial disease and diabetes in order to reduce the incidence of cardiovascular events.
Weight Reduction
D - Obese patients with peripheral arterial disease should be treated to reduce their weight.
Blood Pressure Control
A - Hypertensive patients with peripheral arterial disease should be treated to reduce their blood pressure.
Antiplatelet Therapy
A - Antiplatelet therapy is recommended for patients with symptomatic peripheral arterial disease.
Referral, Diagnosis, and Investigation
Investigations in Secondary Care
Digital Subtraction Arteriography
D - Digital subtraction arteriography is not recommended as the primary imaging modality for patients with peripheral arterial disease.
Computed Tomography Angiography
A - Non-invasive imaging modalities should be employed in the first instance for patients with intermittent claudication in whom intervention is being considered.
Treatment of Symptoms
Licensed Drug Therapy for Peripheral Arterial Disease
Cilostazol
A - Patients with intermittent claudication, in particular over a short distance, should be considered for treatment with cilostazol.
A - If cilostazol is ineffective after three months, or if adverse effects prevent compliance with therapy, the drug should be stopped.
Naftidrofuryl
A - Patients with intermittent claudication and who have a poor quality of life may be considered for treatment with naftidrofuryl.
Oxpentifylline
A - Oxpentifylline is not recommended for the treatment of intermittent claudication.
Inositol Nicotinate
B - Inositol nicotinate is not recommended for the treatment of intermittent claudication.
Unlicensed Research Drugs and Procedures
Statins
A - Statins should be given for risk factor management in patients with intermittent claudication and total cholesterol level >3.5 mmol/L.
Prostaglandins
A - The use of oral prostaglandin therapy in patients with intermittent claudication is not recommended.
Exercise Therapy
A - Patients with intermittent claudication should be encouraged to exercise.
Vascular Intervention
D - Endovascular and surgical intervention are not recommended for the majority of patients with intermittent claudication.
D - For those with severe disability or deteriorating symptoms, referral to a vascular specialist is recommended.
D - The TransAtlantic Inter-society consensus guidelines should be used when advising patients about possible interventions.
Definitions:
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g. case reports, case series)
4: Expert opinion
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group