• Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of peripheral arterial disease. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2006 Oct. 37 p. (SIGN publication; no. 89). [129 references]

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

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of peripheral arterial disease. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2006 Oct. 37 p. (SIGN publication; no. 89). [129 references]

Not applicable: The guideline was not adapted from another source.

2006 Oct

Scottish Intercollegiate Guidelines Network - National Government Agency [Non-U.S.]

Scottish Executive Health Department

Not stated

Guideline Development Group: Professor Gerry Fowkes (Chair) Professor of Epidemiology, Public Health Sciences, University of Edinburgh; Ms Margaret Armitage, Vascular Liaison Nurse, Greater Glasgow Primary Care Trust; Professor Jill Belch, Professor of Vascular Medicine, Ninewells Hospital and Medical School, Dundee; Mr Graham Bell, Lay representative, Penicuik; Ms Julie Brittenden, Senior Lecturer and Consultant Vascular Surgeon, Aberdeen Royal Infirmary; Dr Henry Doig, Lay representative, Glasgow; Dr Ian Gillespie, Vascular (Interventional) Radiologist, Royal Infirmary of Edinburgh; Ms Margaret Greene, Vascular Technologist, Southern General Hospital, Glasgow; Ms Alison Howd, Consultant Vascular Surgeon, Queen Margaret Hospital, Dunfermline; Dr Gordon Isbister, General Practitioner, Beith; Dr Moray Nairn, Programme Manager, SIGN Executive; Dr Jackie Price, Clinical Lecturer, Public Health Sciences, University of Edinburgh; Ms May Roseburgh, Clinical Nurse Specialist, Royal Infirmary of Edinburgh; Ms Mairi Ross, Senior Vascular Physiotherapist, Raigmore Hospital, Inverness; Ms Helen Scott, Superintendent Physiotherapist WESTMAR, Southern General Hospital, Glasgow; Ms Valerie Sinclair, Vascular Nurse, Stirling Royal Infirmary; Ms Christine Smith, Vascular Liaison Nurse, Raigmore Hospital, Inverness; Mrs Ailsa Stein Information Officer, SIGN Executive; Dr Rebecca Walton, Specialist Registrar in Public Health, Lothian NHS Board; Dr Olivia Wu, Health Economist, Reproductive and Maternal Medicine, Division of Developmental Medicine, University of Glasgow

Declarations of interests were made by all members of the guideline development group. Further details are available from the Scottish Intercollegiate Guidelines Network (SIGN) Executive.

This NGC summary was completed by ECRI on November 28, 2006.