• A Quick Fix for Better Walking? That's Probably a Bit of a Stretch.

    Management of patients with symptomatic lower-extremity peripheral artery disease (PAD) remains challenging. There are limited evidence-based options that provide significant functional improvement. There are only two US Food and Drug Administration-approved medications for the indication of claudication in PAD: cilostazol and pentoxifylline. Cilostazol offers only modest improvement in PAD-associated walking impairment and is not well-tolerated by patients because of its adverse effect profile. Furthermore, the most recent US as well as European PAD management guidelines do not recommend the use of pentoxifylline because of lack of evidence for efficacy. Supervised exercise therapy (SET) has been shown to improve claudication symptoms and walking in multiple randomized controlled trials. More recently, the CLEVER trial demonstrated that SET provides durable improvement in functional status and in quality of life for up to 18 months when compared to stent revascularization. Therefore, the Centers for Medicare and Medicaid Services issued a memorandum on May 25, 2017, to establish coverage for SET in PAD patients with claudication. Recent randomized clinical trials have also demonstrated benefits from (non-supervised) home-based walking programs. Despite clear benefits, compliance remains very poor with exercise programs, especially in elderly patients. SET is not widely available, and when available, there are barriers of affordability, accessibility, and transportation. In a recent review of more than 1500 patients with stable symptomatic PAD by Harwood et al. , 50% showed no interest and refused participation in SET, and an additional 19% reported that attending SET is too inconvenient. Thus, approximately 70% of patients declined SET, even when it was available at no cost to them. Elderly patients are also more likely to have limited mobility due to other comorbidities, such as arthritis, coronary artery disease, congestive heart failure, and chronic obstructive pulmonary disease, affecting their exercise capacity. Thus, obviously, more options are needed for PAD patients suffering from intermittent claudication.



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