Premature atherosclerotic peripheral artery disease: An underrecognized and undertreated disorder with a rising global prevalence

Abstract

Premature atherosclerotic peripheral artery disease (PAD) of the lower extremities is characterized by disease diagnosis before the age of 50 years. The global prevalence of premature PAD has increased, and the disease is often underdiagnosed given heterogenous patient symptoms. Traditional cardiovascular risk factors like smoking, diabetes, hypertension, and hyperlipidemia as well as non-traditional risk factors like elevated lipoprotein(a), family history of PAD, hypercoagulability, and systemic inflammation are associated with premature PAD. Patients with premature PAD tend to have an aggressive vascular disease process, a high burden of cardiovascular risk factors, and other concomitant atherosclerotic vascular diseases like coronary artery disease. Prevention of cardiovascular events, improvement of symptoms and functional status, and prevention of adverse limb events are the main goals of patient management. In this review, we discuss the epidemiology, risk factors, clinical evaluation, and management of patients with premature PAD.

Keywords: Atherosclerosis; Claudication; High-risk cardiovascular disease; Pad; Young patients.

Fig. 1.. Change in number of young patients living with peripheral artery disease from 2000 to 2015.

The number of patients living with premature PAD has increased worldwide with a disproportionately greater increase in low/middle-income countries. PAD = peripheral artery disease, LMIC = low/middle-income countries, and HIC = high-income countries. Data derived from Fowkes et al. [9] and Song et al. [10].

Fig. 2.. Risk factors, clinical evaluation, and management of patients with stable premature PAD of the lower extremities.

Young individuals with established AS-CVD and/or a high burden of traditional and certain non-traditional risk factors are at risk for developing premature PAD. Clinical evaluation of these patients involves an extensive history, physical examination with a focus on the vascular system, and resting ABI with or without segmental blood pressure and pulse volume recording measurement. Management goals are three-fold: prevention of cardiovascular events, improvement of limb-related symptoms, and prevention of adverse limb events. These are achieved through a multidisciplinary approach medical management and arterial revascularization when indicated. PAD = peripheral artery disease, Lp(a) = lipoprotein(a), HIV = human immunodeficiency virus, ABI = ankle brachial index, TBI = toe brachial index, BP = blood pressure, PCSK9i = proprotein convertase subtilisin/kexin type 9 inhibitor, ACEi = angiotensinogen converting enzyme inhibitor, GDMT = guideline directed medical therapy, CT = computed tomography, and MR = magnetic resonance.