Approach for Patients with PAD and T2D: Focus on LDL-C Control

PAD is a common manifestation of atherosclerosis and encompasses all vascular sites, including:¹

• Lower extremity arteries

• Carotid artery

• Vertebral artery

• Upper extremity arteries

• Mesenteric artery

• Renal artery

• Aorta

New 2024 ESC guidelines for the management of peripheral arterial and aortic diseases (PAAD) show:²

	Increased risk of CV events in patients with PAD compared with those without PAD2
	Patients with both PAD and T2DM are at a ‘very high’ risk of cardiovascular events2
In a prospective cohort study in Europe, patients with PAD and T2DM had...
	Higher risk of CV events* compared to those with neither PAD nor T2DM3

Screening for lower-extremity arterial disease (LEAD) is recommended on a regular basis, with clinical assessment and/or ankle-brachial index (ABI) measurement.^2,4

Adapted from Marx N et al. 2023 and Mazzolai L et al. 2024.^2,4

^a TBI when ABI >1.4.
^b Further information regarding wound management and exercise training can be found in the 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases.
^c MRA or CTA when duplex sonography is not sufficient for planning revascularisation.

Patients with PAD, with or without T2DM, are at very high CV risk.¹
These patients require a holistic multifactorial approach to prevention and management.

Reduce increased levels of causal CV risk factors, such as:¹

Target: see below

Target: SBP 120–129 mmHg†

Target is <7.0% (53 mmol/mol)

Reducing LDL-C levels represents the primary target for reducing CV risk¹

According to the 2019 ESC/EAS dyslipidaemia guidelines, and 2024 ESC chronic coronary syndromes guidelines, all patients with PAD have the following LDL-C goals.^1,2

An LDL-C reduction of ≥50% from baseline^‡ and an LDL-C goal of <55 mg/dL (<1.4 mmol/L) are recommended

For patients at very high CV risk (including those with PAD and T2DM) not achieving their LDL-C goal on a maximum tolerated dose of statin and ezetimibe, combination with a PCSK9i is recommended.¹

Recommendations for pharmacological LDL-C lowering¹

Adapted from Mach F et al. 2019 and Mazzolai L et al. 2024.^1,2

You should aim to assess your patients response to therapy 6–8 weeks from initiation.1

Prevent The 1^st Event for your
patients with PAD + T2DM^¥

^*When compared to those with neither PAD nor T2DM, HRs adjusted for age, gender, BMI, smoking, hypertension, LDL-C, and HDL-C were 1.26 (95% Cl 0.84, 1.91); P=0.267, HR 4.17 (95% Cl 2.97, 5.85); P<0.001, and HR 7.82 (95% Cl 5.49, 11.12); P<0.001 for those with T2DM only, for those with PAD only and for those with the combination of PAD plus T2DM, respectively.³

^†Provided the antihypertensive treatment is well tolerated.

^‡The term ‘baseline’ refers to the LDL-C level in a person not taking any LDL-C-lowering medication. In people who are taking LDL-C-lowering medication(s), the projected baseline (untreated) LDL-C levels should be estimated, based on the average LDL-C-lowering efficacy of the given medication or combination of medications.¹

^¥Prevent the first major CV event for your ASCVD patients without prior major CV event.

In a prospective cohort study, cardiovascular events were prospectively recorded over a mean follow-up period of 7.2 ± 2.6 years in 1,049 subjects, encompassing 4 groups: 558 with neither PAD nor diabetes, 153 with T2DM but without PAD, 192 with PAD but without T2DM, and 146 with the combination of PAD and T2DM. 4 PAD patients were defined as those with an ankle brachial index <0.9 or with previous revascularisation of peripheral arteries who underwent routine duplex sonography and in whom PAD was sonographically verified.³

ABI = ankle–brachial index; ASCVD = atherosclerotic cardiovascular disease; BMI = body mass index; CI = confidence interval; CTA = computed tomography angiography; CV = cardiovascular; EAS = European Atherosclerosis Society; ESC = European Society of Cardiology; HbA1c = glycated haemoglobin; HDL-C = high-density lipoprotein cholesterol; HR = hazard ratio; LEAD = lower- extremity artery disease; LDL-C = low-density lipoprotein cholesterol; MRA = magnetic resonance angiography; PAAD = peripheral arterial and aortic disease; PAD = peripheral artery disease; PCSK9i = proprotein convertase subtilisin/kexin type 9 inhibitor; SBP = systolic blood pressure; TBI = toe-brachial index; TcPO2 = transcutaneous oxygen pressure; T2DM = type 2 diabetes mellitus; WlfI = Wound, Ischaemia, foot Infection.

MAT-KW-2400462/V1/OCT2024