The 2024 AHA/ACC PAD Guideline: Elevating and Recognizing the Role of Podiatry in Peripheral Artery Disease Care
Peripheral artery disease (PAD) represents a critical and often underrecognized vascular condition that affects millions worldwide. Characterized by atherosclerotic narrowing of the lower extremity arteries, PAD significantly increases the risk of cardiovascular events, limb loss, mortality, and diminished quality of life.1 The understanding of PAD has advanced since the previous Guideline publication almost a decade ago. The 2024 update of the American Heart Association (AHA) and American College of Cardiology (ACC) PAD Guideline is a collaboration with the American Podiatric Medical Association (APMA), the Society for Vascular Medicine (SVM), American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), Association of Black Cardiologists (ABC), Society for Cardiovascular Angiography and Interventions (SCAI), Society for Vascular Nursing (SVN), Society for Vascular Surgery (SVS), Society of Interventional Radiology (SIR), and Vascular & Endovascular Surgery Society (VESS).1 It offers a major step forward in advancing evidence-based care. Notably, this update highlights the indispensable role of podiatry in preventing amputations and improving outcomes in patients with PAD.1
The Expanded Scope of Podiatry in the Evolving Landscape of the PAD Guideline
The 2024 AHA/ACC PAD Guideline marks the first major revision since 2016, driven by substantial advances in scientific knowledge and therapeutic approaches.2 It is also the first inclusion of the APMA and podiatry as a profession in the Writing Committee that developed it, underscoring the growing recognition of the foot and ankle specialist’s crucial role in managing this complex disease.1 Developed through a rigorous, multisocietal process involving cardiologists, vascular surgeons, podiatrists, primary care clinicians, and other specialists, the new Guideline reflects a comprehensive, patient-centered vision of PAD care.
This update is more than a refinement of prior recommendations; it is a call to action to address PAD as both a cardiovascular and limb-threatening disorder. The Guideline places significant emphasis on multidisciplinary collaboration and health equity—areas where podiatry has a unique and powerful contribution to make.1,3 Some of the major differences in the 2024 PAD Guideline compared to the 2016 edition are highlighted in Figure 1.
PAD: A Disease With Limb and Life Consequences
PAD affects up to 20 million people in the United States; despite its prevalence, it remains underdiagnosed and undertreated, particularly in vulnerable populations.4 PAD is a leading cause of nontraumatic lower extremity amputations and is associated with a 2- to 6-fold increased risk of major cardiovascular events such as myocardial infarction and stroke.4,5
Historically, podiatry’s role in PAD management was often limited to addressing foot ulcers or infections after they occurred. The 2024 Guideline encourages a proactive stance—positioning podiatrists as primary physicians for prevention, early detection, and limb preservation.1 The new Guideline also identifies 4 subsets of PAD based on their clinical impressions. Podiatry plays an important role in each subset, though each has a different focus and set of responsibilities. Podiatrists are often the first clinicians to detect early signs of ischemia, such as nonhealing wounds, rest pain, and subtle skin changes. In the Asymptomatic stage, awareness of the disease and early diagnosis with referral to a specialist for appropriate treatment (risk modifications, guideline-directed medical therapy, etc.) is necessary. For the Chronic Symptomatic stage, wound care, structured exercise, or pharmacologic therapy for claudication may be in order. Surgical offloading procedures may become necesary to reduce the risk of future ulcerations. In the more severe categories of critical limb-threatening ischemia (CLTI) and acute limb ischemia (ALI), podiatry provides an adjunctive role that may include wound care, offloading or biomechanical consultation. If a patient requires a partial amputation, our understanding of how the foot functions is valuable in determining the most appropriate surgical procedure to yield a functional foot.
In all stages, podiatry has 3 responsibilities: awareness, monitoring, and protection. Often when the patient leaves the catheterization lab or hospital after an intervention, the podiatrist may become the primary physician responsible for those legs for the remainder of that patient’s life.
The updated Guideline recognizes that timely foot care can prevent progression to CLTI and amputation. It calls for podiatrists to be integral members of the PAD care team, working alongside vascular specialists, primary care providers, endocrinologists, and wound care professionals.1
Through comprehensive foot exams, advanced wound care techniques, offloading strategies, and patient education, podiatrists help reduce the risk of wounds, infection, and amputations. Moreover, as members of limb preservation teams, podiatrists contribute to shared decision-making about revascularization options and postprocedural care.1,3
Some of the Guideline recommendations relevant to podiatry include1:
Routine Foot Surveillance and Risk Stratification
The 2024 Guideline recommends that all patients with PAD receive regular foot examinations (Figure 2). Podiatrists are ideally positioned to provide this surveillance, identify high-risk foot conditions, and initiate prompt interventions. Podiatry is considered a key participant in the medical care of the patient with PAD.1
There are several new medical recommendations our profession should know so they can assist in the guideline-directed care of our patients with PAD. In patients with claudication, cilostazol may improve leg symptoms or walking distance, but prescribers should avoid its use in people with congestive heart failure.1 In those with CLTI who have undergone endovascular or surgical revascularization, low-dose rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin may reduce the risk of major adverse cardiovascular or limb events.1 Management of diabetes and smoking cessation are key, as are the importance of blood pressure and lipid-lowering therapy, which may require higher-intensity drug therapy in PAD treatment (Figure 2).1
Multidisciplinary Limb Preservation Teams
A major innovation in the Guideline is the endorsement of multidisciplinary limb preservation programs. These teams, which must include podiatrists, carry the charge of developing individualized care plans integrating medical therapy, wound care, revascularization, and rehabilitation.1
Podiatrists are experts in caring for wounds of the lower extremity, especially in the diabetic population. Diabetic foot disease occurs through a combination of factors including peripheral neuropathy, metabolic dysfunction, biomechanical and structural anomalies, and ischemia, all of which lead to ulcerations that we see on a regular basis. Our ability to balance foot pressure by offloading techniques, utilizing both insert/shoe modifications and surgical procedures, are key to providing our patients with the best chance of walking throughout their lives. The 2024 Guideline recognizes the importance of podiatry as a critical member of the limb preservation team (Figure 2).
Structured Exercise and Mobility Preservation
Supervised exercise therapy, including walking programs, remains a cornerstone of PAD management. Podiatrists play a vital role in enabling mobility through biomechanical assessments, orthotic interventions, and treatment of foot deformities that may impede exercise. Research continues to validate the benefits of supervised exercise therapy and structured community-based exercise programs that include behavioral changes to patients with symptomatic PAD.1,6
Early Referral for Revascularization
The Guideline encourages prompt referral for vascular imaging and intervention when wounds fail to heal or when signs of CLTI emerge. Podiatrists’ expertise in wound evaluation and classification is critical in determining when revascularization is necessary.1 Notifying our vascular colleagues of situations where we believe ischemia is present or worsening can make all the difference whether a limb can be saved or not. One of the most important functions of podiatry is awareness and education of PAD, not only to our patients and their families, but to our referral systems, including primary care.
Health Equity and Amputation Prevention
A major focus of the 2024 update is reducing disparities in PAD outcomes. The Guideline calls attention to the disproportionate burden of PAD-related amputations in racial and ethnic minority populations, rural communities, and those with lower socioeconomic status.3 The Guideline also identified PAD risk amplifiers, such as age, diabetes, tobacco use, chronic kidney disease, polyvascular disease, microvascular disease, and depression as important considerations that can accelerate this disease process.1
Building Multidisciplinary Collaborations
The development of these guidelines was a truly collaborative effort with about 30 experts from various specialties working together to provide input and opinion on each Guideline recommendation. There is podiatric input within every recommendation and not just those specifically related to the foot. These discussions began when the Writing Committee formed in 2020 and continued for almost 4 years, with the APMA involved with every decision. Podiatry was viewed not only as the experts of the foot, but as crucial members of the limb preservation team whose goal was to improve the life of the patient.
Implementing the recommendations of the 2024 PAD Guideline will require robust multidisciplinary collaboration. Podiatrists are central to this model, working with vascular surgeons, wound care specialists, endocrinologists, physical therapists, and primary care providers.1
Overcoming Barriers and Embracing Opportunities
Despite the clear benefits of podiatric involvement, several barriers remain. Access to podiatric services is inconsistent, especially in underserved geographic areas where there may be few podiatrists.7 The Guideline underscores the need for policy advocacy to expand access to podiatric services and support the establishment of limb preservation programs.3
Telemedicine represents a promising avenue for expanding podiatric reach, particularly for routine foot surveillance and patient education.8,9 The Guideline encourages innovative models, including virtual wound monitoring and remote consultations.1
The Guideline as a Learning and Reference Tool
This document of nearly 100 pages is an excellent reference source for discussing many different topics within PAD treatment and research. Each of the 13 sections include descriptions of the recommendations, followed by a discussion of the research substantiating the opinions. Sections include discussion on clinical assessment and diagnosis, treatment options both pharmacologic and revascularization-oriented, the importance of exercise, and special considerations such as PAD risk amplifiers and health disparities. The Guideline also presents evidence gaps and advocacy priorities to help guide future decisions to improve the health outcomes of our patients.1
Conclusion: A New Era for Podiatry in PAD Care
The 2024 AHA/ACC PAD Guideline represents a pivotal moment for podiatry. By formally recognizing podiatrists as essential members of the PAD care team, the Guideline validates the specialty’s longstanding commitment to limb preservation and patient well-being. It is a valuable resource for all podiatrists to assist in the understanding and treatment of peripheral artery disease.
Dr. Evans is the Chief of Podiatry, in the Department of Orthopedics at Corewell Hospital in Dearborn, MI. He serves the American Heart Association Council on PVD Leadership Committee as APMA Liaison. He is also the Co-Chair of the Research & Data Analysis Subcommittee of the American Limb Preservation Society.
Get insights into PAD, DFU, and more at Podiatry Today’s Wound Care and Limb Preservation Specialty Channel at https://shorturl.at/fubkY.
References
1. 2024 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149:e1-e130.
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3. Conte MS, Bradbury AW, Kolh P, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. Eur J Vasc Endovasc Surg. 2019;58(1S):S1-S109.
4. Yost ML. Addressing disparities in PAD care in underserved populations. Vasc Dis Manag. 2023;20(4):E67-E73.
5. Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States. Circulation. 2004;110:738-743.
6. Treat-Jacobson D, McDermott MM, Bronas UG, et al. Implementation of supervised exercise therapy for patients with symptomatic peripheral artery disease: a science advisory from the American Heart Association. Circulation. 2019;140(13):e700-e710.
7. Couch A, Hill B, Smith T, et al. Describing the factors related to rural podiatry work and retention in the podiatry workforce: a national survey. J Foot Ankle Res. 2023;16(1):4.
8. Takahashi EA, Schwamm LH, Adeoye OM, et al. An overview of telehealth in the management of cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2022;146:e558-e568.
9. DiLosa K, Gibson K, Humphries MD. The use of telemedicine in peripheral artery disease and limb salvage. Semin Vasc Surg. 2023;36(1):1-6.
10. Cohoon KP, Almarshad M, Monteleone P, et al. Implementing the 2024 ACC/AHA multisocietal PAD guidelines into clinical practice: key changes from the 2016 guidelines. Vasc Med. 2025;30(1):110-113.
