2026 ACC/AHA Multisociety PAD Guidelines – Pharmacologic Therapy
2026 ACC/AHA Multisociety PAD Guidelines – Pharmacologic Therapy
JACC | Just Accepted – January 8, 2026
Key Take-Home Messages
• PAD is a high-risk systemic atherosclerotic disease → requires comprehensive medical therapy, not limb-focused treatment alone.
• ACE inhibitors (or ARBs)
• Class I indication – strong recommendation (should be used) in eligible PAD patients, unless contraindicated.
• Considered first-line, evidence-based therapy, not optional.
• Highlighted separately in PAD due to benefits beyond blood pressure control, including:
• Anti-inflammatory effects
• Prevention of adverse vascular remodeling
• Improved endothelial function
• Antiplatelet therapy
• Aspirin or clopidogrel recommended for all PAD patients to reduce MI, stroke, and vascular death.
• In selected high-risk patients, dual pathway inhibition (low-dose rivaroxaban + aspirin) may reduce major adverse cardiovascular and limb events.
• Lipid-lowering therapy
• High-intensity statins for all PAD patients, regardless of baseline LDL.
• Add ezetimibe or PCSK9 inhibitors if LDL targets are not achieved.
• Blood pressure management
• BP control is essential.
• In addition to ACEi/ARBs, other agents (e.g., calcium channel blockers, thiazide diuretics) may be used as needed.
• Diabetes management
• In PAD patients with diabetes, prefer agents with proven CV benefit:
• SGLT2 inhibitors
• GLP-1 receptor agonists
• Symptom-directed therapy
• Cilostazol may improve claudication and walking distance in patients without heart failure.
• Improves function and quality of life but does not reduce CV events.
Core Principle
Pharmacologic therapy in PAD must be systematic, guideline-directed, and comprehensive, targeting both systemic cardiovascular risk and limb outcomes, and integrated with lifestyle modification and structured exercise therapy.
Guidelines include saphenous vein assessment before revascularization.
https://www.jacc.org/doi/10.