ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 Table 12 – Treatment of peripheral arterial occlusive disease of the lower limbs Indication Recommendation Level of evidence Supervised physical exercise to improve function and quality of life and reduce symptoms of claudication 365,369,375,376 I A Home-based physical exercise or other training modalities to improve functional status 366,370,371 IIa A In symptomatic patients, a supervised physical exercise program should be discussed as a treatment option before revascularization 375,376 I B ergometers, have also proven effective. 371 It is also worth noting that physical exercise is contraindicated in patients with critical ischemia, but should be considered as soon as possible after successful interventional treatment. 371-373 A systematic review of 12 clinical trials including a total of 1,548 patients compared patients who received drug therapy with physical training, endovascular intervention, and open surgery for treatment of claudication. All modalities increased walking distance, reduced symptoms, and improved quality of life. 374 Endovascular intervention and open surgery have proven effective in relieving symptoms, increasing walking distance, and improving quality of life, and are indicated when severe symptoms that negatively influence daily life persist despite full clinical treatment (physical exercise and optimized drug therapy). In a randomized clinical trial of 111 patients with aortoiliac disease, the increase in exercise time on a graded treadmill test was greater in the supervised exercise group than in the stent revascularization group. 375 However, after 18 months of follow-up, the functional and quality of life benefits were equivalent in the exercise and revascularization groups, and, in both cases, were superior to those in the group that received medication alone. 376 Several clinical trials have compared the efficacy and effectiveness of supervised physical exercise, angioplasty, and optimized medical care, using a multitude of different designs. Most trials consisted of two treatment arms. The aforementioned systematic reviews suggested that supervised physical exercise may be superior to optimized medical care or angioplasty. However, these meta-analyses included head-to-head comparisons between two specific treatment arms (e.g., angioplasty versus supervised physical training) or used an approach that did not allow inclusion and direct comparison of all available treatments for intermittent claudication. 377 For these reasons, a recent meta-analysis sought to establish comparisons between all available treatments in order to elucidate the best management of patients with symptomatic PAOD. The sample included 2,983 participants with intermittent claudication (mean age, 68 years), 54.5% of whom were male. The comparisons were optimized medical care (n = 688), supervised physical training (n = 1,189), angioplasty (n = 511), and angioplasty plus supervised physical training (n = 395). The mean follow-up period was 12 months. Compared with optimized medical care alone, angioplasty and supervised physical training outperformed all other therapeutic strategies, with a 290 m gain in maximum walking distance (95% CI: 180 to 390 m; p < 0.001), corresponding to a proportional gain of 141% (95% CI: 86.85 to 188.3%; p < 0.001), with an average follow-up period of 12 months. 378 Supervised physical training alone and angioplasty plus supervised physical training again surpassed the other treatment modalities, with an additional gain of 110 m in maximumwalking distance (95% CI: 16 to 200 m; p < 0.001), or a proportional gain of 66% (95% CI: 9.66 to 121%; p < 0.001). Supervised physical training alone yielded a 180‑m gain in maximum walking distance (95% CI: 130 to 230 m), corresponding to a proportional gain of 87% (95% CI: 63 to 111%); this was higher than with angioplasty alone, but lower than with supervised physical training plus angioplasty, in terms of maximum walking distance. 378 These review studies have important implications for clinical practice. This is because all patients with intermittent claudication should receive optimized clinical treatment, in view of the evidence that shows a reduction in future cardiovascular events and an improvement in limb-related outcomes. 379,380 In this context, supervised physical training and angioplasty are essential to improve walking distance and quality of life. This recent meta-analysis cited above strongly suggests that supervised physical training associated with angioplasty should be part of first-line treatment, always in the context of optimized drug therapy. The offer of angioplasty without optimized physical training should be avoided whenever possible. 378 However, DAOP treatment centers often offer angioplasty primarily due to the lack of centers focused on supervised physical training. Furthermore, it cannot be neglected that supervised physical training faces resistance on the part of patients themselves, who are often little adherent to treatment, which partly justifies the majority preference in favor of percutaneous treatment. 381 However, recent studies have demonstrated the benefits of combining treatment modalities for symptomatic PAOD, which may increase the likelihood that CVR will become increasingly widespread and accessible. 378,382 Thus, in addition to optimized medical care, angioplasty combined with supervised physical training seems to be the ideal strategy for initial treatment of patients with intermittent claudication, both to improve maximumwalking distance and to improve quality of life. However, the data from these latest reviews cannot confirm whether supervised physical training should be followed by angioplasty or vice versa. 974