The project was led by a multidisciplinary scientific committee comprising eight representatives of the scientific societies which supported the project: the Spanish Society of Arteriosclerosis (SEA), the Spanish Society of Cardiology (SEC), the Spanish Diabetes Society (SED), the Spanish Society of Endocrinology and Nutrition (SEEN), the Spanish Society of Primary Care Physicians (SEMERGEN), the Spanish Society of Family and Community Medicine (semFYC), and the Spanish Society of Internal Medicine (SEMI).

To reach a consensus among the participants, two rounds of Delphi consultations were conducted. This formal, systemic method is used to reach consensus among experts in a specific area of knowledge or common practice. It is an iterative, anonymous process with controlled feedback that provides a statistical response from the group13.

The first round questionnaire was developedbased on a literature review (MEDLINE/PubMed and gray literature) and a discussion group with the scientific committee. The first round questionnaire consisted of two sections: (1) context: open and closed questions (multiple choice or dichotomous response) on participants’ sociodemographic and workplace characteristics and issues related to the perception of the therapeutic target for low-density lipoprotein cholesterol (cLDL)14 and (2) consensus: description of habitual clinical practice and definition of recommendable strategies for the identification and screening of patients with PAD, the control of risk factors (tobacco use, DM, cLDL, lifestyle, hypertension), and treatment and follow-up of patients with PAD.

The second round only included statements that did not reach consensus in the first round. Each panelist was shown their score and the score awarded by the majority of panelists in the first round.

The level of agreement with the statements presented was evaluated using a 7-point Likert scale (from “1 = completely disagree” to “7 = completely agree”) and from three perspectives: habitual clinical practice, necessity, and feasibility of being implemented in the short- to medium-term (≤5 years). Consensus was defined as at least 75% of panelists coinciding on agreement (5–7) or disagreement (1–3).

Each scientific society selected and invited participants according to their professional experience in managing PAD. A link to the online questionnaire was sent via email to a total of 250 experts. The consultation, which was not remunerated, was carried out between May and June 2019.

The percentages obtained for each response were calculated along with the means and standard deviations (SD) of the values (STATA, version 14). In addition, a subanalysis according to specialty was conducted for some issues.

Of the 23 strategies proposed for managing the risk factors in patients with PAD, panelists agreed on (≥75%) considering 22 of them necessary and 21 feasible to implement in clinical practice. Of these 22 strategies, nine were already implemented in clinical practice in a widespread manner (>75%), six were moderately implemented (50%–75%), and five were hardly followed at present (<50%).

One of the key actions for preventing the progression of PAD and its complications is early diagnosis and treatment15. However, despite the known association between PAD and other diseases such as DM, ischemic cardiopathy, and cerebrovascular disease16, our results indicate that specialties such as cardiology or endocrinology are not as involved in the identification of patients with PAD, revealing the need to promote a more active role of these specialties.

Given that a multidisciplinary approach to controlling risk factors is crucial for the optimization of PAD management, this document intends to highlight the role of other specialties in the control of risk factors for PAD and the need for a holistic management of the disease.

The majority of individuals with PAD do not present with signs of claudication6. Therefore, specific screening using the ABI could be a useful tool for the early initiation of strategies that prevent disease progression17. Our study suggests that in clinical practice, screening is only conducted systematically in people with symptoms suggestive of claudication. This could be due to three factors: the majority of current guidelines do not recommend universal screening, the population profiles in which it is recommended are very heterogeneous among the guidelines9–12, and the excessive workload that all specialties are facing at present. In this work, there was consensus on the patient profiles for which screening would be necessary and feasible.

In regard to reassessment of the ABI, the main clinical practice guidelines do not establish a specific frequency9,10,12 with the exception of the Spanish multidisciplinary consensus guidelines on PAD11, which recommend performing it at least every three years in asymptomatic patients with low-intermediate cardiovascular risk. Though this frequency does not appear to be habitual in clinical practice, the experts agreed on reassessment at least every three years in low-risk patients and annually in high-risk patients.

One of the most important modifiable cardiovascular risk factors is tobacco, with the dose and number of years the patient has smoked being proportional to the risk18,19. Our data suggest that the most widespread strategy to promote tobacco cessation is to provide the patient with information on the need to quit smoking. However, in line with the main clinical practice guidelines9–12, it seems that other strategies are necessary, such as joining programs, referral to specific clinics/units, or the prescribing of/recommendation to use antitobacco drugs. The recent inclusion of coverage for antitobacco drugs in the Spanish public healthcare system and the line of action defined by the public health commission on tobacco use prevention could drive its implementation20.

Another important risk factor is dyslipidemia. Indeed, lipid-lowering treatment is one of the main therapeutic strategies in patients with PAD. cLDL has been shown to have a causal role in atherosclerotic cardiovascular disease, further highlighting its importance14. More than 70% of the experts consulted believed that the therapeutic target set in clinical practice is less than 70 mg/dL, a figure that is somewhat higher than the 53% observed in a previous study21. Given its significance, it is necessary to underscore the importance of establishing and using the therapeutic tools necessary to achieve this target, both in symptomatic and asymptomatic patients with established PAD. It is important to note that this therapeutic target was recommended by the guidelines at the time of consultation9–12. More recently, the European ESC/EAS guidelines for the management of dyslipidemia have set the target at less than 55 mg/dL in patients with very high cardiovascular risk22, which would include patients with PAD.

Doing exercise improves symptoms of PAD as well as distance walked, especially if the exercise is supervised23. An association between healthy eating habits and prevention of PAD and its symptoms has also been suggested24,25. Providing exercise recommendations is very common in clinical practice, but providing nutrition recommendations is less common. According to the results of the PREDIMED study26, the panel of experts considers it necessary to stress the importance of following the Mediterranean diet which includes nuts and extra virgin olive oil. The active role of endocrinologists and nutritionists is crucial in this regard.

Hypertension is another known risk factor. An increase in blood pressure of 20 mmHg is associated with a 63% increase in risk of PAD27. However, the suitability of β-blockers for treating hypertension in patients with PAD is a subject of debate28. The panel of experts cconcluded that hypertensive patients with PAD could be prescribed cardioselective β-blockers when necessary.

Antiplatelet therapies have been the cornerstone of treatment of patients with arteriosclerotic diseases such as PAD for a long time. This practice is followed by nearly all professionals in the case of symptomatic patients and to a lesser extent in asymptomatic patients. This trend could be due to the inconsistencies in the recommendations of the main guidelines as a result of the fact that the body of evidence on asymptomatic patients comes from studies with small sample sizes and heterogeneous populations29. In line with the Spanish multidisciplinary consensus guidelines and the American Heart Association and American College of Cardiology (AHA/ACC) guidelines10,11, in our study, treatment with antiplatelet drugs was considered necessary for asymptomatic patients with a pathological ABI and especially in patients with asymptomatic PAD and DM, given their greater atherothrombotic risk30.

This study has some limitations inherent to its methods, in which consensus was based on the participants’ experience. Although the response rate was not very high (52%), which could have led to a response bias, it is important to note that the results come from the perspective of more than 100 professionals with ample experience in PAD; this is the study’s main strength. Likewise, even though not all specialties involved in the management of these patients participated in the Delphi process, the inclusion of specialists in family and community medicine, internal medicine, cardiology, endocrinology and nutrition, and angiology and vascular surgery has allowed for reaching a multidisciplinary consensus in which the main specialties are represented. The consensus reached must be contextualized within the Spanish healthcare system and is intended to serve as support for improving the multidisciplinary management of risk factors for PAD.