Peripheral arterial disease is a common and underdiagnosed condition that can be an early warning for heart attacks and stroke. New guidelines suggest that looking for this disease early, before symptoms develop, can save lives.
In 2024, both the American Heart Association and the European Society of Cardiology updated their guidelines for the diagnosis and management of peripheral arterial disease (PAD). Both stressed that PAD is an increasingly common disease that has been underdiagnosed. PAD may be an early warning for arterial disease of the heart and neck. Both guidelines stress the importance of screening for PAD in people at risk, alerting patients to the warning symptoms, and starting treatment early to prevent complications like heart attack, stroke, and amputation.
What Is PAD?
PAD is atherosclerosis of the arteries that supply the legs. Atherosclerosis is cholesterol plaque that gradually builds up inside arteries and restricts blood flow. Atherosclerosis also affects the heart arteries and the arteries in the neck that supply the brain. Restricted blood flow to the heart can cause a heart attack, and in the neck it can cause a stroke. In the arteries that supply the lower limbs, it causes PAD.
PAD is a lifetime disease that requires a lifetime of management. It affects about 12 to 14 million Americans. However, that number may be low, since many people with PAD don’t know they have it. PAD is rare before age 50, affecting less than one percent of adults. It becomes more common with age, affecting about one in four people over age 70. As the population ages, PAD is becoming more common.
Symptoms
About 50 percent of people have PAD before they have symptoms. As PAD progresses, it narrows blood flow to the muscles in the leg or legs. This causes the earliest and most important symptom of PAD, called intermittent claudication. Walking, especially brisk walking or walking uphill, causes the muscles in the legs to need increased blood flow. If PAD is reducing blood flow, a person will notice cramping pain in the leg after walking uphill or for a long distance. At first, the pain goes away with rest within a few minutes, but over time, pain becomes more common and occurs with shorter walks. Pain may also be felt in the buttocks or thigh.
About 75 percent of people will have intermittent claudication for about 10 years before it starts to get worse. More advanced PAD is more obvious and more dangerous. In advanced PAD, reduced blood flow starts to cause pain at rest. Any walking becomes difficult. Pain may be worse at night. Other late changes include discoloration of the lower legs, burning pain, cold feet, ulcerations, and wounds that don’t heal. This stage, called chronic limb threatening ischemia (not enough blood), may require a surgical procedure to restore blood flow to the leg and prevent amputation.
Screening and diagnosis
The American and European guidelines both stress the importance of screening for PAD. The guidelines recommend screening for people who are higher risk for PAD due to their age or atherosclerosis equivalents (other diseases caused by atherosclerosis, like heart attack or stroke). Diabetes and smoking are very high-risk factors. Others include high cholesterol, high blood pressure or blood sugar, and chronic kidney disease.
The guidelines recommend a simple and inexpensive office test that can be done by a primary care provider called the ankle-brachial index (ABI) test as the first choice for screening and diagnosis. ABI is simply measuring blood pressure in the arm and blood pressure in the ankle. The more difference between the two pressures, the higher the index for PAD.
Managing PAD
The new guidelines also include the best evidence-based (research supported) ways to manage and treat PAD. For early PAD, treatment may start with lifestyle change. Perhaps the most important is adding exercise. The research says that a community-based or hospital-based supervised exercise program significantly improves PAD symptoms. Other changes may include a healthier diet with less saturated fat, sugar, and salt.
Reducing manageable risk factors for PAD is an important part of management. This may include lowering cholesterol, blood sugar, and blood pressure, if needed. For people with PAD, even normal levels of “bad” (LDL) cholesterol may need to be lowered with medication. For people without PAD, LDL below 100 mg/dL is good, but for PAD that number should be below 70. For people with high blood sugar, an A1c (a measure of average blood sugar levels over 3 months) should be below 7 percent.
Medications for PAD include statin drugs to lower cholesterol. Other drugs called PCSK9 inhibitors may be need to achieve very low LDL levels. Low-dose aspirin and new blood thinners help prevent the formation of blood clots that could lead to a heart attack or stroke. The new diabetes and weight loss medications can help lower blood sugar and cholesterol. For more than 80 percent of people with PAD, these guidelines should prevent dangerous limb ischemia.
For patients who do progress to dangerous limb ischemia, blood flow can usually be restored by a minimally invasive procedure using a catheter threaded into the artery to reach the blocked area and open it up with a tiny balloon or stent. When PAD progresses, the guidelines suggest it is best treated by medical specialists and a vascular surgeon. Restoring blood flow (revascularization) is recommended for patients who have symptoms and have not responded to medical treatment and exercise.
A team approach is the best way to decide who would benefit from types of medical management or surgery, since PAD affects different people differently.
Bottom line
If you have risk factors for PAD, ask your primary care doctor about screening. If you have intermittent claudication, talk to your primary care provider now. Cramping pain in your leg while walking (even if it goes away with rest) is an important early warning symptom that a heart attack or stroke may be in your future. Untreated PAD can be fatal for 20 to 30 percent of people, with the cause of death usually due to a heart attack. The good news is that catching this disease early and managing it according to the new guidelines can change the future for the better for people with PAD.
