Cardiovascular · Topic 40 of 48

Peripheral Artery Disease

Cardiovascular · peripheral vascular disease

Peripheral Artery Disease

Atherosclerosis of the legs: an ABI of 0.90 or less confirms it. Antiplatelet, high-intensity statin, structured exercise and cilostazol come before revascularization.

Key numbers

ABI 0.90 or less confirms PADABI ≤ 0.90

Cilostazol for claudication; never in HF100 mg BID

Structured exercise 3×/week for 12 weeks≥ 3×/week × 12 weeks

ABI over 1.40: get a toe-brachial indexTBI ≤ 0.70

01 · Defined byABI 0.90 or less confirms PAD

Resting ankle-brachial index (highest ankle ÷ highest arm systolic pressure) ≤ 0.90 diagnoses PAD; 0.91–0.99 is borderline, 1.00–1.40 normal, and > 1.40 means noncompressible, calcified arteries.

02 · GiveCilostazol for claudication; never in HF

Cilostazol 100 mg twice daily improves claudication and walking distance; this phosphodiesterase-3 inhibitor is contraindicated (boxed warning) in heart failure of any severity.

03 · DoStructured exercise 3×/week for 12 weeks

Supervised or structured community exercise therapy — at least 3 sessions a week for 12 weeks — is first-line for chronic symptomatic PAD and improves walking distance, function and quality of life.

Presentation

What you'll see

Claudication: exertional leg pain relieved by restIntermittent claudication is reproducible aching, cramping or fatigue in the calf, thigh or buttock with walking, relieved within 10 minutes of rest; calf claudication points to femoropopliteal disease, buttock or thigh to aortoiliac.

CLTI: rest pain, ulcers or gangreneChronic limb-threatening ischemia presents as ischemic rest pain that worsens with leg elevation and eases with dependency, dependent rubor, nonhealing toe or heel ulcers, or gangrene.

Leriche syndrome: buttock claudication and impotenceAortoiliac disease (Leriche syndrome) causes buttock, thigh or calf claudication, hip pain and, in men, erectile dysfunction.

Diagnosis & monitoring

Work-up

ABI over 1.40: get a toe-brachial indexWhen arteries are noncompressible (ABI > 1.40, common with diabetes or CKD), measure the toe-brachial index; TBI ≤ 0.70 diagnoses PAD.

Management

Orders

Antiplatelet for every symptomatic patient must knowSingle antiplatelet therapy — aspirin or clopidogrel — is recommended for all patients with symptomatic PAD to reduce MI, stroke and vascular death.

High-intensity statin; LDL-C goal under 55 must knowEvery patient with PAD gets a high-intensity statin (≥ 50% LDL-C reduction); most symptomatic PAD is very-high-risk ASCVD with an LDL-C goal < 55 mg/dL — add ezetimibe and/or a PCSK9 inhibitor to reach it.

Revascularize CLTI; claudication only if refractoryRevascularization is recommended for CLTI to save tissue and limb; for claudication it is reasonable only when symptoms limit function despite medical therapy and structured exercise, and never solely to prevent progression.

Rivaroxaban 2.5 mg BID plus low-dose aspirinFor symptomatic PAD or after lower-extremity revascularization, low-dose rivaroxaban 2.5 mg twice daily plus low-dose aspirin reduces MACE and major adverse limb events in patients not at high bleeding risk.

Exercise ABI when resting ABI is normalIf the resting ABI is normal or borderline but suspicion is high, measure an exercise (treadmill) ABI — a fall of 20% after exercise diagnoses PAD.

Smoking cessation and foot care for allEvery patient with PAD needs tobacco cessation, control of diabetes and blood pressure, and preventive foot care (daily inspection, proper footwear, podiatry), especially with diabetes or neuropathy.

Red flags & don'ts

Avoid harm

No pentoxifylline, chelation or full anticoagulation avoidPentoxifylline and chelation therapy are not recommended for claudication, and full-intensity oral anticoagulation should not be used for PAD alone without another indication such as atrial fibrillation.

Claudication or pseudoclaudication?

Commonly confused

Cause	Exercise-induced reversible limb ischemia
Relief	Rest alone, within minutes
Distal pulses	Weak or absent below the lesion

More detail

Reference

Show 7 reference facts

PAD has four clinical subsets: asymptomatic, chronic symptomatic, chronic limb-threatening ischemia and acute limb ischemia; asymptomatic patients make up 20–59% and still carry excess cardiovascular risk.

Reduce cilostazol to 50 mg twice daily with strong or moderate CYP3A4 or CYP2C19 inhibitors (e.g., ketoconazole, erythromycin, diltiazem, omeprazole); common adverse effects are headache, diarrhea and palpitations.

In PAD with type 2 diabetes, a GLP-1 receptor agonist or SGLT2 inhibitor reduces MACE; ACE inhibitors or ARBs treat hypertension, and beta-blockers are safe in PAD.

Toe systolic pressure < 30 mmHg predicts that ischemic wounds will not heal, while > 60 mmHg suggests healing is likely.

PAD is a marker of systemic atherosclerosis: most patients also have clinically significant coronary or cerebrovascular disease, which drives their high cardiovascular morbidity and mortality.

Duplex ultrasound, CTA or MRA is used when the ABI is inconclusive or to plan revascularization; most revascularizations are now endovascular, with similar limb salvage to surgical bypass.

When amputation is unavoidable it is done as distally as possible; below-knee is preferred over above-knee amputation to allow a prosthesis and ambulation.

Pearl

Treat the patient's heart through the legs: PAD is systemic atherosclerosis, so antiplatelet plus high-intensity statin for everyone with symptoms — walking and cilostazol for the calves.

Sources · Merck Manual Professional — Peripheral Artery Disease · ACC — 2024 ACC/AHA/Multisociety Guideline for Lower Extremity PAD: Key Points · AFP — Management of Lower Extremity Peripheral Artery Disease: Guidelines From the ACC/AHA (2025) · Cilostazol tablets prescribing information — DailyMed · Gornik HL et al. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease. Circulation 2024;149:e1313–e1410 · ACC — Peripheral Matters | PAD: Putting the 2024 Guideline Into Practice · ACC Expert Analysis — Implications of the 2026 ACC/AHA/Multisociety Dyslipidemia Guideline for Lipid Management in Vascular Disease (2026) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).