Peripheral Arterial Disease


Peripheral arterial disease (PAD) involves the atherosclerotic occlusion of the arterial circulation to the lower extremities. The disease may be asymptomatic (identified only by a reduced blood pressure in the ankle), or it may manifest symptoms of intermittent claudication or severe chronic leg ischemia. The typical patient with PAD presents a decade later than the patient with coronary artery disease and experiences a profound limitation in exercise capacity and quality of life. In addition to affecting the limbs, PAD is a manifestation of systemic atherosclerosis affecting other major circulations involving the cerebral and coronary circulations. Thus, all patients with PAD are at an increased risk of cardiovascular morbidity and mortality. The treatment goals are directed at providing symptom relief and at reducing the risk of systemic cardiovascular morbidity and mortality.


In the Framingham study, subjects were assessed for PAD using a history of claudication as a marker of the disease. Men and women had a similar incidence of intermittent claudication, which increased with age. However, symptoms underestimate the true incidence and prevalence of the disease. Using the ankle-brachial index (ABI; described later), the prevalence of PAD is quite high, affecting 12% of the adult population and 20% of individuals over the age of 70. These figures extrapolate to approximately 8 million persons affected with PAD in the United States.

The natural history of PAD has been evaluated in several studies. These studies have shown that elderly control subjects had an all-cause mortality rate of 1.6% per year. This rate was increased to 4.8% per year in patients with PAD, a 2.5-fold increased risk. Cardiovascular mortality rates are similarly affected, with 3- to 4-fold increased risk for patients with PAD. Importantly, women are at approximately the same risk as men, and even asymptomatic individuals, who are identified solely based on an abnormal ankle-brachial index (ABI), have a markedly increased risk of cardiovascular events. The mortality risk in patients with PAD is maintained after adjustment for other cardiovascular risk factors and even in patients with known coronary artery disease.

What is peripheral arterial disease of the legs?
Peripheral arterial disease (PAD) is poor blood flow in the arteries. The arteries carry blood to the organs and muscles. If arteries get narrowed or blocked because of disease, the muscles and organs may not get enough blood to work properly.

PAD increases your chance of having a heart attack or stroke. People with PAD are 3 to 4 times more likely to die from a stroke or heart attack than people of the same age who do not have PAD.

What causes PAD?

The most common cause is the buildup of plaque on the inside of arteries. Plaque is made of extra cholesterol, calcium, and other material in your blood. Over time, plaque builds up along the inner walls of the arteries, including those that supply blood to your legs.

If plaque builds up in your arteries, there is less room for blood to flow. Every part of your body needs blood that is rich in oxygen. But plaque buildup prevents that blood from flowing freely and starves the muscles and other tissues in the lower body.

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    This process of plaque buildup usually happens at the same time throughout the body. It is called atherosclerosis or hardening of the arteries. If you have this problem in your legs, you most likely will have it in the arteries that supply blood to your heart and brain. These arteries are called coronary arteries and carotid arteries.

    Plaque builds up bit by bit over a lifetime, but symptoms often do not start until after age 65. High cholesterol, high blood pressure, and smoking make you more likely to get atherosclerosis and peripheral arterial disease.

    Women & Vascular Disease
    Heart disease is the #1 killer of women in the United States. Like heart disease, peripheral arterial disease is under-recognized in women. Through early detection, the progression of vascular disease can be halted, saving women from future stroke, heart attack, and early death if PAD is detected early.

    What is the outlook (prognosis) for peripheral arterial disease?

    Studies that have followed-up people with PAD have shown that:

    • Symptoms remain stable or improve in about 15 out of 20 cases.
    • Symptoms gradually become worse in about 4 out of 20 cases.
    • Symptoms become severe in about 1 out of 20 cases.

    So, in most cases, the outlook for the legs is quite good. However, if you have PAD it means that you have an increased risk of developing atheroma in other arteries. Therefore, you have a higher than average risk of developing heart disease (such as angina or a heart attack), or of having a stroke. The main concern for most people with PAD is not that they might need an amputation - but the increased risk of having a heart attack or stroke.

    The chance of developing severe PAD (and heart disease, or a stroke) is much reduced by the self help measures and treatments described below.


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