Management of Suspected Peripheral Artery Disease (PAD)

Initial Assessment

The American College of Cardiology recommends that individuals at risk for PAD should undergo a vascular review of symptoms to assess walking impairment, claudication, ischemic rest pain, and/or the presence of nonhealing wounds 3
A comprehensive pulse examination and inspection of the feet should be performed for all individuals at risk for PAD, as recommended by the American College of Cardiology 3
Individuals over 50 years of age should be asked about family history of abdominal aortic aneurysm (AAA) in first-order relatives, according to the American College of Cardiology 3
Blood pressure should be measured in both arms at least once during initial assessment to identify potential subclavian artery stenosis (difference >15-20 mmHg), as recommended by the American Heart Association 2

The European Heart Journal recommends that ankle-brachial index (ABI) is the initial diagnostic test for confirming PAD, with an ABI ≤0.90 confirming PAD diagnosis 1
If ABI is normal (>0.90) but clinical suspicion remains high, post-exercise ABI should be considered, with a post-exercise decrease >20% being diagnostic for PAD, according to the European Heart Journal 1
For ABI >1.40 (non-compressible vessels, common in diabetes and end-stage renal disease), toe-brachial index (TBI) should be used, as recommended by the Journal of the American College of Radiology 4
Duplex ultrasound is recommended as first-line imaging for PAD screening and diagnosis by the European Heart Journal 1
Segmental pressure measurements and pulse volume recordings can help localize disease, according to the American Heart Association 2

The European Heart Journal recommends that for patients with PAD and high ischemic risk but non-high bleeding risk, combination of low-dose rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg daily) should be considered 5

The European Heart Journal recommends supervised exercise therapy for patients with intermittent claudication, with a training frequency of at least three times per week, session duration of at least 30 minutes, and program duration of at least 12 weeks 5

The American College of Cardiology recommends that patients with CLI should undergo expedited evaluation and treatment of factors that increase amputation risk 3
Early recognition and referral to a vascular team is essential for limb salvage, according to the European Heart Journal 5
Revascularization should be performed as soon as possible in CLI patients, as recommended by the European Heart Journal 5

The European Heart Journal recommends that patients with PAD should be followed up at least annually to assess clinical and functional status, medication adherence, limb symptoms, and cardiovascular risk factors 5
Patients with a history of CLI should be evaluated at least twice annually by a vascular specialist due to the high risk of recurrence, according to the American College of Cardiology 3

The European Heart Journal recommends that revascularization may be considered in patients with symptomatic PAD and impaired quality of life after 3 months of optimal medical therapy and exercise 5
Revascularization is not recommended for asymptomatic PAD or solely to prevent progression to CLI, according to the European Heart Journal 5