Evaluation and Management of Peripheral Arterial Disease (PAD)

Initial Assessment

The American College of Cardiology recommends obtaining a comprehensive vascular history including symptoms of claudication, ischemic rest pain, walking impairment, and presence of nonhealing wounds in patients with absent or diminished pedal pulses 1, 3
Assess for risk factors of PAD: age ≥65 years, age 50-64 with atherosclerosis risk factors (diabetes, smoking, hypertension, hyperlipidemia), or diabetes with additional risk factors 4, 2
Perform a thorough vascular examination with the patient's shoes and socks removed 1, 2
Rate pedal pulses (dorsalis pedis and posterior tibial) on a scale: 0 (absent), 1 (diminished), 2 (normal), or 3 (bounding) 1, 2
Inspect for other signs of PAD: elevation pallor, dependent rubor, asymmetric hair growth, trophic skin changes, and nonhealing wounds 2, 3
Auscultate for femoral bruits, which increase likelihood of PAD when present 1, 3
Measure blood pressure in both arms to identify possible subclavian stenosis (difference >15-20 mmHg) 1, 3

The American College of Cardiology recommends ankle-brachial index (ABI) testing as the initial test for patients with absent or diminished pedal pulses 1, 2
Interpretation of ABI results:
- >1.40: Noncompressible vessels (arterial calcification) 6
- 1.00-1.40: Normal 2
- 0.91-0.99: Borderline 2
- 0.60-0.89: Mild arterial obstruction 6
- 0.40-0.59: Moderate obstruction 6
- <0.40: Severe obstruction 6
For patients with noncompressible vessels (ABI >1.40), toe-brachial index (TBI) should be performed 2, 7
For patients with normal ABI (1.00-1.40) but strong clinical suspicion of PAD, exercise ABI may be considered 2

Refer to vascular specialist for patients with severe PAD (ABI <0.40) 5, 6
Refer to vascular specialist for patients with symptoms of claudication or ischemic rest pain 7, 8
Refer to vascular specialist for patients with nonhealing wounds 5, 7
Smoking cessation is recommended for patients with PAD 1, 2
Diabetes management is recommended for patients with PAD 7, 8
Lipid-lowering therapy is recommended for patients with PAD 1, 2
Antihypertensive therapy is recommended for patients with PAD 1, 2
Antiplatelet therapy is recommended for patients with PAD 1, 2

Multidisciplinary approach for patients with foot ulcers and high-risk feet 7, 8
Specialized therapeutic footwear for high-risk patients with diabetes 7, 8
Structured exercise programs for patients with claudication 4, 2

Regular surveillance for patients with confirmed PAD 7, 8
Annual comprehensive foot evaluation for diabetic patients 7, 8
More frequent foot inspections for patients with sensory loss, prior ulceration, or amputation 7, 8