Promoting an increased awareness and standardized approaches in diagnosing and treating peripheral artery disease



The initial diagnosis of PAD begins with a thorough history and physical examination. Patients in whom a diagnosis of PAD should be considered include those with the following risk factors: [15]

  • Age ≥ 65
  • Age 50-64 with risk factors including diabetes, tobacco use (current or former), hypertension, dyslipidemia, or family history of PAD
  • Age < 50 with diabetes and 1 additional atherosclerosis risk factor
  • Atherosclerotic disease in other vascular beds including coronary, carotid, renal, or mesenteric

Patients at high risk for PAD should be screened for exertional leg symptoms. Of importance, only a minority of patients with PAD will report classic intermittent claudication or present with ischemic rest pain. Since a significant number of PAD patients have co-morbidities such as spinal stenosis, peripheral neuropathy, and osteoarthritis, their symptoms will be more consistent with atypical leg pain that may occur at rest or with exertion [16]. In patients who report no leg symptoms, studies have shown that some degree of functional impairment is usually present [17]. Therefore, even in high-risk patients who are asymptomatic, a thorough history assessing functional capacity is important to detect underlying PAD.

History findings suggestive of PAD:

  • Intermittent claudication
  • Atypical leg pain
  • Functional impairment
  • Ischemic rest pain
  • History of non-healing wounds

Physical examination for PAD:

  • Pulse assessment
    • Femoral, popliteal, dorsalis pedis, and posterior tibial arteries should all be examined.
    • Pulses are graded as 0, absent; 1+, diminished; 2+, normal; 3+, bounding.
    • Pulse examination is not sufficient to establish or exclude PAD diagnosis [18].
    • A hand-held continuous wave Doppler may be used to help determine severity of disease based on signal phasicity.
    • Iliac or femoral bruits may also be suggestive of PAD.
  • Skin examination
    • Arterial ulcers – common on toes and bony prominences; typically painful
    • Gangrene
    • Mottled skin
    • Atrophic nails
    • Extremity hair loss


15. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(12):e686-e725.

16. McDermott MM, Greenland P, Liu K, et al. Leg symptoms in peripheral arterial disease: associated clinical characteristics and functional impairment. JAMA. 2001;286:1599-606.

17. McDermott MM, Fried L, Simonsick E, Ling S, Guralnik JM. Asymptomatic peripheral arterial disease is independently associated with impaired lower extremity functioning. The Women’s Health and Aging Study. Circulation. 2000;101(9):1007-1012.

18. Criqui MH, Fronek A, Kaluber MR, et al. The sensitivity, specificity, and predictive value of traditional clinical evaluation of peripheral arterial disease: results from noninvasive testing in a defined population. Circulation. 1985;71:516-22.