Peripheral arterial disease and claudication

This page covers lower-extremity PAD from the asymptomatic patient to claudication, chronic limb-threatening ischaemia (CLTI) and acute limb ischaemia (ALI).^[1] It follows the 2024 ESC peripheral arterial and aortic diseases guideline for diagnosis, risk-factor treatment, exercise, antithrombotic therapy and revascularization.^[1] Aortic aneurysm is covered in Aortic aneurysm: sizing, growth and repair thresholds and acute aortic syndromes in Acute aortic syndromes: dissection classification and management.

• General prevention is covered in Cardiovascular risk prediction and when to treat, Dyslipidaemia: LDL targets, statin intensity, ezetimibe-PCSK9 and Diabetes as cardiovascular disease: SGLT2i and GLP-1 outcomes.

One disease, four presentations

• The 2024 ACC/AHA lower extremity PAD guideline frames its recommendations across four clinical presentation subsets: asymptomatic, chronic symptomatic, chronic limb-threatening ischemia and acute limb ischemia.^[2]

• Asymptomatic PAD (ESC 2024): suspected by loss of lower-limb pulses or by imaging done for other purposes, and detected by a pathological ABI or TBI; these patients have no intermittent claudication (IC) or atypical effort-related symptoms.^[1]

• Masked PAD: PAD without provoked leg pain because of reduced walking capacity for other reasons or reduced pain sensitivity.^[1]

• Symptomatic (effort-related) PAD: a pathological ABI or TBI with IC, atypical effort-related symptoms or chronic lower-limb wounds (diabetic foot, or non-healing ulceration or gangrene ≥2 weeks) without critically reduced limb perfusion.^[1]

• Intermittent claudication: exertional muscle pain and dysfunction in the territory of the obstructed arterial segment, relieved at rest.^[1]

• CLTI: the more severe chronic presentation, with a critical haemodynamic status (ankle pressure <50 mmHg, toe pressure <30 mmHg or TcPO₂ <30 mmHg) responsible for ischaemic rest pain, non-healing chronic ulceration (>2 weeks) or foot gangrene.^[1]

In women, IC is less prevalent than in men and atypical symptoms are more common.^[1]

• Because wound healing and amputation risk may be affected by PAD, diabetes and/or infection, ESC 2024 text says amputation risk assessment should be systematically performed with the Wound, Ischaemia, and foot Infection (WIfI) classification; its row says WIfI should be considered in PAD with chronic wounds (Class IIa, Level C).^[1]

ESC 2024 Table 7: PAD categorized according to clinical presentation

^{[1] [1]}

Epidemiology and prognosis

ESC 2024 says PAD affects 113 million people aged 40 and older worldwide, 42.6% of them in countries with a low-to-middle sociodemographic index.^[1]

• Global prevalence is 1.52%; it rises with age, reaching 14.91% at 80–84 years, and in that age group it is higher in women than in men (18.03% vs. 10.56%).^[1]

^[1]

Against symptomatic PAD, CLTI further raises the risk of all-cause death (relative risk 2.26) and of MACE (relative risk 1.73).^[1] Higher amputation rates than in the insurance data were reported in trials and registries focused on CLTI.^[1] A major adverse limb event (MALE) carries a three-fold increase in death and a 200-fold increase in later lower-extremity amputation.^[1] The risk of MACE and MALE increases with the number of arterial beds involved.^[1]

Clinical assessment

ESC 2024 says the vascular examination includes pulse palpation, femoral, carotid and abdominal bruit auscultation, heart auscultation, and inspection of the legs and feet.^[1]

• A difference in brachial SBP of more than 15 mmHg raises the risk of cardiovascular death by 50%, so bilateral arm BP measurement is recommended (text; no class or level given).^[1]
• Laboratory tests include a lipid profile with lipoprotein(a) at least once in a lifetime, fasting glucose, HbA1c, renal function, blood count, coagulation, liver function, electrolytes, CRP and ESR.^[1]

Recommendation Table 1 (ESC 2024)

^[1]

ESC 2024 says determining walking impairment, capacity and functional status is mandatory in all patients with PAD.^[1] Treadmill testing with standardized criteria is the gold standard for walking performance.^[1] The maximal walking distance (MWD) is where pain becomes maximal, and the pain-free walking distance (PFWD) is where pain begins.^[1] The Edinburgh Claudication Questionnaire, a modified Rose questionnaire, has a sensitivity of 91% and a specificity of 99% against a physician-based diagnosis.^[1]

The ankle–brachial index and other pressure tests

Recommendation Tables 2 and 11 (ESC 2024)

^[1]

ESC 2024 says the ABI needs to be reported separately for each leg.^[1] Resting ABI has a sensitivity of 68%–84% and a specificity of 84%–99% for PAD.^[1] An ABI ≤0.90 confirms PAD; for values >1.40, the term non-compressible arteries should be used.^[1] An ABI >1.40, seen with arterial stiffness in diabetes, severe kidney failure or advanced age, correlates with increased cardiovascular events and mortality risk.^[1]

• The TBI is measured at the hallux, second or third toe with a laser Doppler probe or plethysmography, and its usual pathological threshold is ≤0.70.^[1]

Beyond limb perfusion, ESC 2024 says the ABI is a surrogate marker for cardiovascular and all-cause mortality.^[1]

Haemodynamic thresholds

^[1]

• When the resting ABI is >0.90 and PAD is still suspected, ESC 2024 says post-exercise ABI measurements should be considered, along with imaging studies, preferably by treadmill (text; no class or level given).^[1]

It warns that recent studies found numerous false positives in healthy people with a post-exercise ABI drop of >20% as the threshold.^[1] A resting TcPO₂ >30 mmHg is a favourable indicator of wound healing.^[1]

^[1]

Imaging

Recommendation Table 12 (ESC 2024)

^[1]

Duplex ultrasound has a sensitivity of 88% and a specificity of 95% for detecting stenosis >50%.^[1] It separates atherosclerotic from non-atherosclerotic lesions, but its reliability depends on the sonographer.^[1] CTA has better spatial resolution and calcium visualization than MRA, but blooming can overestimate stenosis.^[1] Digital subtraction angiography is mostly limited to revascularization procedures.^[1]

Screening

Who to screen

^{[1] [3]}

ESC 2024 calls the ABI the preferred first-line test in asymptomatic people aged ≥65 years, especially women.^[1] It defines multisite artery disease as atherosclerosis in two or more vascular beds.^[1] Screening for asymptomatic disease in additional vascular sites did not seem to improve outcomes, although multisite disease is associated with worse outcomes.^[1]

Treating cardiovascular risk

ESC 2024 says patients with PAD should receive comprehensive optimal medical treatment, including supervised exercise training and lifestyle change.^[1] Patients with PAD are less likely to receive it than patients with coronary artery disease.^[1]

Risk-factor rows (ESC 2024 Recommendation Tables 7–10 and 70)

^{[1] [9]}

Exercise therapy for claudication

Recommendation Table 13 (ESC 2024)

^[1]

ESC 2024 says symptomatic patients should be medically screened before starting SET.^[1] SET is safe and improves treadmill PFWD and MWD, six-minute walking distance, health-related quality of life and cardiorespiratory fitness.^[1] Exercise has not been found to improve the ABI.^[1] Ideally SET is co-ordinated by vascular physicians and supervised by clinical exercise physiologists or physiotherapists.^[1] Home-based training should be proposed when SET is not available, although it is inferior for walking performance.^[1] ESC 2024 adds that prescribing high-pain exercise may hinder uptake and adherence.^[1] SET combined with endovascular revascularization significantly improves walking performance and quality of life and reduces future revascularization.^[1]

Antithrombotic therapy

Asymptomatic PAD

• ESC 2024 reports that a trial of antiplatelet agents in asymptomatic patients with an ABI ≤0.95 showed no effect on MACE or revascularization, although patients with PAD are at very high cardiovascular risk.^[1]

Its text says antithrombotic therapy should not be systematically given in asymptomatic PAD.^[1]

Recommendation Table 14 (ESC 2024), asymptomatic PAD

^[1]

Symptomatic PAD

Recommendation Table 14 (ESC 2024), PAD

^[1]

• High ischaemic risk (ESC 2024 footnote): previous amputation, CLTI, previous revascularization, high-risk comorbidities (heart failure, diabetes, vascular disease in two or more vascular beds) or eGFR <60 mL/min/1.73 m².^[1]
• High bleeding risk (ESC 2024 footnote): dialysis or GFR <15 mL/min/1.73 m², acute coronary syndrome <30 days, a history of intracranial haemorrhage, stroke or TIA, or active or clinically significant bleeding.^[1]

ESC 2024 text says clopidogrel may have a modest advantage over aspirin.^[1]

• It says aspirin with vascular-dose rivaroxaban is more effective than aspirin alone in PAD, reducing MACE and MALE and preventing acute limb ischaemia, but with more major bleeding.^[1]

Patients with a high-risk limb presentation (CLTI, previous amputation or revascularization) or high-risk comorbidities (heart failure, diabetes or polyvascular disease) benefit the most.^[1] After endovascular therapy, ESC 2024 notes that DAPT for 1–3 months is supported by rare randomized studies.^[1]

Atrial fibrillation, polyvascular disease and diabetes

^{[1] [14] [12] [3]}

• ESC 2024 defines high bleeding risk for the polyvascular row as prior intracerebral haemorrhage or ischaemic stroke, other intracranial pathology, recent gastrointestinal bleeding or anaemia from possible gastrointestinal blood loss, other bleeding-prone gastrointestinal disease, liver failure, bleeding diathesis or coagulopathy, extreme old age or frailty, or renal failure needing dialysis or eGFR <15 mL/min/1.73 m².^[1]

Its text adds that when PAD coexists with another indication for an oral anticoagulant, such as AF or a mechanical valve, anticoagulation is warranted.^[1]

• For PAD with AF, read the peripheral-guideline row together with the ESC 2024 atrial fibrillation rows: the peripheral row uses the CHA2DS2-VASc score, and the atrial fibrillation guideline scores thromboembolic risk with CHA2DS2-VA.^[1][14]

^{[5] [8] [6] [7] [1]}

Drugs for walking distance

ESC 2024 says cilostazol, naftidrofuryl, pentoxifylline, buflomedil, carnitine and propionyl-L-carnitine are suggested to increase walking distance in IC without an effect on cardiovascular health.^[1] Their objective benefit is generally limited, from mild to moderate, with considerable variability.^[1] Cilostazol, a phosphodiesterase type III inhibitor, improved MWD compared with placebo and pentoxifylline.^[1] It also has antiplatelet effects, needs cautious combination with other anticoagulant and antiplatelet drugs, and increases bleeding complications.^[1] These drug statements come from the ESC 2024 text (no class or level given).^[1]

When to revascularize for claudication

Recommendation Tables 15 and 16 (ESC 2024)

^{[1] [1]}

• ESC 2024 reports a meta-analysis of aorto-iliac TASC II C–D lesions in which short-term morbidity and mortality favoured the endovascular approach and early and mid-term primary patency favoured open surgery, with comparable secondary patency.^[1]

For femoro-popliteal disease needing revascularization, its text says endovascular therapy should be the first choice even for complex lesions, especially at high surgical risk.^[1] ESC 2024 text says the FDA revised its position, and drug-eluting treatment is now deemed safe and efficient for femoro-popliteal lesions.^[1]

Follow-up

• ESC 2024 recommends following patients with PAD regularly, at least once a year, for clinical and functional status, medication adherence, limb symptoms and risk factors, with duplex ultrasound as needed (Class I, Level C).^[1]

Its text advises annual follow-up for symptomatic PAD or after intervention, with ABI or TBI measurement and duplex ultrasound for new or worsening symptoms.^[1]

Chronic limb-threatening ischaemia

• ESC 2024 says CLTI should be considered in the presence of one of three lower-limb signs or symptoms: ischaemic rest pain, a non-healing lower-limb wound of ≥2 weeks, or lower-limb gangrene.^[1]

Ankle pressure <50 mmHg, toe pressure <30 mmHg or TcPO₂ <30 mmHg may be used to guide diagnosis when CLTI is suspected.^[1] Ischaemic rest pain mainly affects the forefoot, worsens lying flat and eases when the leg is lowered.^[1]

• The standard ABI may be normal or falsely high in CLTI because of non-compressible arteries from medial sclerosis, common in diabetes or CKD, so toe pressure, TBI or TcPO₂ should also be obtained.^[1]

The WIfI classification adds wound size and the extent of foot infection to limb perfusion to estimate the individual risk of amputation.^[1]

Recommendation Tables 11 and 18–21 (ESC 2024)

^[1]

ESC 2024 calls comprehensive vascular imaging mandatory in all patients with CLTI to evaluate revascularization options.^[1] Even when a patient is not a revascularization candidate, it says DSA should be obtained to prevent unnecessary amputation or to limit its extent.^[1] All-cause mortality and MI rates are more than two-fold higher in CLTI than in unselected patients with an ABI ≤0.90.^[1]

• ESC 2024 says patients can be grouped as average procedural risk (peri-procedural mortality <5% and 2-year survival >50%) or high procedural risk (peri-procedural mortality ≥5% and 2-year survival ≤50%).^[1]

Lower-limb amputation carries a 30-day mortality of up to 22%.^[1]

The vascular team should include at least a vascular physician, a vascular surgeon and a radiologist.^[1] Lower-limb exercise training is contraindicated until ulcers are healed, and aggressive offloading should be ensured to allow healing.^[1] Revascularization should aim to restore in-line direct flow to the foot rapidly.^[1] In 40% of cases, inflow treatment of femoro-popliteal disease is needed.^[1] A bypass should be as short as possible, using the saphenous veins.^[1] In short infra-popliteal lesions, endovascular therapy is the first choice.^[1] Spinal cord stimulation may be considered when no viable revascularization option exists.^[1] With extensive necrosis or infectious gangrene, primary major amputation without revascularization may be preferable to avoid complications.^[1]

^{[10] [11]}

Follow-up after CLTI revascularization

ESC 2024 puts the first-year incidence of vein graft stenosis at 20%, with late problems scarce if the first 12 months are uneventful.^[1]

• After bypass, clinical examination, ABI or TBI and duplex should be performed within 4–6 weeks and then at 3, 6, 12 and 24 months (text; no class or level given).^[1]

After endovascular treatment, restenosis and occlusion range from 5% in the pelvic region to >50% in the infra-popliteal arteries.^[1]

Acute limb ischaemia

ESC 2024 defines ALI as an abrupt decrease in arterial limb perfusion and calls it a medical emergency.^[1]

• Causes include PAD progression, cardiac or aortic embolization, aortic dissection, graft or aneurysm thrombosis, popliteal entrapment, trauma, phlegmasia cerulea dolens, ergotism, hypercoagulable states and vascular procedures.^[1]

Skeletal muscle and nerves tolerate ischaemia for roughly 4–6 h.^[1] Sensory loss or, especially, motor deficit signals a threatened limb and requires emergency imaging and revascularization.^[1] Severe sensory deficit with paralysis suggests the limb may be unsalvageable.^[1]

ESC 2024 Table 9: clinical categories of acute limb ischaemia

^[1]

• The same table lists capillary refill as present and biomarkers as not elevated in grade I, and both absent or massively elevated in grade III.^[1]
• Duplex helps set urgency when neurological assessment is difficult: a lost arterial signal suggests limb threat, while a present signal may mean the limb is not immediately threatened and allows ABI measurement.^[1]

^[1]

Recommendation Table 22 (ESC 2024)

^[1]

On diagnosis, ESC 2024 text says to start analgesia, anticoagulation and intravenous fluids.^[1]

• It gives intravenous unfractionated heparin (bolus 5000 IU or 70–100 IU/kg, then an adjusted infusion) or subcutaneous low molecular weight heparin, such as enoxaparin 1 mg/kg twice daily, to prevent further embolization and thrombus propagation.^[1]

Thrombus extraction, thrombo-aspiration and surgical thrombectomy are indicated with neurological deficit, while catheter-directed thrombolysis is more appropriate in less severe cases without neurological deficit.^[1] Systemic thrombolysis has no role in ALI.^[1] If the limb is unsalvageable, primary amputation or comfort care is indicated.^[1] Four-compartment fasciotomy should be performed after long-lasting ischaemia to prevent post-reperfusion compartment syndrome.^[1] Because ALI is frequently thrombo-embolic, Holter ECG, echocardiography and aortic imaging help start the right therapy, in particular anticoagulation.^[1]

Before vascular or other surgery

Recommendation Table 28 (ESC 2022)

^[4]

• The same guideline says non-cardiac surgery should be prioritized in patients needing revascularization for PAD, with careful peri-operative monitoring for worsening limb perfusion, particularly in CLTI.^[4]

Pitfalls

• Trusting a normal or high ABI in diabetes or renal failure: with non-compressible ankle arteries or an ABI >1.40, additional methods such as toe pressure, TBI or Doppler waveform analysis are recommended (ESC 2024, Class I, Level B), and with diabetes or renal failure, measuring toe pressure or TBI is recommended if the resting ABI is normal (Class I, Level C).^[1]
• Revascularizing symptomatic PAD before a 3-month period of optimal medical treatment and exercise therapy: ESC 2024 says revascularization may be considered with impaired PAD-related quality of life after that 3-month period (Class IIb, Level B).^[1]
• Revascularizing to prevent CLTI: not recommended when that is the only reason (ESC 2024, Class III, Level B).^[1]
• Long-term DAPT in PAD, routine ticagrelor in PAD, or oral anticoagulant monotherapy for PAD (unless for another indication): each is not recommended (ESC 2024, Class III, Level A).^[1]
• Prescribing exercise to a patient with CLTI and wounds: lower-limb exercise training is not recommended (ESC 2024, Class III, Level C).^[1]
• Delaying a limb with a neurological deficit for imaging: urgent revascularization is recommended; diagnostic imaging is recommended to guide treatment, provided it does not delay treatment, or if the need for primary amputation is obvious (ESC 2024, Class I, Level C).^[1]
• Systemic thrombolysis for ALI: ESC 2024 says it has no role.^[1]

Evidence, guidelines and regional differences

^{[1] [14] [3] [12]}

• ESC 2024 says rivaroxaban 2.5 mg twice daily plus aspirin 100 mg once daily should be considered in PAD with high ischaemic risk and non-high bleeding risk (Class IIa, Level A) or after lower-limb revascularization with non-high bleeding risk (Class IIa, Level B); ADA 2026 says aspirin 81 mg daily plus rivaroxaban 2.5 mg twice daily should be considered in stable coronary and/or peripheral artery disease with low bleeding risk (recommendation 10.35, grade A).^[1][3]
• ESC 2024 recommends full oral anticoagulation in PAD with newly diagnosed AF and a CHA2DS2-VASc score ≥2, whereas the ACC/AHA/ACCP/HRS 2023 row makes oral anticoagulant monotherapy reasonable over dual therapy in AF with concomitant stable PAD, to reduce the risk of bleeding; the ESC 2024 atrial fibrillation guideline scores thromboembolic risk with CHA2DS2-VA (a score of 2 or more: Class I, Level C).^[1][12][14]
• The 2024 ACC/AHA lower extremity PAD guideline updates the 2016 AHA/ACC guideline, but only its PubMed abstract is held, so none of its rows appear here.^[2]

In Australia and New Zealand

• The Australian guideline on diagnosis and management of PAD, part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease, adapted the 2019 IWGDF guidelines to the Australian context using a panel of national content experts and NHMRC procedures; only its PubMed abstract is held.^[13]
• Its abstract recommends that all people with diabetes and a diabetes-related foot ulcer undergo clinical assessment for PAD with bedside testing (no grade given in the abstract).^[13]
• It says further vascular imaging and possible need for revascularisation should be considered for all patients with a non-healing diabetes-related foot ulcer (DFU), whatever the bedside results, and that all centres treating DFU should have expertise in, and/or rapid access to facilities necessary to diagnose and treat PAD, and should provide multidisciplinary care post-operatively (no grade given in the abstract).^[13]
• No NHFA/CSANZ PAD guideline is quoted, so the other rows on this page come from the guidelines listed below, such as ESC 2024 recommending ABI measurement as the first-line non-invasive test for screening and diagnosis of PAD, using an ABI ≤0.90 as a diagnostic criterion (Class I, Level B).^[1]
• The Australian and New Zealand documents below are those with a held-status entry in the census for this topic.
• Only the PubMed abstract of the 2023 Australian guideline for assessing and managing cardiovascular disease risk (PMID 38623719) is held; its full text is not held and was not checked for this topic.
• The NHFA/CSANZ Comprehensive Australian Clinical Guideline for Diagnosing and Managing Acute Coronary Syndromes 2025 (PMID 40180468) is not held as text in its version of record, so it was not checked for this topic.
• The NHFA/CSANZ Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018 (PMID 30077228) are not held as text in their version of record, so they were not checked for this topic.
• The 2024 CSANZ Position Statement on Indications, Assessment and Monitoring of Structural and Valvular Heart Disease With Transthoracic Echocardiography in Adults (PMID 38749800) is not held as text in its version of record, so it was not checked for this topic; only its PubMed abstract is quotable.
• Only the PubMed abstract of the A summary of the 2023 Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) hypertension in pregnancy guideline (PMID 38763516) is held; its full text is not held and was not checked for this topic.

Guidelines checked for this topic

• Rows on this page come from the ESC 2024 peripheral arterial and aortic diseases guideline and the ESC 2022 non-cardiac surgery guideline.^[1][4]

• Other rows come from the ADA Standards of Care in Diabetes 2026 (section 10) and the 2023 ACC/AHA/ACCP/HRS atrial fibrillation guideline.^[3][12]

• Study results are quoted from the PubMed abstracts of CAPRIE, EUCLID, COMPASS, VOYAGER PAD, the FOURIER PAD analysis, BEST-CLI and BASIL-2.^{[5][8][6][7][9][10][11]}

• For the rows on this page, the same-month and newer guidelines of the same body in the census below were checked and give no revising row, except where a newer row is shown in its place (census 2026-10-23).

• The held guidelines below were checked, and no row from them is used here; each line gives the reason.

• ESC 2023 diabetes (PMID 37622663): its lower-extremity artery disease rows for people with diabetes are older than the ESC 2024 peripheral arterial and aortic diseases rows used here, which cover PAD with diabetes in Recommendation Tables 5, 10, 11 and 14.

• ESC 2021 prevention (PMID 34458905): its rows for lower extremity artery disease, including BP control at <140/90 mmHg in LEAD with hypertension, are older than the ESC 2024 blood pressure rows for PAD with hypertension used in the risk-factor section above.

• Lipid guidelines (ESC/EAS 2019, PMID 31504418, with its 2025 focused update, PMID 40878289; ACC/AHA 2026 dyslipidemia, PMID 41824552): ESC/EAS 2019 places PAD at very high risk in narrative, and ACC/AHA 2026 counts symptomatic PAD as a major ASCVD event in its very-high-risk definition; their rows apply to all ASCVD and are covered in the dyslipidaemia topic, and the PAD lipid rows here come from ESC 2024.

• Blood pressure and cardio-kidney-metabolic guidelines: ESC 2024 hypertension (PMID 39210715) names PAD within established cardiovascular disease and, in narrative, says ABI testing should also be considered in hypertension when PAD is clinically suspected; it has no PAD-specific recommendation row. AHA/ACC 2025 high blood pressure (PMID 40811497) states that it does not provide recommendations on BP prevention and management in patients with PAD; its section 5.3.10 Peripheral Artery Disease is a narrative synopsis without recommendation rows, which says in text that ACEi or ARB should be first line for adults with PAD and hypertension and refers readers to Section 5.3 of the 2024 ACC/AHA lower extremity PAD guideline. AHA/ACC/ADA/ASN 2026 cardiovascular-kidney-metabolic (PMID 42263157) states that it does not provide recommendations regarding the general prevention and management of PAD; both say these topics are the focus of other AHA/ACC guidelines.

• ESC 2026 cardiac rehabilitation (PMID 42661418): it places patients with PAD out of its scope and refers to the 2024 ESC peripheral arterial and aortic diseases guideline.

• Coronary guidelines (ESC 2024 chronic coronary syndromes, PMID 39210710; AHA/ACC 2023 chronic coronary disease, PMID 37471501; ESC 2023, PMID 37622654, and ACC/AHA 2025, PMID 40014670, acute coronary syndromes): their antithrombotic rows apply to coronary disease, and in ESC 2024 chronic coronary syndromes PAD appears in narrative such as COMPASS subgroups; ESC 2024 chronic coronary syndromes also has a row that clopidogrel may be considered in preference to aspirin in symptomatic and asymptomatic patients with either PAD or a history of ischaemic stroke or transient ischaemic attack (Class IIb, Level B), the same class as the ESC 2024 peripheral row. The NHFA/CSANZ 2025 ACS summary (PMID 41693087) and the Fourth (PMID 30571511) and Fifth (PMID 42661425) universal definitions of MI: the census sweep found no PAD wording in their held text. The PAD antithrombotic rows here come from the ESC 2024 peripheral arterial and aortic diseases guideline.

• AHA/ACC 2024 perioperative (PMID 39316661): PAD appears in narrative on the preoperative ECG, and it is replaced by the 2026 edition listed below.

• Aortic, valvular, congenital, pregnancy and sports guidelines (ACC/AHA 2022 aortic disease, PMID 36322642; ESC/EACTS 2025, PMID 40878295, and ACC/AHA 2020, PMID 33332150, valvular heart disease; ESC 2025 pregnancy, PMID 40878294; ACC/AHA/HRS/ISACHD/SCAI 2025, PMID 41411375, and ESC 2020, PMID 32860028, adult congenital heart disease; ESC 2020 sports cardiology, PMID 32860412; AHA/ACC 2025 competitive sports statement, PMID 39973614) and AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR 2021 chest pain (PMID 34709879): outside this topic.

• Heart failure guidelines (AHA/ACC/HFSA 2022, PMID 35363499; ESC 2026, PMID 42661420; NHFA/CSANZ 2018, Heart Lung Circ PMID 30077227 and its Med J Aust summary PMID 30067937): heart failure care, outside this topic.

• Rhythm guidelines (ACC/AHA/HRS 2018 bradycardia, PMID 30412709; ESC 2019 SVT, PMID 31504425; ESC 2021 pacing, PMID 34455430; ESC 2022 ventricular arrhythmias, PMID 36017572): outside this topic.

• ESC 2023 cardiomyopathies (PMID 37622657), AHA/ACC 2024 hypertrophic cardiomyopathy (PMID 38718139), ESC 2023 endocarditis (PMID 37622656), ESC 2025 myocarditis and pericarditis (PMID 40878297), ESC 2019 (PMID 31504429) and AHA/ACC 2026 (PMID 41712677) pulmonary embolism, ESC/ERS 2022 pulmonary hypertension (PMID 36017548) and the 2024 pulmonary hypertension documents (PMIDs 39209475, 39209476): outside this topic.

• Vascular-society documents were checked through PubMed: the Global Vascular Guidelines on CLTI (2019, PMID 31182334), the IWGDF/ESVS/SVS guideline on PAD in diabetes with a foot ulcer (2023, PMID 37724984), the SVS 2025 focused update on intermittent claudication (PMID 40316185) and the ESC 2025 scientific statement on antithrombotic treatment after CLTI revascularization (PMID 40392218) are held only as PubMed abstracts; the ESVS 2024 asymptomatic PAD and claudication guideline (PMID 37949800), the ESVS 2020 acute limb ischaemia guideline (PMID 31899099) and the 2026 Canadian PAD statement (PMID 41856353) have no PubMed abstract and are not held as text; none is used.

• The documents in this list are not used; each line gives the held status recorded in the census for this topic.

• Only the PubMed abstract of the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease (PMID 38743805) is held; its full text is not held and was not checked for this topic.

• Its abstract says it updates the 2016 AHA/ACC lower extremity PAD guideline with new evidence and adds new recommendations on comprehensive care for patients with PAD.^[2]

• The Management of Peripheral Artery Disease in Adults With Diabetes: 2025 ACC Scientific Statement (PMID 41405527) is not held as text in the evidence caches, so it was not checked for this topic.

• Only the PubMed abstract of the 2026 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery (PMID 42804570) is held; its full text is not held and was not checked for this topic.

• The 2018 ESC/EACTS Guidelines on myocardial revascularization (PMID 30165437) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes (PMID 31504439) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation (PMID 32860058) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation (PMID 32860505) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (PMID 34447992) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2021 ESC/EACTS Guidelines for the management of valvular heart disease (PMID 34453165) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization (PMID 34882435) is not held as text in the evidence caches, so it was not checked for this topic.

• The 2022 ESC Guidelines on cardio-oncology (PMID 36017568) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (PMID 37622666) are not held as text in the evidence caches, so they were not checked for this topic.

• Only the PubMed abstract of the Pulmonary hypertension associated with left heart disease (PMID 39209478) is held; its full text is not held and was not checked for this topic.

• The JCS/JPCPHS 2025 Guideline on Pulmonary Hypertension and Pulmonary Embolism/Deep Vein Thrombosis (PMID 42386545) is not held as text in the evidence caches, so it was not checked for this topic.

• The 2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the European Renal Association (ERA) (PMID 42661426) are not held as text in their version of record, so they were not checked for this topic.

• Only the PubMed abstract of the European Respiratory Society clinical practice guidelines update for the treatment of pulmonary arterial hypertension (PMID 42705705) is held; its full text is not held and was not checked for this topic.

Exam pearls

• ABI ≤0.90 confirms PAD; for values >1.40 the term non-compressible arteries should be used; the usual pathological TBI threshold is ≤0.70; haemodynamic criteria that may be used to guide diagnosis in suspected CLTI are ankle pressure <50 mmHg, toe pressure <30 mmHg or TcPO₂ <30 mmHg (ESC 2024 text).^[1]
• Claudication: supervised exercise training is recommended in symptomatic PAD (Class I, Level A); at least three sessions a week of at least 30 min for at least 12 weeks should be considered (Class IIa, Level B); revascularization may be considered if PAD-related quality of life is still impaired after 3 months of optimal medical treatment and exercise therapy (Class IIb, Level B).^[1]
• Antithrombotic rows (ESC 2024): aspirin alone (75–160 mg once daily) or clopidogrel alone (75 mg once daily) is recommended to reduce MACE in symptomatic PAD (Class I, Level A); rivaroxaban 2.5 mg twice daily plus aspirin 100 mg once daily should be considered with high ischaemic risk and non-high bleeding risk (Class IIa, Level A); routine ticagrelor, long-term DAPT and oral anticoagulant monotherapy without another indication are each not recommended (Class III, Level A).^[1]
• In CLTI with a usable great saphenous vein, BEST-CLI (1830 patients with CLTI and infrainguinal PAD, international randomised trial; median follow-up 2.7 years in cohort 1) found a significantly lower incidence of a major adverse limb event or death with surgery than with endovascular therapy (42.6% vs. 57.4%; HR 0.68).^[10]
• In BASIL-2 (345 patients with CLTI needing infra-popliteal revascularization, enrolled July 2014 to November 2020; open-label randomised trial in the UK, Sweden and Denmark), a best endovascular treatment first strategy, compared with a vein bypass first strategy, was associated with better amputation-free survival, largely driven by fewer deaths in the best endovascular treatment group.^[11]
• ALI grade IIB (immediately threatened: sensory loss beyond the toes, mild-moderate motor deficit, no arterial Doppler signal) is salvageable if promptly revascularized; grade III is irreversible (ESC 2024 Table 9).^[1]

References14ShowHide

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2. [2]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: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2024.PMID 38743805
3. [3]American Diabetes Association Professional Practice Committee for Diabetes 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2026. Diabetes Care, 2026.PMID 41358899
4. [4]Halvorsen S, et al. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J, 2022.PMID 36017553
5. [5]CAPRIE Steering Committee A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet, 1996.PMID 8918275
6. [6]Anand SS, et al. Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomised, double-blind, placebo-controlled trial. Lancet, 2018.PMID 29132880
7. [7]Bonaca MP, et al. Rivaroxaban in Peripheral Artery Disease after Revascularization. N Engl J Med, 2020.PMID 32222135
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9. [9]Bonaca MP, et al. Low-Density Lipoprotein Cholesterol Lowering With Evolocumab and Outcomes in Patients With Peripheral Artery Disease: Insights From the FOURIER Trial (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk). Circulation, 2018.PMID 29133605
10. [10]Farber A, et al. Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia. N Engl J Med, 2022.PMID 36342173
11. [11]Bradbury AW, et al. A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial. Lancet, 2023.PMID 37116524
12. [12]Joglar JA, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2024.PMID 38033089
13. [13]Chuter V, et al. Australian guideline on diagnosis and management of peripheral artery disease: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease. J Foot Ankle Res, 2022.PMID 35787293
14. [14]Van Gelder IC, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J, 2024.PMID 39210723