The Peripheral (Peripheral Artery Disease)

Heart and Peripheral Artery Disease (PAD)

Arteries are found throughout our bodies. Acting as pipes, they carry nutrient- and oxygen-rich blood from the heart to organs, muscles, skin and other parts of the body.

Unfortunately, arteries can become stiff, narrowed and even blocked by a buildup of cholesterol and other substances — also known as plaque. This process is called atherosclerosis. It’s similar to when a pipe narrows or becomes blocked because of a buildup of debris. Blood flow slows, depriving muscles and other organs of oxygen and vital nutrients.

We typically think of atherosclerosis as affecting the heart’s arteries (called coronary artery disease), which can cause a heart attack or chest pain. But this process can occur anywhere in the body.

If you have peripheral artery disease (PAD), sometimes not enough blood flows to your arms and legs. Many people don’t have any symptoms at first, but as PAD progresses you may notice:

  • Your legs feel very tired, heavy or start to cramp when you walk, and you might need to stop and rest
  • Your walking speed becomes slower
  • You have leg or foot pain, or both
  • Ulcers or wounds that won’t heal

The main concern is that PAD also increases the chance of a fatal heart attack or stroke. Use this condition center to learn more about how PAD increases your risk — and how you can protect your heart.

Understand the Connection

Peripheral Artery Disease, also called PAD, isn’t limited to your limbs. For many patients, PAD can signal a greater tendency to deposit cholesterol (and develop atherosclerosis) in the arteries elsewhere in the body, including those supplying the heart and brain. That means you are more likely to have a heart attack or stroke.

Compared with people who have heart blockages only, people with PAD and CAD have more than twice the risk of cardiovascular-related death in one year.

Without good circulation:

  • Muscles can ache, or become weak or tired
  • Organs can be damaged and even fail (heart attack, stroke, kidney disease)
  • Skin can become dry or pale and have wounds that don’t heal well

PAD is said to be a marker for systemic atherosclerosis, similar to cancer that has spread to other parts of the body. So if you have PAD, you likely have some degree of plaque buildup in other areas of circulation, such as your heart arteries or carotid arteries. Taking steps to protect your health and slow any further harm to your arteries can help.

Bottom line: If you have PAD, all efforts need to be made to lower your cardiovascular risk. This means aggressively managing risk factors and perhaps using medications known to protect against heart attack and stroke, if recommended.

Be an Advocate

Many people — even clinicians — aren’t aware of how closely linked PAD is with heart and cerebrovascular problems. Adding to the problem is that many people don’t even know they have PAD.

What You Can Do

If you think you have PAD and haven’t yet been diagnosed, ask to be evaluated:

  • Don’t be shy, especially if you have a hard time keeping up with your peers, notice leg discomfort when walking or feel as though you’re slowing down. Many times, people dismiss signs of PAD as a normal part of the aging process.
  • Talk with your health professional about a simple test called the ankle brachial index (ABI). For this test, your doctor will compare the blood pressure readings in your ankles and arms to help assess blood flow to your legs using an ultrasound machine.

If you’ve been diagnosed with PAD:

  • Develop a plan with your health care providers. Talk about how to assess and protect your arteries, including those supplying your heart, brain and other vital organs. Often, lifestyle changes and medications can help slow the progression or treat risk factors that can make blockages worse.
  • If you smoke, you’ll want to ask for help to quit.
  • Make sure you receive appropriate testing. Studies show that only a small portion of patients are referred to a vascular specialist. This expert may order tests to find out whether circulation (blood flow) can be restored to the muscle and tissue as well as find ways to help you move better. Revascularization is a procedure that can work in some patients to open clogged arteries in the legs.
  • Remember, it’s OK to ask for a second opinion.

Early Detection and Treatment Are Key

By finding PAD early on, you can help prevent or delay further damage to the blood vessels. You’ll also be able to take advantage of less invasive treatment options, including medical therapy, a supervised exercise program or both.

Treatments will depend on whether you have symptoms, and there may be other considerations, too. Overall, therapy is aimed at managing symptoms and preventing further atherosclerotic buildup and may include:

  • Supervised exercise
  • Medications (note that aspirin or statins may be recommended even if your cholesterol is normal because they help reduce inflammation in the blood vessels)
  • Procedures or surgeries to open blocked or narrowed arteries
  • In rare cases, amputation
  • Clot-preventing therapies
  • Other lifestyle changes.

Keep Your Risk in Check

If you have peripheral artery disease, or PAD, there are a few things to keep in mind:

1. Complications of PAD aren’t limited to the affected limb.

People living with PAD are at risk for worsening leg pain with exercise and even amputation(s) (loss of a limb) due to permanent tissue damage. This can happen because the skin was deprived of blood supply and vulnerable to injury.

If you have symptoms of PAD, it is likely that they will remain relatively stable for a time. However, the risk of having a heart attack or stroke will — perhaps silently — worsen.

2. Even if you have PAD, but no symptoms, it’s important to take care of your heart.

Although you might not have symptoms, or if they are mild, you still need to pay attention to your heart. People with PAD have a higher chance of having a heart attack and stroke.

“If you have PAD, you could also be hiding significant coronary or cerebrovascular disease. Think of it as a red flag, and talk with your care team.” – Gregory Piazza, MD, FACC, Brigham and Women’s Hospital in Boston

Lowering your overall cardiovascular risk is critical if you have PAD, and may include:

  • Exercise therapy — a supervised exercise program during which you will be asked to walk to the point of moderate pain (claudication — leg pain during walking that is relieved by rest) then rest and repeat.
  • Lifestyle changes, including daily (walking) exercise and eating a healthy diet
  • Weight loss
  • Not smoking
  • Managing other health risk factors such as blood pressure, blood sugar and cholesterol

3. Know your overall risk for blocked arteries.

There are calculators that your health care team can use to estimate your risk of having a heart attack or stroke over a set period of time. It’s important to know your personal risk and to understand that it changes over time. This can help you and your doctor develop a plan to aggressively manage your risk factors — those things that make heart disease and stroke more likely.

4. If you smoke, find help to quit.

It’s not easy to kick the habit. But if you have PAD, you need to reach out and get the help and support you need to stop smoking. Why?

People who smoke are 2 to 6 times more likely to develop PAD, and the symptoms and complications tend to be worse. Smokers also tend to develop symptoms sooner, usually between 40 and 50 years old.

5. Ask questions.

Talk with your health care team about PAD and cardiovascular disease, especially if you already have PAD or suspect you might have it. Here are some questions to help get you started:

  • I’ve heard PAD can be a red flag for heart disease. Is that a concern for me?
  • What steps can I take prevent or slow other arteries being affected?
  • How will we know if other arteries in my body are affected?
  • What tests do I need to assess my heart health and risk for stroke?
  • How often should I have arterial testing done?
  • What are the best treatment options for me?
  • What are the signs and symptoms of heart disease or stroke?

Many PAD Cases are Undetected

While millions of Americans are living with peripheral artery disease (PAD), many don’t know it, which means they:

  • Aren’t getting timely care
  • Remain vulnerable to heart attacks, stroke or even early death — one study showed that nearly 2 out of 3 people with PAD also had evidence of narrowing or blockages in their heart’s arteries

There are many reasons why patients may not know they have PAD:

  • Many patients with PAD don’t notice symptoms right away and even if they do they can be subtle.
  • The minority of patients — only 1 in 10 — have the classic calf cramping with exercise that is thought of as the hallmark sign of PAD.
  • Many people falsely think “slowing down” and not being able to walk as far as they used to do is simply part of getting older.
  • Women tend to have less obvious symptoms than men.
  • Some patients may not be active enough to get symptoms.
  • Many symptoms can mimic other conditions (for example, back, knee or hip pain, arthritis)
  • Having diabetes can mask symptoms, too, because the nerves in the extremities may be damaged and fail to send signals to the brain; therefore, legs will not ache or cramp, but may just feel tired or like they are going to give out.

Who’s at risk for PAD?

The American College of Cardiology and American Heart Association have established guidelines to help better identify people who might have PAD or be at risk of developing it. You are more likely to have PAD if you are 50 or older and have risk factors for atherosclerosis, including:

  • High blood pressure
  • High cholesterol
  • History of smoking
  • Diabetes

Other factors that make it more likely you have PAD include:

  • Family history of PAD
  • Other blockages in your arteries, such as coronary artery disease, carotid artery disease, previous heart attack or stroke

African Americans are especially likely to develop PAD. This may be, in part, due to the fact that this group also tends to have higher rates of diabetes and high blood pressure that can raise the risk of PAD. Also, women with PAD may have less common symptoms and may be diagnosed later.

If you suspect or know that you or someone else has PAD, be your own best advocate. Speak up and act. Doing so can help protect your heart, too.

The Peripheral (Peripheral Artery Disease)

Treatment and living with PAD


While there is no cure for PAD, you can stop it from getting worse and take steps to prevent heart and limb problems.

  • Ask about starting a supervised exercise program. This will help you walk more easily and hurt less. It can also help you avoid other forms of heart disease. Make physical activity a routine part of your day.
  • Quit smoking or don’t start. This will help you avoid more deadly forms of heart disease. It’s OK if you fail at first. Keep trying. Ask your care team about quit-smoking programs that are proven to help.
  • Keep your other medical issues under control. It’s very important to stay on top of diabetes and get your cholesterol and blood pressure to a healthy level. This will help stop your PAD from getting worse.

In addition to exercise and keeping up with other healthy choices, your care team might recommend medicines or treatments. Many of these have the double benefit of helping with PAD while also helping to prevent or slow other forms of heart disease.

Your treatment plan might also include:

  • Cilostazol, a medicine that helps open narrowed arteries and makes walking easier
  • Cholesterol-lowering drugs, which help prevent plaque from building up in your arteries 
  • Blood thinners, which help prevent you from developing dangerous blood clots
  • Surgeries and medical devices, which can help open blocked arteries so blood can flow better if medications and lifestyle changes don’t work

In PAD, the buildup of plaque in the arteries slows blood flow. This buildup is made up of primarily cholesterol, calcium and other debris. This is the same disease process that blocks the arteries in the heart (causing heart attacks), neck (causing strokes) and elsewhere.

If you have PAD, you have a much higher risk of also having blockages in other arteries throughout your body. Be sure to talk about your risk for heart attack or stroke with your care team.

Living With PAD

If you are living with peripheral artery disease (PAD), you can take steps to help stop your condition from getting worse. Maintain a healthy lifestyle, stay active, don’t smoke, and know how to control other health issues that you may have.

Because of blockages or not enough blood flow to leg muscles, feet and toes, you need to protect these body parts. Blood not only heals, but it also maintains health by sending oxygen and nutrients to your skin and muscles.

Not enough blood flow can lead to a small sore or ulcer. This can become a big problem with slow and poor healing. It might cause infection or a wound that won’t heal. It could even lead to loss of a leg or foot if the skin or tissue dies (gangrene). If you have PAD, you should not walk barefoot but wear shoes that fit you. Examine your feet each day for redness or sores.

You may need to use a mirror to see the soles of your feet or have a family member help you. Feel all around the foot for bumps, sores or tenderness. You might also see a podiatrist on a regular basis depending on how advanced the PAD is and what other risk factors you have.

PAD can also slowly rob you of your ability to be active. Your muscles need oxygen and blood to work, provide strength and balance. You may notice heaviness in your legs or cramping while walking.

If you feel you can’t do as much as you used to or if you notice you are walking shorter distances or more slowly, you should talk to your care team.

At later stages of PAD, pain while you are at rest can occur. If you find you are less active or can’t keep up with others, it could mean your PAD has gotten worse.

Focus on You

Remember, you are the most important member of your health care team. Speak up about your preferences and what matters most to you when it comes to your care.

If it’s hard to stick with your treatment plan, ask for help finding ways to make it easier. You can do this!

The Peripheral (Peripheral Artery Disease)

Exams and Tests

Anyone with symptoms or signs of peripheral artery disease (PAD) should be tested. Some people should be screened for PAD even in the absence of symptoms or signs, such as individuals older than 65 or if you have:

  • Other risk factors for atherosclerosis such as diabetes, smoking history, high cholesterol, or high blood pressure
  • Family history of PAD
  • Other artery disease, for example coronary artery disease, renal artery disease, or subclavian artery disease

The diagnosis of PAD begins with a simple exam by your clinician or podiatrist. They will look at the skin on your legs and feet for color changes, ulcers, or wounds that may be slow to heal. They will feel the temperature of your skin and check the pulses in your legs and feet.

Your clinician will also ask you questions about how active you are able to be and if you have slowed down for any reason. Your medical record will be reviewed to assess other risk factors you have for PAD.

Blood tests looking for signs of diabetes, kidney disease and high cholesterol may be done.

If your doctor suspects you have PAD, then they will likely arrange for you to have an Ankle-Brachial Index test (ABI). This is a simple test that can be done in the office to check circulation in the legs. It consists of taking blood pressure in the arms and at the ankles with an ultrasound probe. The exam takes about 10 minutes, and you will be asked to lie down flat. After the two blood pressure readings, a ratio is calculated to get the value of your ABI.

An ABI of 0.90 or less is considered a sign of PAD. An ABI of greater than 1.3 may signal stiff arteries that may or may not be blocked.

In some cases, a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan may be required – usually if after the ABI test or ultrasound test more information is needed or to guide the best treatment options.

Finally, you may have an invasive catheter angiogram that can serve as both a test and a treatment. This procedure involves injecting dye into the affected arteries and taking X-ray images to see where blockages may be. If blockages are found, your clinician may open up these arteries during the procedure. They can use a device to cut, drill or shave through the plaque to allow more blood to flow through. 

The Peripheral (Peripheral Artery Disease)

Prevention of peripheral artery disease

It is important to learn about factors that increase your chance for developing peripheral artery disease (PAD) as you age. Addressing these risk factors can lower your chance of developing PAD, and of having a stroke or heart attack.

Adopting healthy habits can help. In some cases, medications may be needed as well. Here are steps you can take to help prevent PAD.

Stay active: Regular physical activity or exercise can lead to weight loss and improve your fitness level. In general, adults should get at least 150 minutes of moderate-intensity exercise or 75 minutes of vigorous physical activity each week to promote good health. To reach that goal, you could try walking briskly for 30 minutes five times in one week. If you can do it daily and make it a habit, that is even better.

Don’t use tobacco products: If you smoke, ask your care team about ways to quit. There are many programs and products that can help you.

Monitor your weight: If you are overweight or obese, talk with your care team about a healthy weight loss program, which includes a healthy diet and exercise.

Eat healthy: A healthy diet is an important part of any program to help prevent heart disease. The 2019 ACC/AHA Primary Prevention Guideline recommends following a diet rich in fruits, vegetables, nuts, whole grains, fish or lean meats. Stay away from foods with solid fats, added sugars and refined grains. Don’t eat foods that are fried in oil or prepared with shortening or butter. Try to eat foods with omega-3 fatty acids such as tuna, salmon, and walnuts.

Control blood pressure: Check your blood pressure regularly, avoid salt and take medication if your care team advises it.

Lower cholesterol: Addressing high cholesterol with diet and/or medication can help cut plaque buildup. You have to check your cholesterol level by having a blood test.

Treat elevated blood sugar (diabetes): Having your care team check and monitor your blood sugar may also help you maintain healthy circulation.

While some factors are outside of your control, including family history, age, race and your sex, it’s important to focus on the factors that you can control.

Finally, take good care of your feet and legs. Inspect them regularly and keep your skin soft with lotions. Be careful clipping your toenails and wear comfortable shoes that fit you. See a podiatrist if you have any concerns.

The Peripheral (Peripheral Artery Disease)

Signs and Symptoms of peripheral artery disease

Many people don’t notice anything at first, but you may begin to have symptoms as PAD progresses.

Not enough blood flowing to the leg muscles in your calf or thigh can cause pain or cramping in the legs while walking that gets better when you stop. Some people with PAD say they have heaviness in the legs, weakness, or a feeling that their legs may give out.

Over time, people with PAD might limit what they do so they don’t feel pain. They might walk more slowly or even use a cane. With PAD, it’s normal to have some pain when you’re moving around. In fact, exercising to the point of mild to moderate discomfort has benefits. However, the pain should not be severe, and it should go away when you stop exercising.

In later stages of PAD, you may have:

  • Pain or cramping in your limbs while at rest
  • Cool or discolored skin
  • Wounds that don’t heal, or heal slowly
  • Sudden loss of blood supply that can lead to surgery to remove a leg or even death

What Increases Your Risk?

There are a number of factors that make it more likely for people to have peripheral artery disease (PAD).

Common risk factors include:

Older age: Being older than 65 increases the chance you will have PAD

Smoking: Smoking is the most important risk factor that you can control. A person who smokes can get PAD 10 years earlier than someone who doesn’t. Furthermore, people who use tobacco have poorer survival rates and a greater chance of developing wounds that don’t heal. People who smoke more often have blockages that happen again after arteries are cleaned out and less success after bypass surgery when compared with people who don’t smoke.

Diabetes: Diabetes increases the risk of developing PAD by up to four times and leads to an increased risk of cardiovascular events and early death. Diabetes (and poor foot care) is a common cause of loss of foot or leg (amputation) in the United States. If you have diabetes, it’s very important to manage the condition.

High blood pressure: High blood pressure increases your chance of atherosclerosis, including PAD. As many as 9 out of 10 patients with PAD have high blood pressure.

High cholesterol: An elevated cholesterol level has been associated with twice the risk for chronic leg pain. According to the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey, more than 6 out of 10 patients with PAD had high cholesterol.

Family history: Family history of atherosclerosis in first-degree relatives – such as your mother or father – is also a risk factor for PAD.

Metabolic syndrome: Metabolic syndrome (the combination of obesity, high cholesterol, high blood pressure, and high blood sugar) increases the risk for PAD, as it does for coronary artery disease.

Other risk factors: Being Black or Hispanic, or having chronic kidney disease also are associated with increased risk of PAD.

The Peripheral (Peripheral Artery Disease)

Overview and intro of Peripheral Artery Disease (PAD)

Peripheral artery disease, or PAD, affects more than 8 million Americans. Many people don’t know they have it. But PAD is a very serious condition that has also been linked to heart attack and stroke.

If you have PAD, blood is not flowing well to your arms, legs, or kidneys and other vital organs. Lack of oxygen-rich blood can harm the nerves and tissues in these areas. That’s why having artery disease in your legs can make it hard to walk. You might have painful cramping or numbness.

Not enough blood in the legs can also make infections more likely. In some cases when lack of blood goes on for a while, muscles and tissue can die and cause some people to need to have have surgery to remove their leg, also called an amputation.

The good news is treatments and lifestyle changes can help manage PAD. By treating it, you can also prevent related heart attack, stroke, surgery to remove a leg, and death. The more you know about managing PAD, the more empowered you will be to improve your health.


Peripheral artery disease (PAD) happens when fat and cholesterol, also called plaque, build up in the walls of the arteries in your limbs – most often the legs. This buildup can cause the arteries to become stiff and narrow so not enough blood flows to your arms and legs.  

PAD also can cause you to suddenly lose blood supply in your limbs. This is like a heart attack in your leg. If not treated quickly, it can cause you to have surgery to remove your leg, or even death.

PAD is a red flag that you could be more likely to have a heart attack or stroke in the future.

The risk factors for developing PAD are similar to those for coronary artery disease (CAD). Many people who have PAD either have diabetes or have smoked, or both.

Other risk factors for developing PAD include high blood pressure, high cholesterol, and family history of PAD. As we age, the chance of having PAD also increases.