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Peripheral arterial disease (PAD) encompasses a number of disorders that affect the arterial beds of the body aside from the coronary arteries. The arteries of the lower extremities are the main areas affected, and PAD is defined by an ankle-brachial index (ABI) of 0.90 or less. PAD is a manifestation of atherosclerosis and shares risk factors with coronary atherosclerosis. Data from the Framingham Heart Study determined the risk for developing PAD was increased when several common conditions were present including diabetes, hypercholesterolemia, cigarette smoking, and hypertension.

PAD patients are often asymptomatic, but may present with symptoms of impaired lower extremity arterial circulation including aching, pain, discomfort, and fatigue in leg muscles upon exertion. This type of leg ischemia is also referred to as intermittent claudication. Symptoms are relieved with rest. PAD is stratified based on presentation: asymptomatic, atypical leg pain, classic claudication, and critical limb ischemia.

Lower extremity pain is the most common clinical presentation, but clinical history and physical examination findings are not reliable for detecting PAD; therefore, diagnostic tests are critical. Diagnostic tests include ABI and exercise treadmill testing, as well as angiography if necessary for further workup. Table 4-1 lists key factors associated with the clinical presentation of PAD.

TABLE 4-1Clinical Presentation of Peripheral Arterial Disease


The first steps in the treatment of PAD include exercise training and risk factor modification. Specific goals for the first steps of PAD treatment include the following:

  1. Exercise rehabilitation through 30- to 45-minute sessions three times per week for 12 weeks with exercise to the point of symptom-limiting claudication

  2. Control of comorbid conditions and risk factors

    1. Smoking cessation

    2. Diabetes control with hemoglobin A1c goal of less than ...

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