Sometimes, pulses can be difficult to assess especially in obese people. In the primary care setting, an ankle-brachial pressure index can be measured. A value of less than 0.8 is indicative of peripheral arterial disease. The other options are all helpful but would not be the initial investigation of choice in primary care to diagnose PAD. Duplex ultrasound is certainly first choice to look for stenosis if a patient is being considered for revascularisation therapy but would take longer to arrange.

Patients with rest pain are at significant risk with approximately 25% dying within a year and 33% requiring a major lower limb amputation.

Intermittent claudication – muscle pain brought on by exercise and relieved by rest. This is a classic feature of peripheral arterial disease caused by atheroma of the arteries supplying the feet and legs.  It is more common in men and increases with age. Risk factors include high blood pressure, dyslipidaemia, smoking, diabetes, obesity and family history of atherosclerotic cardiovascular disease.

All patients with peripheral arterial disease should be offered advice, support and treatment regarding the secondary prevention of cardiovascular disease - this includes lifestyle measures, lipid modification and smoking cessation. In line with recommendations on antiplatelet therapy, clopidogrel is recommended for the prevention of occlusive vascular events in patients with peripheral arterial disease. If clopidogrel is contraindicated or not tolerated, then low dose aspirin alone can be given. If both clopidogrel and aspirin are contraindicated or not tolerated, give modified-release dipyridamole alone.

Vasodilators such as naftidifuryl are only recommended if supervised exercise therapy has failed and surgical intervention is not wanted.

Resources

NICE. Peripheral Arterial Disease: diagnosis and management. CG147. Updated 2020.

NICE. Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events. TA210. 2010.

BNF. Clopidogrel.

NICE. Antiplatelet treatment. Updated 2023.

NICE. Peripheral arterial disease: diagnosis and management. CG147. 2012 (updated 2020).

• Peripheral arterial disease (CKS) (covers acute limb ischaemia, critical limb ischaemia, intermittent claudication)

• Treating critical limb ischaemia (NICE)