Peripheral Arterial Disease: An underdiagnosed condition with major cardiovascular risk
A common disease associated with high mortality
Lower-limb peripheral arterial disease (PAD) is a clinical manifestation of systemic atherosclerosis. It affects more than 230 million people worldwide (1), and its prevalence continues to rise with population aging and the increasing burden of cardiovascular risk factors (2).
Beyond its functional consequences and risk of limb loss (1), PAD is a powerful marker of cardiovascular morbidity and mortality. Patients with PAD have a two- to threefold higher risk of major adverse cardiovascular events including myocardial infarction, stroke, and cardiovascular death, compared with individuals without PAD (3).
As emphasized by Dr. Laroche, a specialist in vascular medicine with experience both in private settings and at Montpellier University Hospital, PAD represents one of the most severe clinical expressions of atherosclerosis:
“If you take one patient with a coronary stent and another with a femoral stent, the one who dies first is not the coronary patient, it’s the PAD patient.”
Dr Laroche’s observation underlines a critical issue: coronary artery disease is systematically screened and aggressively managed, PAD is still often detected late, sometimes only when it progresses to the stage of critical limb ischemia. (1,3,4).
Why is PAD still underdiagnosed?
Despite its high prevalence and strong prognostic impact, PAD remains largely underdiagnosed.
Several factors contribute to this diagnostic gap:
A significant proportion of patients are asymptomatic.
Intermittent claudication may be absent in elderly patients with reduced mobility.
Symptoms are often attributed to aging or musculoskeletal disorders.
As a result, many patients are identified only at advanced stages of disease, sometimes when critical limb ischemia has already developed.
“These are fairly elderly patients who don’t walk much, don’t have claudication… and one day, they present with critical limb ischemia.”
Importantly, absence of symptoms does not mean absence of disease. Screening studies in asymptomatic populations have demonstrated a substantial prevalence of subclinical PAD. In some cohorts, up to 25% of at-risk individuals had an abnormal Ankle-Brachial Index (ABI) despite lacking typical symptoms (5).
PAD as a marker of systemic atherosclerotic disease
International guidelines strongly emphasize that any patient with atherosclerotic disease in one vascular territory should be considered at risk for involvement in other vascular beds (1,4,6).
The following populations should be prioritized for periodic PAD screening:
Patients aged over 65 years
Patients with diabetes
Current or former smokers
Patients with hypertension or dyslipidemia
Individuals with established coronary artery disease, carotid stenosis, or abdominal aortic aneurysm
As Dr. Laroche notes:
“Anyone with coronary disease should undergo an extension assessment… and that includes screening for PAD.”
Identifying PAD in a patient with coronary artery disease significantly modifies overall cardiovascular risk stratification and may justify intensification of secondary prevention strategies, including antiplatelet therapy, high-intensity statins, and stricter risk factor control (4,6).
Early detection: A major challenge in primary care
The Ankle-Brachial Index (ABI) remains the first-line diagnostic test recommended for PAD detection (4,6). An ABI ≤ 0.90 confirms the diagnosis.
Both ESC and ACC/AHA guidelines recommend ABI measurement in at-risk patients, even in the absence of symptoms (4,6).
In clinical practice, however, screening is still insufficiently integrated into routine cardiovascular assessment. Yet ABI measurement is simple, non-invasive, reproducible, and can be performed in outpatient settings, including by trained healthcare professionals.
Dr. Laroche stresses the need for a change in mindset:
“As soon as there is a risk factor or any vascular warning sign, it (screening) should be done systematically. We find a lot of (confirmed PAD) cases.”
Screening campaigns conducted in France have shown that approximately one-quarter of asymptomatic participants had previously undiagnosed subclinical PAD, underscoring the magnitude of underdetection.
Towards more systematic and structured screening
Given the prognostic burden associated with PAD, several priorities emerge:
Integrate PAD screening into comprehensive cardiovascular evaluation, particularly in patients with coronary disease or diabetes.
Don't wait for symptoms to appear before measuring ABI.
Structure PAD screening in primary care by facilitating access to simple, reliable, and reproducible diagnostic tools.
PAD should no longer be considered a secondary peripheral condition, but rather a central marker of global cardiovascular risk.
Unfortunately, it still remains
Underestimated,
Underdiagnosed,
And undertreated.
Early identification enables timely implementation of appropriate cardiovascular prevention strategies and helps prevent severe systemic and limb-related complications.
Screening should not be viewed as an exceptional measure, but as an integral part of systematic cardiovascular risk assessment in at-risk patients.
