What is the most common symptom of Peripheral Arterial Disease (PAD)?

From the Guidelines

The most common symptom of peripheral arterial disease (PAD) is exertional leg symptoms, including claudication, which is characterized by pain, aching, cramping, or tiredness in the legs that occurs during walking or exercise and subsides with rest. According to the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease 1, up to 80% of patients with objectively proven PAD report exertional leg symptoms. These symptoms can be described as a pain, aching, cramping, or tired/fatigued feeling located in the buttocks, thigh, calf, or foot that occurs consistently during walking, does not start at rest, does not improve during walking, and is usually relieved within approximately 10 minutes of rest. The guideline also notes that chronic symptomatic PAD is associated with significant functional (walking) impairment, regardless of whether symptoms are typical of claudication.

Some key characteristics of claudication include:

• Pain or discomfort in the legs that occurs during walking or exercise
• Pain that subsides with rest
• Pain that typically affects the calf muscles but can also occur in the thighs or buttocks
• Sensations of aching, cramping, tiredness, or weakness
• Predictable and reproducible pain that occurs after walking a certain distance and resolves within a few minutes of rest

It's worth noting that some patients with PAD may be asymptomatic or experience atypical symptoms, while those with advanced disease may develop rest pain, especially at night, or tissue damage such as ulcers or gangrene. Early recognition of claudication is important as PAD indicates systemic atherosclerosis and increased risk for heart attack and stroke. In contrast to the 2017 ACR Appropriateness Criteria for vascular claudication-assessment for revascularization 1, which estimates that only 6% to 20% of patients with peripheral arterial occlusive disease have symptoms of claudication, the more recent guideline 1 provides a more comprehensive understanding of the symptoms of PAD.

From the Research

Symptoms of Peripheral Arterial Disease

• The most common symptom of peripheral arterial disease (PAD) is intermittent claudication, which is characterized by leg muscle pain, cramping, and fatigue brought on by ambulation or exercise, and relieved by rest 2, 3, 4, 5.
• Intermittent claudication is caused by inadequate blood supply to the legs and is a marker of atheroma, indicating a high risk of cardiovascular morbidity and mortality 3.
• Symptoms of intermittent claudication can be induced by walking or exercise and usually resolve with rest, with disease severity varying from asymptomatic to unremitting symptoms 5.

Diagnosis and Treatment

• Diagnosis of intermittent claudication involves a comprehensive review of the patient's medical history, physical examination, and diagnostic tests such as ankle-brachial index (ABI) 3, 5.
• Treatment of PAD aims to maintain or improve functional status, reduce or eliminate ischemic symptoms, and prevent disease progression, with exercise and aggressive risk factor modification representing the cornerstones of treatment 2, 5.
• Pharmacotherapeutic interventions, such as cilostazol, can improve walking distance and reduce symptoms of intermittent claudication, although they may be associated with adverse side effects such as headache, diarrhea, and dizziness 6.

Management and Prevention

• Management of PAD involves a multidisciplinary approach, including risk factor modification, exercise therapy, and pharmacological treatment, to reduce the risk of cardiovascular events and improve quality of life 2, 3, 4, 5.
• Prevention of PAD involves addressing modifiable risk factors, such as smoking, diabetes, hypertension, and hyperlipidemia, through lifestyle changes and pharmacological interventions 2, 3, 4, 5.