In patients over 55 with peripheral arterial disease (PAD) and typical atherosclerotic risk factors, are they more likely to also have coronary artery disease (CAD)?

Yes, patients with peripheral arterial disease have a very high likelihood of also having coronary artery disease.

Between 60-80% of patients with PAD have significant coronary artery disease affecting at least one coronary artery, even when they have no cardiac symptoms. 1, 2 This extraordinarily high prevalence makes PAD one of the strongest clinical markers for coexisting coronary disease.

The Evidence for This Strong Association

The relationship between PAD and CAD is remarkably consistent across multiple diagnostic approaches:

• One-third to one-half of PAD patients have CAD based on clinical history and electrocardiogram alone 1, 2
• Two-thirds have CAD when stress testing is performed 2
• Up to 60-80% have significant coronary stenosis when coronary angiography is performed 1, 2, 3

The 2024 ESC Guidelines report that among patients presenting with PAD, the prevalence of CAD ranges from 10-70% depending on diagnostic criteria used, with higher rates when more sensitive testing is employed 1

Why This Matters Clinically

The presence of PAD dramatically increases mortality risk, with 75% of PAD patients dying from cardiovascular events—primarily myocardial infarction and stroke—rather than from limb complications. 2 This underscores that PAD is fundamentally a marker of systemic atherosclerosis rather than an isolated limb problem.

Specific mortality data demonstrates:

• All-cause mortality is 3.1 times greater in PAD patients compared to those without PAD 1, 2
• Cardiovascular death is 5.9 times greater 1, 2
• Annual mortality rate is 4-6% per year, with most deaths due to MI and stroke 2

Patients with PAD and CAD together have a higher risk of all-cause death over 5 years (adjusted HR: 1.35) compared with those with CAD alone 1

The Shared Pathophysiology

PAD and CAD share identical atherosclerotic risk factors and disease mechanisms:

• Smoking and diabetes show the strongest association with both conditions 2
• The severity of PAD correlates directly with the severity and extent of coronary disease 1
• Atherosclerosis is a systemic disease affecting multiple arterial beds simultaneously 4, 5

According to the 2024 ESC Guidelines, approximately 1 in 4-6 patients with atherosclerosis have polyvascular disease (clinically relevant obstructive lesions in at least two major arterial territories), and patients with PAD are most likely to have polyvascular disease at baseline 1

Screening Considerations and Caveats

The 2024 ACC/AHA Guidelines state that CAD screening in PAD patients may be helpful to optimize medical treatment, though it is not intended to increase the rate of coronary interventions. 1 This is a critical distinction—the goal is risk stratification and aggressive medical management, not routine revascularization.

The 2017 AHA/ACC Guidelines explicitly note that there is no evidence that systematic screening for CAD in stable PAD improves outcomes 1 because:

• Intensive atherosclerosis risk factor modification is justified regardless of CAD presence
• Revascularization has never been shown to reduce MI, stroke, or death in asymptomatic CAD detected through screening 1

Common pitfall: Ordering extensive cardiac testing in stable PAD patients without cardiac symptoms rarely changes management beyond what guideline-directed medical therapy already provides 1

When to Consider Cardiac Evaluation

Cardiac assessment should be considered in PAD patients who:

• Are scheduled for open vascular surgery with poor functional capacity or significant risk factors 1
• Have symptoms suggestive of CAD 1
• Require risk stratification before major surgical procedures 1

Evaluation can be performed by stress testing or coronary CT angiography; invasive coronary angiography is less suitable due to its invasive nature 1

The Treatment Imperative

All PAD patients should receive the same intensive medical therapy as patients with known CAD, regardless of whether CAD has been formally documented. 1, 6 This includes:

• Antiplatelet therapy (aspirin 75-325 mg daily or clopidogrel 75 mg daily) 1, 2
• High-intensity statin therapy 1, 2
• Aggressive risk factor modification 1

Research demonstrates that PAD patients without documented CAD are significantly undertreated compared to those with known CAD, despite having equivalent cardiovascular risk 6