Do patients with peripheral arterial disease (PAD) have a higher risk of developing coronary artery disease (CAD)?

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Yes, People with PAD Have Substantially Higher Rates of Coronary Artery Disease

Patients with peripheral arterial disease (PAD) have a 60-80% prevalence of significant coronary artery disease (CAD), even when they have no cardiac symptoms, making PAD a powerful marker of systemic atherosclerosis and elevated cardiovascular risk. 1, 2

The Magnitude of the Problem

Prevalence Data

  • When coronary angiography is performed, 60-80% of PAD patients demonstrate significant coronary stenosis, regardless of whether they report chest pain or other cardiac symptoms 1, 2

  • Using only clinical history and resting electrocardiogram, approximately one-third to one-half of PAD patients meet criteria for CAD 1, 2

  • Approximately 1 in 4-6 patients with atherosclerosis have polyvascular disease (clinically relevant obstructive lesions in at least two major arterial territories), and PAD patients are the most likely subgroup to have polyvascular involvement at baseline 1

  • The severity of PAD correlates directly with the severity and extent of coronary disease, meaning more advanced limb disease predicts more extensive coronary atherosclerosis 2

Why This Matters for Survival

The real danger of PAD is not losing a limb—it's dying from a heart attack or stroke:

  • All-cause mortality is 3.1-fold higher in individuals with PAD compared to those without PAD 2

  • Cardiovascular mortality is 5.9-fold higher in PAD patients 2

  • 75% of PAD patients die from cardiovascular events (primarily myocardial infarction and stroke), not from limb complications 2

  • The morbidity and mortality of patients with PAD is high due to cardiovascular complications, with high CAD event rates driving this excess risk 1

  • Polyvascular disease independently increases major cardiovascular event risk, roughly doubling with the number of affected arterial beds 1

The Shared Disease Process

PAD and CAD share the same underlying pathophysiology—systemic atherosclerosis:

  • PAD is a marker of systemic atherosclerosis, and most patients with PAD have concomitant CAD 3

  • PAD patients without clinical evidence of CAD have the same relative risk of death from cardiac or cerebrovascular causes as those diagnosed with prior CAD, consistent with the systemic nature of atherosclerotic disease 3

  • The same risk factors that contribute to CAD also lead to PAD development, including smoking, diabetes, hypertension, and hyperlipidemia 3, 4

Clinical Screening Recommendations

When to Screen for CAD in PAD Patients

The 2024 ESC Guidelines provide nuanced guidance on screening:

  • CAD screening in PAD patients may be helpful to optimize medical treatment, but it is not intended to increase the rate of coronary interventions 1, 2

  • There is no evidence that systematic screening for CAD in stable PAD improves outcomes, so routine screening is not recommended in asymptomatic, stable patients 1

  • Consider CAD screening in PAD patients scheduled for open vascular surgery with poor functional capacity or significant risk factors or symptoms 1

  • Evaluation can be performed by stress testing or coronary CT angiography, while coronary angiography is less suitable due to invasiveness unless revascularization is being actively considered 1, 2

The Rationale Behind Limited Screening

Despite the high prevalence of CAD in PAD patients, extensive cardiac testing rarely changes management:

  • Performing extensive cardiac testing in stable PAD patients rarely changes management beyond what guideline-directed medical therapy already provides 2

  • All PAD patients should receive the same intensive medical therapy as patients with documented CAD, irrespective of whether CAD has been formally identified 2

Essential Medical Management

Regardless of whether CAD is formally diagnosed, all PAD patients require aggressive cardiovascular risk reduction:

Antiplatelet Therapy

  • Antiplatelet therapy with either low-dose aspirin (75-325 mg daily) or clopidogrel (75 mg daily) is recommended for all PAD patients 2

  • In patients with PAD in at least one territory and without high bleeding risk, treatment with a combination of rivaroxaban (2.5 mg twice daily) and aspirin (100 mg once daily) should be considered 1

Lipid Management

  • An LDL-C reduction by ≥50% from baseline and an LDL-C goal of <1.4 mmol/L (<55 mg/dL) are recommended in patients with polyvascular disease 1

  • High-intensity statin therapy is advised for PAD patients to achieve aggressive lipid lowering 2

Comprehensive Risk Factor Control

  • Aggressive modification of atherosclerotic risk factors is essential, including smoking cessation, diabetes control, blood pressure management, and lifestyle changes 2

  • Cardiovascular risk factor control is crucial to prevent progression and complications 1

Common Pitfalls to Avoid

  1. Don't assume PAD patients without chest pain are free of CAD—the majority have silent coronary disease 1, 2

  2. Don't order extensive cardiac testing in stable PAD patients expecting it to change management—focus instead on optimizing guideline-directed medical therapy 1, 2

  3. Don't treat PAD as an isolated limb problem—it's a manifestation of systemic atherosclerosis requiring comprehensive cardiovascular risk reduction 3, 4

  4. Don't underestimate the cardiovascular mortality risk—PAD patients are nearly 6 times more likely to die from cardiovascular causes than those without PAD 2

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

High Prevalence of Coronary Artery Disease in Patients with Peripheral Arterial Disease

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Research

Peripheral arterial disease: considerations in risks, diagnosis, and treatment.

Journal of the National Medical Association, 2009

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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