Peripheral artery disease isn’t just about sore legs after walking. It’s a warning sign that your arteries are clogging up - not just in your legs, but possibly in your heart and brain too. If you’re over 50, smoke, have diabetes, or high blood pressure, you’re at risk. And yet, most people don’t know they have it. Only about 1 in 5 patients with PAD get tested, even though the condition triples your chance of a heart attack or stroke. This isn’t a rare problem. In the U.S., over 8 million people have it. In the UK, it’s likely just as common, especially among older adults. The good news? If caught early, it’s manageable. And if ignored, it can lead to amputation or death.

What Does Peripheral Artery Disease Actually Feel Like?

Many people think leg pain during walking is just part of getting older. It’s not. The classic sign of PAD is claudication - a cramping, aching, or tired feeling in your calves, thighs, or buttocks that shows up when you walk or climb stairs and disappears after a few minutes of rest. It’s predictable. Same distance, same pain. Stop walking, rest, and it fades. Start again, and it comes back. That’s not normal aging. That’s your muscles screaming because they’re not getting enough blood.

Not everyone has this clear symptom. About half of people with PAD don’t feel anything at all. That’s why it’s called a silent disease. But if you’re one of the ones who do, here are other signs to watch for:

• Cold feet or legs, especially compared to the rest of your body
• Shiny, thin skin on your lower legs
• Leg hair that stops growing or falls out
• Toenails that thicken, grow slowly, or stop growing
• Sores on your toes, feet, or legs that won’t heal
• Pain in your legs even when you’re resting - especially at night
• Erectile dysfunction in men - this is often an early warning sign

If you have non-healing wounds or pain while lying down, that’s critical limb ischemia - the most serious stage. Without urgent treatment, tissue death and amputation become likely. This isn’t something to wait on.

How Do Doctors Diagnose PAD?

There’s no mystery to diagnosing PAD. The first test is simple, painless, and takes less than 10 minutes. It’s called the ankle-brachial index, or ABI. Your doctor measures your blood pressure in your arm and then in your ankle. They compare the two numbers. If the ankle pressure is 90% or less of the arm pressure (ABI ≤ 0.90), you have PAD. It’s that straightforward. And it’s accurate in 95% of cases.

But here’s the problem: most GPs don’t check it unless you have clear symptoms. And even then, many skip it. If you’re over 65, or over 50 with diabetes or a history of smoking, you should ask for this test. It’s recommended by the American Heart Association for exactly that group.

If the ABI is borderline or if you have diabetes (where arteries can harden and give false readings), your doctor may use the toe-brachial index (TBI) instead. It’s more accurate for people with stiff arteries.

For more detail, doctors may order an ultrasound. This shows exactly where the blockage is and how bad it is. In more advanced cases, they might use a CT or MRI angiogram - these give 3D pictures of your arteries. But these are expensive and usually only done if surgery is being considered.

The real issue isn’t the test. It’s the lack of testing. CDC data shows only 20% of people who should get screened actually do. That’s why so many cases are caught too late.

What Happens If You Don’t Treat It?

PAD isn’t just about your legs. It’s a sign that your whole vascular system is under attack. Atherosclerosis doesn’t pick and choose. If your leg arteries are clogged, chances are your heart arteries are too. That’s why people with PAD have a 3 to 5 times higher risk of heart attack or stroke than those without it. The 5-year death rate for untreated PAD is 30-40%. That’s worse than many types of cancer.

And if you keep smoking? Your risk of amputation goes up 8-fold. Your chance of dying jumps by 300%. Quitting isn’t just helpful - it’s life-saving.

Even if you don’t have symptoms, having a low ABI means you’re at high risk. That’s why treatment isn’t just about walking better - it’s about staying alive.

How Is PAD Treated? (Step by Step)

Treatment for PAD has three clear steps: lifestyle changes, medication, and procedures - in that order.

Step 1: Move More - Even If It Hurts

The most effective treatment for claudication isn’t a pill. It’s walking. A supervised walking program - 30 to 45 minutes, 3 to 5 times a week - can increase how far you walk without pain by 150% to 200% in just 12 weeks. You don’t need a gym. You need consistency. Walk until the pain hits, rest until it goes, then walk again. Repeat. Over time, your body learns to use blood more efficiently. It builds new tiny blood vessels. It’s called collateral circulation.

Studies show this works better than stents or surgery for mild to moderate cases. And it costs about $1,200 for a full course. Compare that to a stent, which can cost $20,000.

Step 2: Take the Right Medications

There are four key drugs for PAD:

• Antiplatelets: Either aspirin (81 mg daily) or clopidogrel (75 mg daily). Clopidogrel is slightly better at preventing heart attacks and strokes.
• Statin: Every single person with PAD needs one, no exceptions. Even if your cholesterol is normal. The goal is to get LDL below 70 mg/dL. This cuts your risk of heart events by 25-30%.
• Cilostazol: This drug helps you walk farther by improving blood flow. It’s not for everyone - it’s not safe if you have heart failure.
• Blood pressure control: If you have high blood pressure, get it under 130/80. ACE inhibitors or ARBs are often preferred.

These aren’t optional. They’re standard care. The American College of Cardiology says they’re Class I recommendations - meaning they’re proven, necessary, and backed by strong evidence.

Step 3: Procedures - When Medication Isn’t Enough

If you’re still in pain after 3 months of walking and meds, or if you have a non-healing wound, it’s time to consider a procedure.

• Balloon angioplasty: A tiny balloon is inflated inside the blocked artery to open it. Works well for short blockages - success rate around 90%.
• Stent: A metal mesh tube is left in place to keep the artery open. Good for longer blockages, with 80% patency after one year.
• Atherectomy: A device shaves away the plaque. Used when the blockage is hard and calcified.
• Bypass surgery: A vein from your leg or a synthetic graft is used to reroute blood around the blockage. Best for long, severe blockages. About 80% stay open after 5 years.

The BASIL trial showed that for claudication, doing a procedure plus walking gives faster relief - but after two years, walking alone does just as well. So unless you’re in serious pain or have a wound, start with exercise and meds.

Who’s at Risk - And Why It’s Worse for Some People

The biggest risk factors are clear:

• Smoking - the #1 cause
• Diabetes - doubles your risk
• High blood pressure and high cholesterol
• Age over 50
• Family history of heart disease

But here’s the unfair part: Black and Hispanic patients are 30-40% less likely to get revascularization procedures, even when their disease is just as bad. Why? Access, bias, lack of referrals. This isn’t about biology - it’s about healthcare gaps.

And if you have diabetes? Your risk of amputation is 15 times higher. That’s because nerve damage hides the pain, so wounds go unnoticed. By the time you feel it, it’s too late. That’s why diabetics need foot checks every visit - not just for ulcers, but for pulses, skin changes, and temperature.

What’s New in PAD Treatment?

Research is moving fast. The VOYAGER PAD trial showed that adding a blood thinner called rivaroxaban to aspirin cuts major limb events by 15% in people who’ve had a procedure. This combo is now recommended for high-risk patients.

Stem cell therapy is being tested in early trials. Injecting a patient’s own stem cells into the leg has helped 65% of patients with non-healing wounds - compared to 35% with standard care. It’s not standard yet, but it’s promising.

And in 2022, the U.S. passed the PAD Awareness Act - $5 million a year to fund screening in high-risk communities. It’s a start. But in the UK, there’s still no national screening program. That’s why you need to ask for your ABI test. Don’t wait for your doctor to bring it up.

What Should You Do Right Now?

If you’re over 50 and smoke - get tested.

If you’re diabetic - ask your doctor to check your ankle pulses and ABI at least once a year.

If you have leg pain when walking - don’t ignore it. Start walking. Talk to your doctor about clopidogrel and a statin.

If you have a sore that won’t heal - get it checked today. Don’t wait for it to get worse.

PAD is not a death sentence. But it is a wake-up call. Treat it like one.