Peripheral artery disease (PAD) represents a significant global health burden, affecting >200 million people and accounting for approximately 10-15% of the population >50 years of age.^1,2 In Western populations, PAD affects approximately 3-10% of adults; in Asia and other developing regions, prevalence rates can exceed 20%.^1,2 A higher prevalence of PAD has been observed in patients with established predisposing risk factors, such as hypertension (HTN), hyperlipidemia, diabetes mellitus (DM), chronic kidney disease (CKD), polyvascular atherosclerotic disease, and smoking history. However, PAD remains underdiagnosed, rendering these statistics inaccurate, especially among patients with limited health care access or residing in underprivileged areas.

The 2024 multisociety Guideline for Lower Extremity PAD emphasizes that PAD is a common cardiovascular (CV) disease associated with increased risk of amputation, myocardial infarction, stroke, and death, as well as impaired quality of life (QoL), walking performance, and functional status.³ This relationship between PAD and major adverse cardiovascular events (MACE) is well established. Patients with PAD have a twofold to sixfold increased risk of MACE compared with those without PAD.⁴ Patients with known underlying risk factors, such as multivessel atherosclerotic disease, HTN, DM, CKD, and smoking, are at particularly elevated risk, and the guideline emphasizes the importance of risk-factor modification in the patient population with PAD.³

PAD is strongly linked to major adverse limb events (MALE), highlighting an increased risk of limb-threatening conditions, such as tissue necrosis, nonhealing ulcers, and, ultimately, limb amputation.⁵ The severity of PAD correlates with higher rates of MALE, emphasizing the importance of early detection and comprehensive management strategies to preserve limb function and enhance overall patient prognosis. However, the risk of amputation is notably elevated in patients with critical limb-threatening ischemia , with approximately 1-3% of patients with PAD undergoing major amputations annually.^5-7

QoL impairment in PAD has been well documented, encompassing physical limitations, pain, and psychological distress. Functional limitations due to claudication restrict daily activities and mobility, leading to decreased exercise capacity and gradual functional decline. Anxiety and depression are common due to the fear of amputation and the chronic progression of the disease, further compromising QoL. Among patients who have already undergone amputations, depression rates are particularly high, especially among older patients, women, those who are socially isolated, and those with previous functional limitations.³ Therefore, a multidisciplinary management approach is essential, including exercise rehabilitation, psychotherapy, pharmacotherapy, and smoking cessation assistance, to alleviate symptoms and improve QoL outcomes.

The guideline highlights the significance of conducting psychological assessments to address the emotional and mental health needs of patients with PAD, alongside managing their physical health to alleviate the overall health care burden.³ Establishing support groups for patients with PAD or those who have undergone amputations is crucial.

PAD exacerbates societal and health care burdens, leading to increased costs due to worsening complications that impair patients' QoL and functional abilities. This impact is particularly witnessed in patients requiring amputations, as it often results in job loss, disability, and heightened risks of subsequent amputations or complications such as osteomyelitis, further burdening health care resources. It is crucial to recognize that many patients with PAD, especially those with complications, come from socioeconomically disadvantaged backgrounds, making it difficult for them to afford job loss, orthotics, medical follow-ups, and prescribed medications.

Overall, PAD represents a significant public health challenge because of its high prevalence, underdiagnosis, lack of awareness, and associated risks of limb loss, CV events, and death. Early recognition of symptoms, aggressive risk-factor modification, and timely revascularization interventions are essential in optimizing outcomes and reducing disease burden. Hence, addressing this global burden requires comprehensive strategies focused on early detection, aggressive risk-factor modification, and effective management to reduce the incidence of complications and improve patient outcomes.

References

1. Fowkes FGR, Rudan D, Rudan I, et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet 2013;382:1329-40.
2. Criqui MH, Aboyans V. Epidemiology of peripheral artery disease. Circ Res 2015;116:1509-26.
3. Gornik HL, Aronow HD, Goodney PP, et al.; Writing Committee Members. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024;83:2497-604.
4. Bonaca MP, Hamburg NM, Creager MA. Contemporary medical management of peripheral artery disease. Circ Res 2021;128:1868-84.
5. Szarek M, Hess C, Patel MR, et al. Total cardiovascular and limb events and the impact of polyvascular disease in chronic symptomatic peripheral artery disease. J Am Heart Assoc 2022;11:[ePub ahead of print].
6. Long CA, Mulder H, Fowkes FGR, et al. Incidence and factors associated with major amputation in patients with peripheral artery disease: insights from the EUCLID trial. Circ Cardiovasc Qual Outcomes 2020;13:[ePub ahead of print].
7. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). J Am Coll Cardiol 2006;47:e1-192.