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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Peripheral arterial disease

Cardiology · UK scope · Sources checked 25 Aug 2026 · Clinical review pending

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Escalate

Acute limb ischaemia—sudden pain, pallor, pulselessness, paraesthesia, perishing cold or paralysis—is a vascular emergency. Motor or sensory loss means an immediately threatened limb. Call vascular surgery now, give analgesia and IV unfractionated heparin unless contraindicated, and obtain imaging only if it will not delay revascularisation.

Synopsis

Diagnose lower-limb PAD, distinguish intermittent claudication from limb-threatening ischaemia, deliver cardiovascular prevention and activate urgent revascularisation pathways.

  • Suspect PAD with exertional calf, thigh or buttock pain relieved by rest, non-healing leg/foot wounds, rest pain, gangrene, absent pulses or before leg compression/intervention.
  • Measure ABPI with Doppler after supine rest: use the highest ankle artery pressure in each leg divided by the highest brachial pressure.
  • ABPI 0.90 or lower supports PAD, but a normal or high ABPI does not exclude disease in diabetes or CKD because calcified vessels may be incompressible.
  • Stable intermittent claudication is treated first with smoking cessation, lipid/BP/diabetes management, antithrombotic secondary prevention and supervised exercise.
  • NICE suggests supervised exercise for 2 hours weekly for 3 months, encouraging exercise to maximal claudication pain within a structured programme.
  • Lifestyle-limiting claudication despite risk-factor management and supervised exercise warrants vascular assessment; duplex is first-line imaging when revascularisation is being considered.
  • Chronic limb-threatening ischaemia means ischaemic rest pain, non-healing wound or gangrene; it needs urgent vascular-team assessment and revascularisation planning.
  • Acute limb ischaemia can cause irreversible nerve and muscle injury within hours; do not send a threatened limb through a slow outpatient pathway.
  • Do not perform major amputation until a vascular multidisciplinary team has considered every revascularisation option, except when immediate life-saving source control is necessary.

Key red flags

Chronic limb-threatening ischaemia

Ischaemic rest pain, non-healing ulcer for at least 2 weeks or gangrene. Haemodynamic support includes ankle pressure below 50 mmHg, toe pressure below 30 mmHg or transcutaneous oxygen below 30 mmHg, interpreted with the whole clinical picture.

Acute limb ischaemia

Sudden pain, pallor, pulselessness, paraesthesia, perishing cold and paralysis. Sensory loss or muscle weakness means an immediately threatened limb needing emergency revascularisation.

Infected or wet gangrene

Spreading infection, systemic toxicity, gas, wet necrosis or sepsis requires emergency vascular and surgical source-control assessment alongside antibiotics.

Investigation priorities

01
Vascular examination and handheld-Doppler ABPIFirst step

Confirm haemodynamic PAD and document baseline severity.

02
Duplex ultrasoundFirst line

First-line anatomical imaging when revascularisation is being considered.

Management branches

NICE preferredStable intermittent claudication

Exertional limb symptoms without rest pain, ulcer, gangrene or acute neurological deficit.

  1. Offer smoking cessation, supervised exercise, healthy weight/diet support and management of BP and diabetes; give high-intensity statin and appropriate antithrombotic secondary prevention.
  2. Offer a supervised programme, aiming for about 2 hours of supervised exercise weekly for 3 months and exercise to maximal claudication pain when safe.
  3. If symptoms remain substantially lifestyle limiting after risk-factor management and exercise, refer for vascular assessment. Use duplex first when revascularisation is considered.
  4. Offer angioplasty when imaging is suitable and conservative treatment has failed. Consider bypass for severe lifestyle-limiting disease when angioplasty is unsuitable or has failed; use autologous vein for infra-inguinal bypass where possible.
  5. Naftidrofuryl is a later option only when supervised exercise has not produced satisfactory improvement and the person does not want vascular referral; review at 3–6 months and stop if no worthwhile benefit.

Key medicines

Clopidogrel75 mg orally once daily.Active pathological bleeding and severe hepatic impairment are contraindications; review bleeding risk, bruising, interacting anticoagulants/antiplatelets and planned procedures.
Atorvastatin80 mg orally once daily for secondary prevention; use a lower dose when interactions, high adverse-effect risk or patient preference make 80 mg unsuitable.Check baseline liver enzymes; review myalgia/weakness, CYP3A4 interactions, pregnancy and severe liver disease.
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Sources and review status10 sources · checked 25 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 25 Aug 2026; clinical approval remains outstanding.

  • NICE CG147: Peripheral arterial disease—recommendationsUK diagnosis, exercise, revascularisation, CLTI and analgesia pathway.
  • NICE TA210: Clopidogrel and modified-release dipyridamole
  • NICE NG238: Cardiovascular risk and lipid modification
  • NICE TA607: Rivaroxaban for preventing atherothrombotic events
  • Rivaroxaban 2.5 mg tablets SmPCLicensed vascular dose and creatinine-clearance cautions.
  • NICE TA223: Naftidrofuryl oxalate for intermittent claudication
  • 2024 ESC Guidelines for peripheral arterial and aortic diseasesALI classification, anticoagulation doses, CLTI haemodynamic criteria and emergency intervention details where NICE is less specific.
  • NICE TA223: Naftidrofuryl technology detailsLicensed dose range and calcium-stone contraindication.
  • NHS: How and when to take paracetamol for adultsUsual adult interval and daily maximum.
  • Morphine sulfate injection SmPCLicensed slow-IV adult dose range and opioid safety.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom