Claudication, ↓ pulses, shiny hairless skin; smoker
Best initial test: ABI <0.9 = disease (<0.6 severe)
Most accurate: Angiography — only before revascularization, not to diagnose
Treat: Smoking cessation (counsel) + high-intensity statin + rivaroxaban 2.5 mg BD combined with low-dose aspirin (Class 1, 2024 ACC/AHA PAD GL; clopidogrel 75 mg alone is a reasonable antiplatelet alternative); cilostazol for claudication
Severe/critical ischemia → Revascularization / bypass
Order set
- ABI
- Doppler
- Lipids, HbA1c
- Foot exam
Criteria
AdmitCritical limb / acute limb ischaemia
ICUPost-revascularisation instability
DischargeRisk factors addressed, revascularisation plan, wound care
Key
- Cilostazol contraindicated in heart failure.
- Rivaroxaban 2.5 mg BD + low-dose aspirin is Class 1 to reduce MACE and limb events in PAD (2024 ACC/AHA; COMPASS/VOYAGER).
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Rest pain
- Ulcer/gangrene
- Sudden cold pulseless limb (acute ischaemia)
Differentials
- Spinal stenosis
- Venous claudication
- Arthritis
Common mistakes
- Angiography before non-invasive testing
- Missing critical limb ischaemia
Disposition & follow-up
Risk-factor control, supervised exercise; vascular referral if critical.
Discharge package
MedicationsRivaroxaban 2.5 mg BD + aspirin 75 mg + high-intensity statin; cilostazol for claudication
Follow-upVascular; supervised exercise
Vaccination—
LifestyleSmoking cessation essential; foot care
Warning symptomsRest pain, non-healing ulcer, sudden cold pale limb
💊 Treatment detail — doses & preparation
Aspirinantiplatelet
DoseACS: 150–325 mg chewed once, then 75 mg OD. PV/stroke prevention: 75 mg OD
Preparation300 mg dispersible (chew/dissolve for loading); 75 mg enteric-coated maintenance
MonitorBleeding, dyspepsia; avoid in viral illness in children
ClopidogrelP2Y12 inhibitor
DoseLoad 300–600 mg PO, then 75 mg OD
Preparation75/300 mg tablets
MonitorBleeding; CYP2C19 poor metabolisers — consider ticagrelor
Atorvastatinstatin
Dose20–80 mg OD (post-ACS 80 mg)
Preparation10/20/40/80 mg tablets, any time of day
MonitorLFTs baseline, muscle symptoms; target LDL reduction ≥50%
CilostazolPDE3 inhibitor
Dose100 mg BD (50 mg with CYP3A4/2C19 inhibitors)
Preparation50/100 mg tablets, 30 min before food
MonitorAvoid in heart failure; headache, palpitations
📖 ESC Peripheral Arterial DiseaseReviewed July 2026