Early diagnosis of peripheral arterial disease can save limbs.

Prompt identification and management of patients with peripheral arterial disease can improve quality of life, save limbs and reduce cardiovascular events. The most common initial symptom is leg pain on exertion or intermittent claudication. More severe or critical limb ischaemia can present with pain at rest, ulceration, tissue loss and/or gangrene, In most patients the symptoms remain stable, but approximately 20% will develop limb threatening critical ischaemia. The incidence of peripheral arterial disease increases with age and up to 20% of people aged over 60 are affected to some degree. The incidence is also high in smokers, diabetes patients, and those with coronary disease. A focused history should identify the presence and severity of intermittent claudication and any critical limb ischaemia. Examination should concentrate on the palpation of lower limb arterial pulses and look for signs of critical ischaemia such as ulceration. The key primary care investigation in suspected peripheral arterial disease is measurement of the ankle brachial pressure index. Lifestyle interventions are a key component of management. NICE recommends that a supervised exercise programme is offered to all patients with intermittent claudication. Pharmacological therapy should always include an antiplatelet agent and statin. Vasoactive drugs such as naftidrofuryl oxalate should be considered for symptom control in intermittent claudication when exercise has not led to a satisfactory improvement and the patient prefers not to be referred for revascularisation. Patients with severe and inadequately controlled symptoms should be referred to secondary care with a view to further imaging to assess the appropriateness of revascularisation.