Peripheral arterial disease: the AU general practice approach

Peripheral arterial disease (PAD) is the narrowing of arteries supplying the limbs — almost always caused by atherosclerosis, the same process responsible for coronary artery disease and cerebrovascular disease. It affects approximately 10–14% of Australians aged 65 and over and around 20% of people with type 2 diabetes. About half of those affected have no leg symptoms at all, which makes opportunistic diagnosis in general practice particularly important.

PAD is not primarily a leg condition — it is a marker of systemic atherosclerosis. Five-year mortality with symptomatic PAD is approximately 30%, and 10-year mortality approaches 50%, driven overwhelmingly by heart attack and stroke rather than limb loss. The dominant treatment goal is cardiovascular risk reduction, not symptom management.

Aboriginal and Torres Strait Islander Australians carry approximately three to five times higher rates of lower limb amputation related to diabetes and PAD than non-Indigenous Australians — a profound health equity gap that demands proactive early detection and management.

A. Core clinical — the AU general-practice framework

Who to assess

Consider assessing ankle-brachial index (ABI) in adults with any of the following:

• Exertional leg pain, cramping, or fatigue that resolves with rest
• Non-healing lower limb wound or ulcer lasting more than two weeks
• Smoking history aged ≥50
• Type 2 diabetes aged ≥50 (or ≥30 with ≥10 years of diabetes duration)
• Prior cardiovascular event (coronary artery disease, stroke, TIA)

Per the RACGP Red Book, population-level ABI screening in asymptomatic adults without risk factors is not recommended; targeted assessment in the groups above is appropriate.

History

• Claudication characteristics — location (calf corresponds to femoropopliteal disease; thigh/buttock to aortoiliac), exertion distance or time to onset, recovery time at rest (2–10 minutes in true claudication), reproducibility
• Distinguishing neurogenic claudication — pain in neurogenic claudication is provoked by standing or walking downhill and relieved by spinal flexion (leaning forward on a trolley), not simply by standing still; ABI is normal
• Rest pain — typically forefoot or toes, nocturnal, partially relieved by hanging the foot off the bed (gravity-dependent perfusion)
• Wound history — location, duration, appearance; arterial ulcers are typically lateral or on the dorsum of the foot; venous ulcers favour the medial calf
• CV risk factors — smoking (quantity, pack-years, quit status), type 2 diabetes, blood pressure control, lipid levels, family history of premature cardiovascular disease, CKD
• Functional impact — walking distance to claudication onset, occupation, quality of life

Examination

• Pulse examination — femoral, popliteal, posterior tibial, dorsalis pedis bilaterally; note that absence of dorsalis pedis is a normal variant in about 8% of the population
• Auscultation — femoral and iliac bruits; abdominal bruit (aortoiliac disease)
• Foot inspection — colour, temperature, hair loss, atrophic skin changes, ulcers, callus, fungal nails, deformity, prior amputations; Buerger’s test (elevation pallor followed by dependency rubor)
• Resting ABI measurement — Doppler probe and sphygmomanometer; compare bilateral brachial systolic pressures (use the higher); measure systolic pressure at dorsalis pedis and posterior tibial in each foot; ABI = highest ankle pressure ÷ highest brachial pressure

Investigations

Per eTG cardiovascular guidelines and Australian Medicines Handbook:

First-line:

• Resting ABI — sensitivity ~95%, specificity ~99% at threshold ≤0.90

ABI	Interpretation
>1.40	Non-compressible (use toe-brachial index)
1.00–1.40	Normal
0.91–0.99	Borderline
0.70–0.90	Mild PAD
0.40–0.70	Moderate PAD
<0.40	Severe PAD / chronic limb-threatening ischaemia

• Toe-brachial index (TBI) — if ABI >1.40 (non-compressible vessels in diabetes or CKD); TBI <0.30 or toe pressure <30 mmHg indicates chronic limb-threatening ischaemia (CLTI)
• Pedal Doppler waveforms — triphasic (normal), biphasic (mild), monophasic (significant disease)
• Bloods — full blood count, UEC, lipids, HbA1c, eGFR, UACR

Second-line (specialist):

• Duplex ultrasound — anatomical localisation, first-line vascular imaging
• CT angiography — pre-procedural mapping; less useful in heavily calcified vessels
• MR angiography — avoid gadolinium if eGFR <30

B. Secondary prevention — the evidence base

Smoking cessation

Smoking is the single highest-yield intervention in PAD. Cessation reduces amputation risk by approximately 40% and myocardial infarction risk by 30%, and dramatically slows the progression of claudication to chronic limb-threatening ischaemia. The RACGP supporting smoking cessation guideline recommends combining pharmacotherapy with behavioural support for the highest quit rates. Varenicline (PBS Authority Required, Streamlined) delivers approximately 2–3 times higher quit rates than unassisted cessation. Nicotine replacement therapy (patches, lozenges, gum) is available on the PBS for selected populations.

Statin therapy

PAD is an established cardiovascular disease equivalent — automatic high-risk classification per the Heart Foundation 2023 guideline. A high-intensity statin (atorvastatin 40–80 mg or rosuvastatin 20–40 mg) is recommended for all patients with PAD, targeting LDL-C <1.8 mmol/L. Ezetimibe and PCSK9 inhibitors are added as needed. Statins also reduce PAD progression independent of their lipid effects.

Antiplatelet therapy

Aspirin 100 mg daily or clopidogrel 75 mg daily is standard. The CAPRIE trial demonstrated marginal superiority of clopidogrel over aspirin specifically in the PAD subgroup. On the PBS, clopidogrel for symptomatic PAD requires an Authority (Streamlined). Dual antiplatelet therapy is generally not recommended for stable PAD without a recent vascular event.

Vascular-dose rivaroxaban plus aspirin

The COMPASS trial (NEJM 2017) demonstrated that rivaroxaban 2.5 mg twice daily combined with aspirin 100 mg daily reduced major adverse cardiovascular and limb events by approximately 24% relative risk compared with aspirin alone in stable ASCVD including PAD. VOYAGER PAD extended this finding post-revascularisation. This combination is reasonable in stable PAD patients without high bleeding risk. PBS Authority Required (Streamlined) for symptomatic PAD; verify current PBS restrictions before prescribing.

Blood pressure and glycaemic control

Target blood pressure <130/80 mmHg; ACE inhibitor or ARB are preferred first-line agents (renal protection and cardiovascular outcome benefit). Beta-blockers are not contraindicated in PAD — the evidence shows no clinically significant worsening of claudication, and they remain strongly indicated for comorbid coronary artery disease or heart failure. For diabetes, individualise HbA1c targets; intensive control modestly reduces microvascular complications.

C. Symptom management and revascularisation

Supervised exercise therapy

Supervised exercise therapy (SET) is first-line for intermittent claudication. The structured protocol involves walking to near-maximal pain, resting 2–5 minutes, and resuming — sessions of 30–45 minutes at least three times per week for a minimum of 12 weeks. The Cochrane systematic review of SET (2017) found improvements in pain-free walking distance of 200–300 metres and substantial improvements in maximal walking distance. The CLEVER trial demonstrated SET superior to endovascular intervention for treadmill walking improvement in aortoiliac disease.

Referral to an exercise physiologist via GPCCMP allows SET to be funded. Home-based structured walking programs, while achieving approximately 70% of SET benefit, are a reasonable substitute when supervised programs are inaccessible.

Cilostazol

Cilostazol 100 mg twice daily — a phosphodiesterase III inhibitor — improves pain-free walking distance by approximately 50% and is a reasonable pharmacological adjunct when SET alone is insufficient. It is contraindicated in heart failure of any class due to the class effect of PDE3 inhibitors on cardiac mortality. PBS Authority Required (Streamlined) for stable intermittent claudication unresponsive to lifestyle and exercise measures. Common side effects: headache, diarrhoea, palpitations.

Revascularisation

• Endovascular (angioplasty ± stenting) — preferred for focal short-segment disease, particularly aortoiliac and proximal femoropopliteal locations
• Open surgical bypass — for long-segment disease; the BEST-CLI trial demonstrated vein bypass superior to endovascular treatment in CLTI patients with adequate single-segment saphenous vein
• Major amputation — last resort; five-year mortality post-major amputation approaches 50%

Chronic limb-threatening ischaemia pathway

CLTI — rest pain lasting ≥2 weeks, ischaemic ulcer, or gangrene with objective PAD evidence — requires urgent vascular referral within 24–48 hours. Multidisciplinary high-risk foot services (vascular surgery, endocrinology/diabetes, podiatry, wound care, infectious diseases) deliver the best outcomes.

D. Australian operations

MBS and care planning

Standard consultation items (23, 36, 44) apply. The GPCCMP (items 965 and 967) is well-suited to PAD as an ongoing cardiovascular condition — plan elements include supervised exercise (via exercise physiologist), podiatry referral, smoking cessation, statin and antiplatelet optimisation, foot care education, and 3-monthly review. The diabetes annual cycle of care (MBS items 2517, 2521, 2525) mandates annual foot examination including pulse check, sensation testing, and footwear assessment.

Podiatry for high-risk feet: up to 5 allied health visits per year (10 for Aboriginal and Torres Strait Islander patients) via GPCCMP. Vascular ultrasound (lower limb arterial duplex, MBS item 55274) is radiologist-billed and requires a specialist referral.

No specific MBS item exists for the ABI measurement itself — it is bundled within the GP consultation.

PBS essentials

• Aspirin 100 mg — General Schedule, widely available OTC
• Clopidogrel 75 mg — Authority Required (Streamlined) for symptomatic PAD
• Rivaroxaban 2.5 mg (vascular dose) — Authority Required (Streamlined) for chronic CAD or symptomatic PAD with high ischaemic risk; combined with aspirin 100 mg
• Cilostazol 100 mg — Authority Required (Streamlined); avoid in heart failure
• Varenicline — Authority Required (Streamlined) for smoking cessation; one attempt per 12 months initially
• Statins, ezetimibe, PCSK9 inhibitors — as per dyslipidaemia management

E. Special populations

Diabetes. Medial arterial calcification in longstanding diabetes elevates ABI falsely above 1.40 — always measure toe-brachial index or Doppler waveforms in this group. Neuropathy masks rest pain, meaning CLTI may present as an ulcer without classic symptoms. Emphasise foot inspection at every visit. Per Diabetes Australia foot care guidance, daily self-inspection with a mirror, closed footwear at all times, and prompt podiatry referral for any callus, corn, or wound are essential.

Older adults. Frailty and limited walking ability can confound ABI interpretation. Functional limitation may be reported as dyspnoea or generalised fatigue rather than claudication. Balance falls risk when choosing revascularisation procedures.

Aboriginal and Torres Strait Islander Australians. The ATSI Health Assessment (item 715) includes foot screening and should be completed every 9 months in eligible patients. Targeted cardiovascular and diabetes management programs should actively reach this population given the dramatically higher amputation and mortality rates.

Suspected neurogenic claudication (spinal stenosis). MRI lumbar spine, not vascular investigation, is the appropriate next step when leg pain occurs on standing as well as walking, is relieved by spinal flexion, and the ABI is normal.

When to escalate

• Call 000 immediately — any sudden cold, pale, pulseless, painful leg or foot (acute limb ischaemia — irreversible damage occurs within 4–6 hours)
• Same-day referral to emergency or vascular surgery — suspected acute limb ischaemia, gangrenous change, severe diabetic foot infection with systemic sepsis
• Urgent referral within 24–48 hours — CLTI (rest pain ≥2 weeks, non-healing ulcer, gangrene)
• Routine vascular referral — refractory claudication despite 12+ weeks of SET plus optimal medical therapy, ABI <0.5 with disabling symptoms, for revascularisation assessment

Send with the referral: resting ABI/TBI values, Doppler waveform description, claudication distance and duration, current medications, lipid and HbA1c results, smoking status, BP, prior imaging, foot photographs.

What this article is and is not

This is general health information based on current Australian guidelines — Therapeutic Guidelines, the NHMRC-endorsed Diabetes Feet Australia PAD guideline, RACGP Red Book, and Heart Foundation CVD risk framework. It does not constitute personal medical advice. Decisions about investigation, revascularisation, and pharmacotherapy for an individual patient are made with your GP and treating vascular surgeon.

For reliable consumer information: HealthDirect — Peripheral arterial disease, Heart Foundation — Peripheral artery disease, Better Health Channel — Peripheral vascular disease.

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Sources cited

1. Diabetes Feet Australia / NHMRC — Australian guideline on diagnosis and management of PAD (2021)
2. RACGP — Red Book 10th edition
3. Therapeutic Guidelines (eTG) — Cardiovascular: PAD
4. Australian Medicines Handbook
5. Heart Foundation — Australian CVD risk guideline
6. Exercise Is Medicine Australia
7. AIHW — Lower limb amputation in diabetes
8. HealthDirect — Peripheral arterial disease
9. Heart Foundation — Peripheral artery disease
10. Better Health Channel — Peripheral vascular disease
11. Diabetes Australia — Foot care
12. TGA
13. PBS
14. RACGP — Supporting smoking cessation
15. COMPASS — rivaroxaban plus aspirin in PAD (NEJM 2017)
16. Cochrane — supervised exercise therapy for PAD (2017)
17. 2024 ACC/AHA Lower Extremity PAD Guideline