PAD: Peripheral artery disease
Also known as peripheral vascular disease or hardening of the arteries in the legs, peripheral arterial disease is when your peripheral arteries – usually those that carry blood to your legs – become narrow or hardened.
When this happens, the circulation or blood supply to your legs and feet can be affected, and less blood carrying important nutrients and oxygen gets to the cells where it’s needed. And because PAD is caused by a build-up of fatty deposits called plaques inside the arteries, it also increases your risk of developing coronary heart disease or having a heart attack or stroke.Also known as peripheral vascular disease or hardening of the arteries in the legs, peripheral arterial disease is when your peripheral arteries – usually those that carry blood to your legs – become narrow or hardened.
How common is PAD disease?
According to the National Institute of Health and Care Excellence (NICE), an estimated 200 million or more people worldwide have peripheral arterial disease (PAD) (i). Patient UK suggests one in five men and one in eight women aged 50 - 75 in the UK have PAD (ii). Indeed, the older you get, the more likely you are to develop PAD – four to 12 per cent of people aged 55 - 70 are affected by it, rising to 15 - 20 per cent of those aged 70 and older (iii).
The real number of people with PAD, may be even higher
, since many don’t even know they have the condition. This is because PAD doesn’t cause symptoms in everyone – in fact, according to the Vascular Society , only a quarter of those with PAD will experience symptoms or problems (iv). Even if you don’t have symptoms, having PAD can still increase your risk of complications like heart problems.
It’s also thought that PAD symptoms are often mistaken for something else: some people, for instance, may just put them down to the normal aches and pains of getting older, or they may be mistaken for conditions such as deep vein thrombosis, leg cramps or sciatica.
What is the primary symptom of peripheral arterial disease?
The most common symptom of PAD is pain, cramps or aching in one or both legs – most often the calf muscles – when you walk or exercise, with the sensation subsiding when you rest. Usually both legs are affected at the same time, though one leg may be more painful than the other. The level of pain varies from one person to another, and if your symptoms are mild your legs may simply feel tired. The medical name for this symptom is intermittent claudication.
Other peripheral arterial disease symptoms
PAD can go on to cause other symptoms too, which usually develop gradually rather than suddenly. These include:
Lack of leg hair below the knee
Smooth, shiny skin on the legs
Numbness in the legs
Brittle toenails that grow slowly
Skin on the legs turning pale or blue
Leg muscle wasting (shrinking)
Weak or no pulse in the feet
* Erectile dysfunction in men
Sometimes PAD affects the arms instead of the legs and causes similar symptoms – though this isn’t common.
Meanwhile, if the blood flow to the legs and feet gets much worse it can cause constant pain, often in the toes and feet, even when you’re in bed or otherwise resting. When PAD gets to this stage, it’s called critical limb ischaemia. You can also go on to develop sores that don’t heal very well on your feet or the lower parts of your legs. This can lead to gangrene in a small number of cases, the treatment for which may be amputation.
Can symptoms of PAD worsen?
The good news is that, for most people with PAD, the outlook isn’t too bad at least where leg health is concerned. According to Patient UK, studies that have focused on people with PAD show that (ii):
In 15 out of 20 cases symptoms remain stable or improve
In about four out of 20 cases symptoms become gradually worse
In one in 20 cases, symptoms become severe
But while there’s a good chance your leg health won’t deteriorate too much, if you have PAD you will still be far more likely than others to develop heart problems such as angina or a heart attack, or a stroke – indeed, it’s thought your risk will be six or seven times higher than someone who doesn’t have PAD (ii). So while PAD directly affects the legs and feet, the biggest concern with it is that you could develop more serious complications. Other related problems can include reduced quality of life if your mobility is severely affected (that is, you may not be able to walk very far), as well as mental health problems such as depression, which has been linked with advanced PAD.
What is the main cause of peripheral artery disease?
PAD is most often caused by a narrowing or hardening of one or more arteries in your leg, often the femoral artery. The name for this process is atherosclerosis, and it can affect all of your arteries, not just those in your arms and legs (when it happens in the heart arteries, for instance, it causes coronary heart disease). Plaques formed by waxy substances in your bloodstream such as fat and cholesterol build up in your arteries, and over time this buildup makes your arteries harder and narrower.
This can cause pain in your legs when you’re walking or exercising because your leg muscles need extra blood and oxygen to work effectively. If the arteries in your legs have become narrowed, hardened and/or blocked, the extra blood and oxygen can’t get through, causing pain. And the harder your muscles have to work, the faster you may feel the pain (when climbing stairs or a hill, for instance, compared with walking on flat ground).
Other things that can cause PAD besides atherosclerosis include infection or inflammation of a blood vessel, an injury to your arm or leg, unusual muscle and ligament anatomy in the leg (if they are irregularly shaped, for instance), or exposure to radiation.
What are the risk factors of PAD?
Around one in five people aged 60 or older in the UK has PAD to some degree or other (vi). But besides your age there are several other conditions and risk factors that can increase your susceptibility to developing PAD, including:
Diabetes (type 1 and type 2) is strongly linked with an increased risk of PAD, particularly in those with poorly controlled blood sugar as well as people who have had diabetes for a long time. According to NICE, people with diabetes who develop PAD have worse outcomes than those with PAD but not diabetes (v). Experts elsewhere claim around one in three people with diabetes who are over the age of 50 have developed PAD (vii)
Smoking is also one of the strongest risk factors for PAD, with smokers at least twice as likely as non-smokers to develop the condition (v). If you’re a smoker and have PAD and you continue to smoke, you’re twice as likely to eventually need a limb amputation than a smoker with PAD who quits their habit (v). Find out more about giving up smoking by reading our stop smoking guide.
High blood pressure has been found to be linked with PAD
High cholesterol, meanwhile, is thought to be significantly linked with the condition
Chronic kidney disease has been linked with PAD in several studies, says NICE, particularly in people with end-stage renal disease needing dialysis (v)
Coronary heart disease (people with PAD can often also have coronary heart disease and vice versa)
Doing little or no exercise
Family history (heart and blood vessel disease can be a hereditary condition (iv))
Additionally, the more risk factors and conditions you have, the higher your chances of developing PAD. According to NICE, having one condition or risk factor increases your risk by one and a half, while three or more risk factors increases it tenfold (v).
How is PAD diagnosed?
If you go to your GP with one or more symptoms of PAD, they may carry out a test called the ankle brachial pressure index (ABPI) test. This checks the blood pressure in your upper arms and your ankles, and compares one with the other. If you have PAD, the blood pressure in your ankles will be lower than that in your arms because one or more arteries in your legs will have become narrower, which affects the blood supply to the ankle.
Some people, however, develop PAD but have a normal ABPI test result. In these cases – as well as those where surgical treatment is being considered – further tests may be necessary if a doctor thinks the symptoms are PAD related. These tests include ultrasound, CT and MRI scans that can show whether or not an artery or arteries have become narrowed.
Can PAD be cured?
There’s no cure for PAD but according to the NHS, lifestyle changes and medicine can help reduce the symptoms and help reduce your risk of developing cardiovascular-related problems too (viii).
If you’re a smoker, giving up your habit is one of the most important lifestyle changes you can make if you’ve been diagnosed with PAD. By quitting smoking, you will effectively reduce your risk of your condition getting much worse as well as another problem with your circulation developing. If you keep smoking, however, you’ll be much more likely to develop a cardiovascular-related complication such as a heart attack than if you gave up.
Thankfully these days there are lots of products and stop-smoking aids you can use to quit successfully and remain smoke-free in the long term. These include nicotine replacement therapy (NRT) products that help reduce cigarette cravings, such as patches, lozenges and gum. Find out more in our guide to stop smoking.
How can I improve my peripheral artery circulation?
Try to stay active Along with quitting smoking, getting more regular exercise is a significant lifestyle change you should try to make if you’ve been diagnosed with PAD. NHS experts claim there’s evidence to suggest regular exercise can help reduce the severity and frequency of PAD symptoms as well as reducing the risk of developing other cardiovascular diseases (viii).
NICE recommends GPs to prescribe a supervised exercise programme for those who have PAD and are experiencing intermittent claudication (ix). Such programmes typically include two hours of supervised exercise for a week for three months, where you’re encouraged to exercise until your legs are in the maximum amount of pain. But if there isn’t a supervised exercise programme available where you live, your GP may suggest that you take a 30-minute walk three to five times a week where you keep going until your symptoms start, then rest until they have subsided (then start again).
Eat healthily Following a healthy, balanced diet can help make sure your body is getting all the nutrients it needs as well as help you maintain a healthy weight (or lose weight if you need to). Try to eat plenty of fruit and vegetables – at least five portions a day – and limit the amount of fat, sugar and salt in your diet. If you do need help with losing weight, your GP may be able to provide you with the information you need. There’s also lots of advice and tips in our guide to weight loss.
Drink in moderation Drinking too much alcohol can also contribute to weight gain, so try to stick to the government’s recommendation of no more than 14 units of alcohol each week on a regular basis, spreading your intake evenly over at least three days instead of having them all together. For more advice on managing your alcohol intake, read our guide to alcohol misuse.
Can PAD be prevented?
Some of the lifestyle changes people with PAD are advised to make may also help prevent the condition in those who aren’t affected by it. In other words:
Get plenty of exercise: if you’re an adult aged 19 - 64 you should aim to do at least 150 minutes of moderate activity a week spread evenly over four to five days or every day, as well as strengthening activities that work all the major muscle groups on at least two days each week (x). Older adults should do the same, but they’re also advised to do activities that improve their flexibility (xi)
Have a healthy diet (low in fat and sugar but high in fruit and veg)
Have tests to check for conditions that are risk factors for PAD as often as your GP suggests, including diabetes, high blood pressure and high triglycerides. Take steps to manage any of these conditions if they affect you – for instance, if you have diabetes try to make sure your blood sugar levels stay as healthy as possible (read more about what you can do to manage your diabetes in our guide to diabetes diet and lifestyle)
Keep an eye on your weight
What is the best treatment for peripheral artery disease?
Most people who have PAD will also be advised to take medication in addition to making lifestyle changes to keep their symptoms manageable.
Treatments you may be offered include blood-thinning medicines to help prevent blood clots forming in your arteries; medicines to treat high blood pressure; and medicines called statins to reduce levels of LDL (or ‘bad’) cholesterol. Some people may also be offered medicines that aim to open up their arteries – though these don’t work for everyone.
Surgery is another option, but it’s not routinely offered as most people with PAD don’t need it. But it can be helpful if you have severe symptoms including pain while resting (critical limb ischaemia). There are different types of surgery available for people with PAD that your GP or specialist can discuss with you.
What vitamins can help to improve circulation in the legs?
As well as changing your lifestyle and making healthy choices there are a few nutritional supplements that may be beneficial if you have leg pain caused by intermittent claudication. However, if you decide to try any supplement or herbal remedy, always check with your GP or specialist first, as some may interact with medicines used to treat intermittent claudication.
Here’s what we know about a few of the supplements that may be useful:
Links between B vitamins and PAD have been the subject of several research papers. One, for instance, that investigated B vitamins and PAD risk in men suggests the higher your intake of folate (or folic acid, which is the form used in supplements), the less likely you may be to develop PAD (xii).
Another study – which focused on a supplement that combined omega-3 fatty acids, folic acid, oleic acid and vitamins B6 and E – found it helped men with PAD to walk further without pain and improved their ankle-brachial pressure index test results (xiii).
High-strength fish oils
Oily fish such as salmon, herring, mackerel and sardines contain the beneficial omega-3 fatty acids EPA and DHA, which may help improve blood flow in the arteries – including those in the legs. There’s also some evidence to suggest people with PAD may not be getting enough omega-3s in their diet (xiv). Researchers elsewhere have suggested omega-3s may be linked with a significant improvement of vascular function and that they may also help lower high blood pressure (xv).
Some studies also suggest ginkgo – a herb often used to boost circulation – may be effective for intermittent claudication, with some claiming it may increase pain-free walking distance significantly (xvi). However, people who are taking blood-thinning medicines (including low-dose aspirin) should check with their GP before taking ginkgo supplements.
If your vitamin D level is low it could increase your risk of developing PAD, suggests a study of more than 4,800 people (xvii). However the study didn’t go as far as investigating whether supplementing with vitamin D might help reverse that risk or relieve PAD symptoms.
Vitamin D deficiency is thought to be common in some countries including the UK, which explains why Public Health England advises adults and children over the age of one year old to consider taking a daily supplement containing 10mcg of vitamin D, particularly during autumn and winter (xviii). However if your skin is rarely exposed to the sun – if you spend most of your time indoors, for instance, or if your skin is always covered when you’re out and about – you may need to take vitamin D throughout the year. People with dark skin from African, Afro-Caribbean and South Asian backgrounds should consider taking vitamin D all year round too, PHE advises.
The recommended form of vitamin D is vitamin D3 or cholecalciferol, as it’s the natural form of vitamin D that the body makes when it’s exposed to sunlight. Vitamin D3 supplements are available in tablet form, and now you can get them in veggie-friendly drops too. However most vitamin D3 supplements are made from the fat of lamb’s wool, which means they’re unsuitable for vegans. The good news is that vegan vitamin D3 supplements sourced from lichen are now more widely available.
Taking vitamin K2 may reduce your risk of PAD, especially if you have high blood pressure, say researchers writing in the journal Atherosclerosis (xix). You can also boost your vitamin K levels by adding certain foods to your diet, including kale, spinach, broccoli, onions, asparagus, Brussel sprouts and lettuce.
Found in dark-skinned fruits such as blueberries, cranberries, raspberries, blackberries and red grapes – as well as vegetables such as red cabbage, red onions and aubergines – anthocyanidins and their derivatives anthocyanins are potent antioxidant compounds. They may be useful for people with PAD as they may help strengthen and repair the walls of veins and capillaries by protecting collagen in the body (collagen being the structural protein that gives blood vessels their strength).
Anthocyanidins are also available in supplement form (choose a product that combines anthocyanidins with vitamin C, as vitamin C supports the body’s ability to produce collagen).
Find out more
If you’ve been diagnosed with PAD, there are a lot of things you can do to help yourself and improve your symptoms as well as your reducing the risk of complications. In fact, your chances of developing severe symptoms or cardiovascular-related problems can be reduced significantly if you use self-help measures and follow your GP’s advice. It may also be important to learn about the condition if you have some of the symptoms but haven’t yet been diagnosed, as the earlier you receive treatment the more effective it will be. In the meantime there is plenty more information on a wide range of other conditions – take a look around our pharmacy health library to find out more.
(i) Available online: https://cks.nice.org.uk/topics/peripheral-arterial-disease/background-information/prevalence/
(ii) Available online: https://patient.info/heart-health/peripheral-arterial-disease-leaflet
(iii) Available online: https://patient.info/doctor/peripheral-arterial-disease-pro
(iv) Available online: https://www.vascularsociety.org.uk/patients/conditions/7/peripheral_arterial_disease
(v) Available online: https://cks.nice.org.uk/topics/peripheral-arterial-disease/background-information/risk-factors/
(vi) Available online: https://www.bhf.org.uk/informationsupport/heart-matters-magazine/medical/peripheral-arterial-disease
(vii) Available online: https://www.diabetes.co.uk/diabetes-complications/peripheral-arterial-disease.html
(viii) Available online: https://www.nhs.uk/conditions/peripheral-arterial-disease-pad/treatment/
(ix) Available online: https://cks.nice.org.uk/topics/peripheral-arterial-disease/management/intermittent-claudication/
(x) Available online: https://www.nhs.uk/live-well/exercise/
(xi) Available online: https://www.nhs.uk/live-well/exercise/physical-activity-guidelines-older-adults/
(xii) Merchant AT et al. The Use of B Vitamin Supplements and Peripheral Arterial Disease Risk in Men Are Inversely Related. The Journal of Nutrition, Volume 133, Issue 9, September 2003, Pages 2863–2867. Available online: https://academic.oup.com/jn/article/133/9/2863/4688248
(xiii) Carrero JJ. Daily supplementation with (n-3) PUFAs, oleic acid, folic acid, and vitamins B-6 and E increases pain-free walking distance and improves risk factors in men with peripheral vascular disease. J Nutr 2005 Jun;135(6):1393-9. Available online: https://academic.oup.com/jn/article/135/6/1393/4663831?login=true
(xiv) Ramirez JL et al. Peripheral Artery Disease Is Associated with a Deficiency of Erythrocyte Membrane n-3 Polyunsaturated Fatty Acids. Lipids 2019 Apr;54(4):211-219. Available online: https://aocs.onlinelibrary.wiley.com/doi/10.1002/lipd.12140
(xv) Colussi G et al. Impact of omega-3 polyunsaturated fatty acids on vascular function and blood pressure: Relevance for cardiovascular outcomes. Nutr Metab Cardiovasc Dis 2017 Mar;27(3):191-200. Available online: https://www.nmcd-journal.com/article/S0939-4753(16)30118-1/fulltext
(xvi) Pittler MH, Ernst E. Ginkgo biloba extract for the treatment of intermittent claudication: a meta-analysis of randomized trials. Am J Med. 2000;108:276-281. Available online: https://www.amjmed.com/article/S0002-9343(99)00454-4/fulltext. Peters H, Kieser M, Holscher U. Demonstration of the efficacy of ginkgo biloba special extract EGb 761 on intermittent claudication—a placebo-controlled, double-blind multicenter trial. Vasa. 1998;27:106-110. Available online: https://pubmed.ncbi.nlm.nih.gov/9612115/
(xvii) Melamed ML et al. Serum 25-Hydroxyvitamin D Levels and the Prevalence of Peripheral Arterial Disease. Arterioscler Thromb Vasc Biol 2008 Jun;28(6):1179-85. Available online: https://www.ahajournals.org/doi/10.1161/ATVBAHA.108.165886
(xviii) Available online: https://www.gov.uk/government/news/phe-publishes-new-advice-on-vitamin-d
(xix) Vissers LET et al. The relationship between vitamin K and peripheral arterial disease. Atherosclerosis 2016 Sep;252:15-20. Available online: https://www.atherosclerosis-journal.com/article/S0021-9150(16)31216-3/fulltext
Disclaimer: The information presented by Nature's Best is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. Self-treatment is not recommended for life-threatening conditions that require medical treatment under a doctor's care. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or pharmacist for any health problem and before using any supplements or before making any changes in prescribed medications.
Christine Morgan has been a freelance health and wellbeing journalist for almost 20 years, having written for numerous publications including the Daily Mirror, S Magazine, Top Sante, Healthy, Woman & Home, Zest, Allergy, Healthy Times and Pregnancy & Birth; she has also edited several titles such as Women’ Health, Shine’s Real Health & Beauty and All About Health.