A three-part series published Sept. 22 in The Lancet underscores the growing global impact of peripheral artery disease (PAD) and reinforces the need for earlier diagnosis, improved treatment and better access to care. The papers examine the disease's epidemiology, management, outcomes and future challenges while reinforcing the importance of prevention and risk-factor modification.

In the first paper, Christian-Alexander Behrendt, MD, et al., describe PAD as an underrecognized and undertreated disease despite its substantial burden. Affecting more than 113 million people aged 40 years or older worldwide, PAD can remain asymptomatic for decades, yet advanced disease is associated with a five-year mortality of 30-50%, exceeding that of some cancers and acute myocardial infarction (MI). The authors identify aging populations, smoking, diabetes and other cardiovascular risk factors as key drivers of the disease's growing prevalence. They also highlight the strong association between PAD and polyvascular disease, which affects 46-68% of patients with PAD and substantially increases cardiovascular risk.

Although evidence supporting population-wide screening remains limited, the authors cite the current ACC/AHA Guideline for the Management of Lower Extremity PAD for risk-based screening and provide step-by-step outlines for understanding the ankle-brachial index (ABI) and diagnosing PAD.

"It appears highly probable that both the medical community and health-care policy makers continue to underestimate the scale of the problem due to systemic limitations inherent to available epidemiological studies," Behrendt and colleagues write. "The high and increasing disease prevalence along with accumulating evidence for missed opportunities in terms of prevention, early detection and best medical therapies call for actions not only in the vascular community but also in the wider public health area."

The second paper, led by Riikka Tulamo, PhD, emphasizes that risk-factor modification should remain the cornerstone of PAD management, including smoking cessation, exercise, lipid lowering, blood pressure control, diabetes management and appropriate antithrombotic therapy. Supervised exercise therapy remains one of the most effective treatments for intermittent claudication, improving walking capacity and quality of life while potentially reducing the need for invasive procedures. Yet access remains limited, with supervised exercise programs available in only 59% of European countries and just 24% of European vascular surgeons reporting access to such programs.

While endovascular and surgical interventions play an important role for patients with chronic limb-threatening ischemia (CLTI), the authors note substantial regional variation in care, with studies showing up to 86% variability in treatment approaches across U.S. centers alone.

"Safety, efficacy and cost-effectiveness are crucial to the success of new therapeutic strategies, and rigorous data that report on each of these outcomes are becoming increasingly essential in the face of rising health-care costs," write Tulamo and colleagues. "Ensuring equitable access to cutting-edge evidence-based care through global health initiatives, education, technology transfer and investment in health-care infrastructure is essential to closing the gap and reducing the global burden of PAD."

Jonathan Golledge, MChir, and colleagues focus on the effects of advanced PAD in the third paper, including chronic pain, impaired mobility, mental health disorders, amputation and death. A systematic review found that PAD increased the risk of falls 1.82-fold, while more than 40% of U.S. patients with CLTI require assistance walking, use a wheelchair or are bedridden. Patients with PAD also face substantially elevated risks of MI, stroke and cardiovascular death, with a low ABI (≤0.9) associated with a doubling of 10-year rates of major coronary events, cardiovascular mortality and all-cause mortality.

There are also persistent disparities in outcomes across sex, race, geography and socioeconomic status, with the authors noting that underserved populations often experience delayed diagnosis, reduced access to specialty care, and higher rates of advanced disease and amputation.

"In order to address the huge and escalating global burden of PAD a paradigm shift in the current systems for managing this disease are needed," Golledge and colleagues write. "Health-care systems need revising to better reimburse treatment of early-stage disease, better train specialists in PAD medical care, and incorporate standalone multidisciplinary models to deliver medical and rehabilitation care. Greater resources must also be allocated to public awareness campaigns, education and research to test ways to better treat PAD to reduce burden and inequality of outcomes."

In response to these challenges and in recognition of PAD Awareness Month, clinicians can review the 2024 ACC/AHA PAD Guideline and share CardioSmart patient education resources to help improve recognition and earlier intervention for a disease that has critical effects on cardiovascular outcomes, limb health and quality of life around the world.