# Peripheral Arterial Disease Claudication and Medical Therapy > Peripheral arterial disease for NEET-PG Medicine: claudication, ankle-brachial index, Fontaine and Rutherford staging, antiplatelets, statins and cilostazol. - Canonical URL: https://prepelephant.com/topics/neet-pg/medicine/peripheral-arterial-disease - Exam / course: NEET-PG · Subject: Medicine - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-08 - Last updated: 2026-10-08 - Reference basis: Harrison's Principles of Internal Medicine; ESC Guidelines on peripheral arterial and aortic diseases; Bailey and Love's Short Practice of Surgery - How to cite: "Peripheral Arterial Disease Claudication and Medical Therapy", PrepElephant, https://prepelephant.com/topics/neet-pg/medicine/peripheral-arterial-disease ## Direct answer Peripheral arterial disease is atherosclerotic narrowing or occlusion of the arteries supplying the legs, most often in the femoropopliteal segment, causing calf pain on walking that eases with rest. The ankle-brachial index is the key screening test, and a value of 0.90 or less confirms the diagnosis. Management centres on risk-factor control, antiplatelet therapy, a high-intensity statin, smoking cessation and supervised exercise, with revascularisation reserved for limb-threatening or disabling symptoms. ## What you must remember - **Fontaine staging:** stage I is asymptomatic, IIa mild claudication, IIb moderate to severe claudication, III ischaemic rest pain, and IV ulceration or gangrene. - **Rutherford categories:** 0 is asymptomatic, 1 to 3 are claudication from mild to severe, 4 is ischaemic rest pain, and 5 and 6 are minor and major tissue loss. - **Ankle-brachial index:** the ankle systolic pressure divided by the higher brachial pressure; 0.90 or less is diagnostic, while values above 1.30 to 1.40 suggest calcified, non-compressible vessels in diabetes or chronic kidney disease. - **Medical therapy:** aspirin or clopidogrel, a high-intensity statin, strict smoking cessation and supervised exercise therapy. - **Cilostazol:** improves walking distance in claudication, but it is a phosphodiesterase-3 inhibitor and is contraindicated in heart failure of any severity. - **Leriche syndrome:** aortoiliac occlusion causing buttock and thigh claudication, erectile dysfunction and absent femoral pulses, typically in male smokers. ## A 62-year-old smoker who cannot reach the market A 62-year-old diabetic smoker reports calf pain after walking about 200 metres, which settles within a few minutes of standing still. The work-up follows a fixed sequence. 1. **Examine the pulses:** Femoral, popliteal, dorsalis pedis and posterior tibial pulses are palpated on both sides, and trophic change such as hair loss or shiny skin is noted. 2. **Measure the index:** Systolic pressures are recorded at both ankles and both arms, and the index is calculated using the higher brachial value. An index of 0.90 or less confirms disease. 3. **Check for calcification:** An index above 1.30 to 1.40 means the vessels are probably calcified, so the reading is falsely reassuring, and a toe-brachial index or Doppler waveform is requested instead. 4. **Treat stable claudication:** Antiplatelets, a high-intensity statin and a supervised walking programme are used, commonly about thirty to forty-five minutes three times a week. This improves walking distance more than most drugs. 5. **Add cilostazol if disabling:** Cilostazol may be added for disabling symptoms if cardiac function is preserved. 6. **Refer appropriately:** Revascularisation is reserved for rest pain, tissue loss, or claudication that stays disabling despite optimal therapy, and urgent vascular referral is needed for ulceration or gangrene. ## Where the examiner pulls the trap Vascular claudication is easily confused with several other causes of leg pain. - **Trap:** Confusing vascular with neurogenic claudication. — **Correct:** Spinal stenosis is relieved by sitting or leaning forward over a trolley and has normal pedal pulses, whereas vascular claudication is relieved by standing rest and has diminished pulses. - **Trap:** Missing Buerger disease in a young male smoker. — **Correct:** Thromboangiitis obliterans causes distal arterial occlusion that can involve the upper limbs as well as the legs, and tobacco cessation is the treatment that matters because continued smoking defeats every other measure. - **Trap:** Assuming rest pain and claudication are managed the same way. — **Correct:** Tissue loss threatens the limb itself, whereas claudication threatens only walking distance, which is why rest pain warrants urgent vascular assessment for revascularisation. ## Frequently asked questions ### Which test confirms peripheral arterial disease? The ankle-brachial index confirms peripheral arterial disease when the ratio of ankle to brachial systolic pressure is 0.90 or less. A value above 1.30 to 1.40 suggests calcified vessels, and toe pressures or Doppler waveforms are then used instead. ### What distinguishes vascular claudication from neurogenic claudication? Vascular claudication from peripheral arterial disease is relieved by standing rest and is accompanied by reduced pedal pulses. Neurogenic claudication from lumbar spinal stenosis is relieved by sitting or leaning forward, and the peripheral pulses are normal. ### Why is cilostazol avoided in heart failure? Cilostazol is a phosphodiesterase-3 inhibitor, a class linked to higher mortality in heart failure, so it is contraindicated in heart failure of any severity. It is used for disabling claudication only when cardiac function is preserved. ### Which antiplatelet agent is used for symptomatic peripheral arterial disease? Aspirin or clopidogrel is used for secondary prevention in symptomatic peripheral arterial disease, usually alongside a high-intensity statin. Clopidogrel is a reasonable alternative to aspirin and is a reasonable alternative, for example when aspirin is not tolerated.