Peripheral Artery Disease in Women: The Leg Pain That Predicts Heart Disease

Peripheral artery disease affects 6.6% of women globally, yet fewer than 25% receive a diagnosis before their first cardiovascular event. The 2019 Lancet Global Health analysis found women have slightly higher PAD prevalence than men in older age groups, but women are half as likely to be screened with ankle-brachial index testing. PAD is not a leg problem. It is systemic atherosclerosis announcing itself in the arteries you can measure without catheterization. A woman with an ABI below 0.90 faces a 2.5-fold increased risk of heart attack, stroke, or cardiovascular death within four years.

The Missed Diagnosis

She thought it was her arthritis. Her legs ached, especially on walking. ABI: 0.72 on the right. PAD. Not arthritis. A marker that her atherosclerotic disease had spread beyond the coronary arteries.

I see this pattern weekly. A woman in her late sixties presents for a wellness visit. She mentions, almost as an afterthought, that her legs tire easily on her evening walks. She has stopped walking as far. She assumes this is normal aging. Her primary care physician documented “musculoskeletal leg pain” and ordered knee X-rays. Nobody measured her ankle pressures.

The PARTNERS study published in JAMA in 2001 revealed the scope of this problem. Among patients aged 70 and older in primary care practices, PAD prevalence reached 29%. Hirsch 2001 Yet only 11% of these patients had a prior PAD diagnosis. The disease was hiding in plain sight.

Women face an additional diagnostic barrier. The classic PAD symptom is intermittent claudication: cramping pain in the calf that begins at a predictable walking distance and resolves within minutes of rest. Men describe this textbook presentation. Women often do not.

In the PARTNERS study, 50.1% of women with PAD reported atypical symptoms versus 34.5% with classic claudication. Women describe leg fatigue. Leg heaviness. Aching that does not localize to one muscle group. Pain that persists longer after stopping. Symptoms that sound like venous insufficiency or arthritis or deconditioning. Symptoms that do not trigger the PAD checkbox in a physician’s mind.

The 2023 European Heart Journal review by Hamburg and Creager named this directly: PAD is “a hidden problem in women.” Hamburg 2023 Women present later. Women receive fewer diagnostic tests. Women undergo fewer revascularization procedures. And women have worse limb outcomes when they finally receive a diagnosis. 5 / Solid

The ABI Problem

The ankle-brachial index should be simple. Measure systolic blood pressure at the ankle. Divide by systolic pressure at the arm. Normal is 1.00 to 1.40. Below 0.90 indicates PAD. Below 0.50 indicates critical limb ischemia.

But the 0.90 threshold was validated predominantly in male populations. Women have, on average, lower baseline ankle pressures due to shorter stature, smaller vessel caliber, and different peripheral vascular resistance. A woman with an ABI of 0.94 may harbor significant disease that the standard cutoff misses.

The Multi-Ethnic Study of Atherosclerosis (MESA) demonstrated this. Researchers found that using an ABI threshold of less than 1.00 in women improved sensitivity for detecting subclinical atherosclerosis without sacrificing specificity. Criqui 2010 The borderline zone between 0.91 and 1.00 deserves attention in symptomatic women rather than reassurance.

There is a second problem. Diabetic women and women with chronic kidney disease often have medial arterial calcification that makes arteries incompressible. The ABI reads falsely normal or even elevated above 1.40. In these patients, the toe-brachial index or exercise ABI testing unmasks disease that resting ABI misses.

I apply what I call the Symptomatic Override Rule. If a woman describes exertional leg symptoms that reproduce with walking and improve with rest, she has PAD until proven otherwise, regardless of her resting ABI. The next step is exercise ABI testing or arterial duplex ultrasound. The resting ABI is a screening tool, not a verdict.

The 2024 AHA/ACC Peripheral Artery Disease Guideline codifies this approach. For patients with exertional leg symptoms and a resting ABI between 0.91 and 1.40, the guideline recommends exercise treadmill ABI testing to unmask hemodynamically significant disease. Gerhard-Herman 2024 This recommendation applies equally to women, though the guideline acknowledges that diagnostic testing rates remain lower in women across all categories. 5 / Solid

The Systemic Marker

PAD is not a leg disease. It is atherosclerosis you can detect without a catheter.

The atherosclerotic plaque that narrows a femoral artery is identical to the plaque narrowing a coronary artery. The processes are the same: endothelial injury, lipid accumulation, inflammatory cell infiltration, fibrous cap formation, and eventual calcification or rupture. When plaque appears in the legs, it exists in other arterial beds. You simply cannot see it yet.

The REACH Registry followed patients with established atherosclerotic disease or multiple risk factors across 44 countries. Among women with symptomatic PAD, the risk of cardiovascular death, myocardial infarction, or stroke over four years was 2.5 times higher than women without PAD. Steg 2007 PAD was a stronger predictor of cardiovascular events than any single risk factor.

This makes physiologic sense. Coronary arteries are smaller than leg arteries. A 50% stenosis in the superficial femoral artery might reduce ABI without causing symptoms. A 50% stenosis in a coronary artery causes angina or ischemia on stress testing. By the time leg symptoms appear, the total-body atherosclerotic burden is substantial.

Women don’t die from what they have. Women die from what they hold.

A woman who holds PAD in her legs holds coronary disease in her heart and carotid disease in her neck. She holds years of uncontrolled risk factors that allowed plaque to accumulate. She holds a diagnosis that demands immediate systemic treatment, not just leg management.

The 2019 global analysis published in Lancet Global Health estimated 236 million people worldwide have PAD. Song 2019 Among high-income countries, age-standardized prevalence was 6.6% in women versus 6.4% in men for adults over 25. In the oldest age groups, women exceeded men. Yet women remain underscreened, underdiagnosed, and undertreated. The epidemiology shows more affected women. The clinical reality shows fewer treated women. 5 / Solid

The Three-Vessel Problem

I teach my residents to think of PAD diagnosis as activating what I call the Three-Vessel Problem. When you find disease in one vascular bed, you must evaluate all three: coronary, cerebrovascular, and peripheral.

A woman with PAD needs:

Cardiac evaluation. At minimum, this means risk stratification and optimization of medical therapy. Many warrant stress testing or coronary CT angiography to assess for obstructive coronary disease. The yield is high. Studies show 40-60% of PAD patients have significant coronary artery disease on testing.

Carotid assessment. Carotid duplex ultrasound screens for stenosis that might warrant intervention before stroke occurs. The 2024 guidelines recommend carotid imaging in PAD patients with cerebrovascular symptoms and consideration in asymptomatic patients with multiple risk factors.

Limb-focused therapy. This means supervised exercise, smoking cessation, antiplatelet therapy, statin therapy, and consideration of dual-pathway inhibition. In patients with lifestyle-limiting claudication despite medical therapy, revascularization options include angioplasty, stenting, or surgical bypass.

The inverse also applies. A woman diagnosed with coronary artery disease should be screened for PAD. A woman with carotid stenosis should be screened for PAD. The diseases travel together. Finding one mandates looking for the others.

The Vascular Study Group of New England published data on sex-specific factors in PAD in 2019. Duval 2019 Women undergoing lower extremity revascularization had higher rates of critical limb ischemia at presentation compared to men. Women were more likely to present with tissue loss rather than claudication. This reflects later diagnosis: women arrive at the vascular surgeon’s office with advanced disease because earlier stages went unrecognized. 4 / Promising

Medical Therapy That Changes Outcomes

The treatment of PAD has evolved beyond aspirin and statins, though those remain foundational.

Antiplatelet therapy is standard. Aspirin 81-325mg daily or clopidogrel 75mg daily reduces cardiovascular events in symptomatic PAD. The choice between them is individualized based on aspirin tolerance and other indications.

Statin therapy is non-negotiable. High-intensity statin therapy (atorvastatin 40-80mg or rosuvastatin 20-40mg) reduces cardiovascular events and slows atherosclerosis progression. The target LDL is below 70 mg/dL, with many guidelines now pushing toward below 55 mg/dL for established atherosclerotic disease.

The COMPASS trial transformed PAD management in 2018. Anand 2018 Among PAD patients randomized to rivaroxaban 2.5mg twice daily plus aspirin versus aspirin alone, the dual-pathway group had:

Major adverse cardiovascular events: 5.0% versus 7.9% (hazard ratio 0.63, 95% CI 0.42-0.96) Major adverse limb events: 1.5% versus 3.0% (hazard ratio 0.54, 95% CI 0.35-0.84)

The combination reduced both heart attacks and amputations. The trade-off was increased bleeding: major bleeding 2.4% versus 1.5%. But the net clinical benefit favored dual-pathway inhibition for PAD patients without high bleeding risk.

This changes the conversation. A woman with symptomatic PAD should discuss low-dose rivaroxaban with her physician. The 2024 guidelines include dual-pathway inhibition as a class IIa recommendation for PAD patients at high cardiovascular risk without high bleeding risk. 5 / Solid

Cilostazol deserves mention for claudication. This phosphodiesterase inhibitor improves pain-free walking distance by 50-100% in responders. It is contraindicated in heart failure but otherwise well-tolerated. Side effects include headache, diarrhea, and palpitations.

Blood pressure targets matter. Below 130/80 is the goal. ACE inhibitors show particular benefit in PAD, likely through vascular protective effects beyond blood pressure lowering.

Glucose control matters. Hemoglobin A1c below 7% for most diabetic patients. Diabetes accelerates PAD progression and worsens limb outcomes.

Smoking cessation is the single most powerful intervention. Continued smoking doubles the risk of amputation in PAD patients. Smoking cessation halts disease progression in many patients. Pharmacotherapy for cessation, including varenicline and bupropion, should be offered actively, not passively mentioned.

The Walking Prescription

Supervised exercise therapy is the most underused treatment in PAD. It works. The evidence is unambiguous. Yet fewer than 5% of eligible patients receive referral.

The protocol is specific. Walk on a treadmill or track until moderate claudication pain develops. Stop. Rest until pain resolves, typically 2-5 minutes. Resume walking. Repeat for 30-50 minutes per session, three times weekly, for 12 weeks minimum.

This structured approach increases pain-free walking distance by 50-200% in most patients. The mechanism involves collateral vessel development, improved muscle oxygen extraction, and enhanced endothelial function. The benefits rival or exceed revascularization for claudication.

The barriers are predictable. Insurance coverage remains inconsistent. Programs are not available in all communities. Patients find the sessions inconvenient. But when I explain that a walking program can double walking distance without surgery, most patients become interested.

Home-based exercise programs show benefit when supervised programs are unavailable. The key elements: structured walking prescription, symptom-limited intervals, and regular follow-up to ensure adherence and progression.

For women specifically, the social and psychological barriers to exercise programs may differ from men. Women may have more caregiving responsibilities limiting their ability to attend sessions. Women may feel less comfortable in cardiac rehabilitation settings historically dominated by male heart attack survivors. Programs that acknowledge these realities see better enrollment and adherence among women.

The Screening Question

Who should undergo ABI testing? The guidelines provide clear criteria.

Age 65 and older: Screen once, regardless of symptoms. Age 50-64 with risk factors: Screen if diabetes, smoking, hypertension, hyperlipidemia, or family history of PAD exists. Any age with exertional leg symptoms: Test regardless of age or risk factors. Known atherosclerotic disease elsewhere: Screen if coronary artery disease, carotid disease, or aortic aneurysm is present.

This approach remains underimplemented. The ABI takes 15 minutes. It requires a standard blood pressure cuff and a handheld Doppler. It costs less than a basic metabolic panel. Yet most primary care practices do not routinely perform it.

The cost of missing PAD is paid in cardiovascular events and amputations. Women pay disproportionately because their symptoms do not match the classic textbook description that triggers physician suspicion.

If you are a woman over 50 with any cardiovascular risk factor and you have never had your ABI measured, you should request it. If your ABI is borderline between 0.91 and 1.00 and you have symptoms, request exercise ABI testing or arterial duplex ultrasound. Do not accept reassurance based solely on a borderline normal resting ABI.

What to Do Next

At your next appointment, ask specifically: “Can we measure my ankle-brachial index today?” If the result is below 1.00 and you have exertional leg symptoms, request further evaluation. If PAD is confirmed, request referral to a supervised exercise program and discussion of dual-pathway antiplatelet therapy.

Print this article. Bring it with you. The diagnosis begins with asking the question.

Frequently Asked Questions

What does leg pain from PAD feel like in women?

Women with peripheral artery disease rarely describe the textbook cramping that medical students learn. Instead, they report a diffuse achiness or fatigue in both calves that builds during walking. The sensation is often described as heaviness or tiredness rather than sharp pain. Many women attribute it to being out of shape or to arthritis affecting their knees or hips. The distinguishing feature is reproducibility: walking the same distance triggers the same discomfort, and rest relieves it, though sometimes more slowly than the 2-5 minute resolution typical of classic claudication. Women are more likely to modify their activity gradually, walking shorter distances over months or years, rather than experiencing a sudden limitation that prompts medical evaluation.

Can I have PAD with a normal ABI result?

Yes. The standard ABI cutoff of less than 0.90 was established in studies with predominantly male participants. Women have lower baseline ankle pressures on average, meaning an ABI between 0.91 and 1.00 may represent significant disease in a symptomatic woman. Additionally, women with diabetes or chronic kidney disease often have arterial calcification that makes vessels stiff and incompressible, producing falsely normal or elevated ABI readings. If your resting ABI is borderline or normal but you have classic walking-related leg symptoms, request exercise ABI testing. A drop in ABI after treadmill walking unmasks hemodynamically significant disease that resting measurement misses. Toe-brachial index testing is another option when arterial calcification is suspected.

Does PAD mean I will have a heart attack?

PAD indicates that atherosclerosis exists throughout your arterial system. The plaque in your leg arteries is the same disease process occurring in your coronary arteries and carotid arteries. The REACH Registry demonstrated that women with symptomatic PAD faced a 2.5-fold increased risk of cardiovascular death, myocardial infarction, or stroke over four years compared to women without PAD. However, this is not a death sentence. It is a warning and an opportunity. Aggressive risk factor modification with high-intensity statin therapy, blood pressure control, smoking cessation, and antiplatelet therapy can substantially reduce that elevated risk. Think of PAD as atherosclerosis revealing itself early enough to intervene before a coronary event occurs.

Should I take aspirin if I have PAD?

Antiplatelet therapy is standard for symptomatic peripheral artery disease. Aspirin at 81-325mg daily or clopidogrel 75mg daily reduces cardiovascular events. The more important question is whether to add low-dose rivaroxaban. The COMPASS trial demonstrated that adding rivaroxaban 2.5mg twice daily to aspirin reduced major adverse cardiovascular events from 7.9% to 5.0% and major adverse limb events from 3.0% to 1.5% in PAD patients. The trade-off is increased bleeding risk. This dual-pathway approach is now recommended by guidelines for PAD patients at high cardiovascular risk who do not have high bleeding risk. Discuss specifically with your physician whether you are a candidate for aspirin plus low-dose rivaroxaban.

What exercise is safe with peripheral artery disease?

Supervised walking exercise is not just safe but is first-line therapy for PAD. The protocol involves walking until moderate claudication develops, resting until pain resolves, then resuming. This interval approach, repeated for 30-50 minutes three times weekly for 12 weeks, increases pain-free walking distance by 50-200% in most patients. The mechanism involves new collateral blood vessel development, improved muscle oxygen extraction, and enhanced endothelial function. The benefits rival revascularization for claudication symptoms. Ask your physician for referral to a supervised exercise program covered by Medicare and most insurers. If no program is available locally, a structured home walking program with specific distance and interval targets provides benefit, though supervised programs show superior outcomes.