Top Things to Know: Understanding the Pain Experience and Treatment Considerations Along the Spectrum of Peripheral Artery Disease

Published: February 10, 2025

Prepared by Barbara Entl, MD, Science and Medicine Advisor

Peripheral artery disease (PAD) is a common cardiovascular condition that raises the risk of amputation, myocardial infarction, stroke, and death and negatively affects the quality of life by impairing walking performance and functional status.
Managing PAD involves addressing pain and clinical risk profiles, focusing on how pain impacts presentation, treatment, and outcomes, with chronic pain varying among patients.
The Rutherford classification of PAD, detailed in this statement, outlines all six stages of disease severity and categorizes PAD based on the severity of symptoms and the extent of arterial occlusion. It also includes a table summarizing pain symptoms by nature, location, and intensity according to the Rutherford/Fontaine classification.
Intermittent claudication, explained in this statement, is pain triggered by walking and relieved by rest, involving both nociceptive pathways (muscle acidity stimulating pain fibers) and inflammatory pathways (elevated inflammatory markers).
Claudication pain originating from deep muscle tissue is contrasted with ischemic rest pain, typically felt superficially in the skin. Understanding these distinctions can provide clarity in diagnosis and treatment.
The biopsychosocial model of pain is reviewed, highlighting that in patients with PAD, pain is often musculoskeletal but may also coexist with chronic postsurgical, post-traumatic, or neuropathic pain.
PAD is viewed as a chronic pain syndrome, with exercise therapy improving walking distance. However, research indicates that pain relief from exercise is only partially linked to improved blood flow, suggesting that other factors beyond new blood vessel formation contribute to pain improvement.
Current pain management approaches are reviewed in this statement, including medical therapy, risk factor mitigation, and psychological interventions, with an outline of their benefits and limitations.
The statement evaluates PAD-specific instruments for assessing pain, noting limitations of the International Classification of Diseases-10 (ICD) in aligning with the biopsychosocial model and diagnosing chronic neuropathic pain.
Key areas for future focus include enhancing awareness of pain’s multidimensionality in PAD, improving educational efforts for effective pain management, advancing research on pain pathways, and establishing pain management standards.

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Citation

Smolderen KG, Ujueta F, Buckley Behan D, Vlaeyen JWS, Jackson EA, Peters M, Whipple M, Phillips K, Chung J, Mena-Hurtado C; on behalf of the American Heart Association Council on Peripheral Vascular Disease; Council on Cardiovascular and Stroke Nursing; and Council on Quality of Care and Outcomes Research. Understanding the pain experience and treatment considerations along the spectrum of peripheral artery disease: a scientific statement from the American Heart Association. Circ Cardiovasc Qual Outcomes. Published online February 10, 2025. doi: 10.1161/HCQ.0000000000000135