Peripheral Artery Disease in Black Adults: Save the Leg

Peripheral artery disease (PAD) is the narrowing of the arteries that carry blood to your legs, caused by the same fatty plaque that clogs the arteries to the heart. If you have it in your legs, your heart and brain arteries are usually affected too, which is why PAD signals a high risk of heart attack and stroke. Black adults carry roughly double the risk, and when PAD goes untreated they are far more likely to end up with an amputation. The catch is that PAD is often silent, so many people never get the warning that would have saved the leg.

About 6.5 million people age 40 and older in the United States have PAD, according to the CDC. It is the buildup of fatty plaque, called atherosclerosis, inside the arteries that feed the legs and feet. Less blood reaches the muscles and skin, especially during activity when the legs demand more.

The same process is rarely confined to the legs. The CDC is direct about the stakes: if you have PAD, you are at risk for coronary artery disease and cerebrovascular disease, which could lead to a heart attack or stroke. A PAD diagnosis is a reason to get your heart and blood vessels evaluated, not just your legs.

The 2023 American Heart Association scientific statement on PAD disparities puts numbers to it: an estimated 30% of Black men and 27% of Black women will develop PAD over their lifetime, compared with 19% of White adults. Black adults also develop it younger and more severely. In the long-running Atherosclerosis Risk in Communities study, hospitalization for critical limb ischemia, the most dangerous stage, was roughly two to four times more common in Black participants than White participants.

A large part of this tracks the risk factors that already hit Black communities hardest: type 2 diabetes, high blood pressure, smoking, high cholesterol, and kidney disease. Each one accelerates plaque in the leg arteries. Diabetes is especially important here, both because it is more common and because it changes how PAD shows up.

The classic sign of PAD is claudication: cramping, aching, or fatigue in the calf, thigh, or buttock that comes on with walking and eases within minutes of resting. If you get reliable calf pain after walking a block or two that stops when you stand still, that is PAD until proven otherwise.

The trap is that most people with PAD do not get that clean signal. The CDC reports that up to 4 in 10 people with PAD have no leg pain at all. In community studies, only about 1 in 10 people with a low ankle-brachial index have classic claudication, while most are asymptomatic or have atypical symptoms. In diabetes the picture is worse, because nerve damage (neuropathy) can blunt the pain that would normally warn you. Research on PAD in diabetes shows it often surfaces instead as a foot wound that will not heal, a cold or pale or bluish foot, hair loss on the legs, or pain in the foot at rest, often at night. If you have diabetes and numbness in your feet, you can have advanced PAD and not feel it. (See our guide to numbness and tingling in diabetes.)

PAD is diagnosed with the ankle-brachial index, a painless test that compares the blood pressure at your ankle to the pressure in your arm. It takes a few minutes with blood-pressure cuffs and a handheld Doppler, and a ratio below 0.90 is the standard cutoff for PAD. You do not need a hospital for it. If you have diabetes, are over 65, smoke, or have leg symptoms, ask your primary care clinician directly: "Can we do an ankle-brachial index to check my leg arteries?" Asking by name matters, because PAD is under-screened, and Black patients are diagnosed later in the course of the disease.

This is the part that should make every reader insist on early testing. When Black and White patients have similar PAD severity, Black patients still face a higher risk of amputation. A study of more than 155,000 Veterans Affairs patients found that Black race was linked to a 37% higher risk of major amputation, independent of socioeconomic status. The AHA statement documents the mechanism: later diagnosis, less access to vascular specialists, and lower rates of limb-saving revascularization. When the artery can still be opened with surgery or a stent, Black patients are more likely to be sent to amputation instead.

The gap is not biological destiny. It is a treatment and access gap, which means it responds to earlier diagnosis and a clinician who fights for the limb.

The 2024 ACC/AHA guideline for lower-extremity PAD lays out treatment that both saves legs and lowers heart-attack and stroke risk. The core pieces:

• Stop smoking. Nothing else moves the needle as much. Smoking cessation slows the disease and lowers amputation and heart risk.
• Walk on a schedule. Supervised exercise therapy, or a structured community or home walking program, is a frontline treatment that improves how far you can walk before pain.
• Take a statin and an antiplatelet. A high-intensity statin plus aspirin or clopidogrel cuts cardiovascular events and limb events. For some patients, low-dose rivaroxaban with aspirin lowers limb loss further.
• Control blood sugar and blood pressure. Both directly drive plaque and limb risk.
• Protect the feet. If you have diabetes, check your feet daily and have a clinician inspect them at every visit. A small wound caught early is a treatable wound.
• Open the artery when needed. For advanced disease, angioplasty, stenting, or bypass can restore blood flow and save the limb. The point is to get this option, not skip to amputation.

Start with a clinician who will test, not wait. Ask your primary care doctor for an ankle-brachial index, and if you have symptoms or advanced disease, ask for a referral to a vascular specialist who does limb-salvage procedures, not only amputations. You can find a Black cardiologist, vascular specialist, or primary care clinician in our directory. Bring your risk factors to the visit, and if amputation is raised, ask directly: "Has a vascular specialist evaluated whether this artery can be reopened first?"