PAD Risk Amplifiers and Screening Strategies: A Talk with Foluso Fakorede, MD

In this expert discussion, interventional cardiologist Foluso Fakorede, MD, outlines the difference between traditional risk factors for peripheral artery disease (PAD) and risk amplifiers—conditions that worsen PAD progression and outcomes. Speaking with Grace, Dr. Fakorede emphasizes the importance of recognizing PAD as part of a broader polyvascular syndrome and explains how clinicians can identify high-risk patients using simple diagnostic tools like the ankle-brachial index (ABI) and toe-brachial index (TBI). He also addresses the limitations of current screening guidelines and offers practical tips for identifying symptomatic patients who may not yet present with classic signs of disease.

Dr Fakorede is the chief executive officer of Cardiovascular Solutions of Central Mississippi in Cleveland, Mississippi, and cochair of the Association of Black Cardiologists’ and PAD initiative.

The following transcript has been edited for clarity, style, and length.

Patient Care: In your presentation, you talked about some risk amplifiers. Can you discuss them further?

Foluso Fakorede, MD: Yes, absolutely. The difference between risk factors and PAD-related amplifiers is important to understand. Risk factors are things that predispose patients to PAD, while amplifiers are factors that accelerate the progression of the disease or the risk factors that led to the condition in the first place.

So, what are the PAD-related risk amplifiers? Anyone over the age of 75, or the geriatric population, as I like to call it—our community full of wisdom, but also frail—is at higher risk. Anyone with diabetes, chronic kidney disease, or end-stage renal disease is considered a PAD-related risk amplifier. Smoking tobacco, using smokeless tobacco, or chewing nicotine products are also amplifiers.

Additionally, conditions like microvascular disease or dysfunction—such as retinopathy, neuropathy, and nephropathy—are also risk amplifiers. Depression is another amplifier. And finally, polyvascular disease, which I call the “brain, heart, and leg syndrome,” is a critical factor. If a patient has blockages in the brain, heart, or legs, we must be vigilant, as these areas are all interconnected.

Patient Care: So, you emphasize that PAD should always be considered a polyvascular disease, correct? Could you expand on that a bit more?

Fakorede: Absolutely. As PAD advocates and specialists, what we’re trying to prevent is a situation where patients with PAD have a 30% risk of experiencing a major adverse cardiovascular event. In its most advanced stages—such as chronic threatened limb ischemia or critical limb ischemia—the mortality risk jumps to 50% to 65% within three to five years if left untreated.

In the first year after diagnosis, that risk is 25% to 30%, but it amplifies over time. That's why it’s crucial to intervene early to prevent heart attacks, strokes, and death.

If a patient presents with a history of coronary disease, stroke, and PAD—even before intervention or amputation—it’s critical to treat them aggressively. That means using evidence-based lifestyle interventions and medications that reduce major adverse cardiovascular events. Medications include statins, antidiabetic medications, and antiplatelet therapies. Along with these, lifestyle changes—such as exercise, tobacco cessation, and dietary improvements—are essential.

Patient Care: What are the indications for testing, and what are the benefits and locations of the technology you discussed in your presentation?

Fakorede: When it comes to screening, patients who meet the guidelines or show symptoms should be screened with an ABI. If there are limitations with ABI, we may use an exercise ABI, where the patient walks on a treadmill, or a TBI, which is useful in diabetic patients or those with heavily calcified vessels where ABI might be limited.

Testing is indicated for patients with PAD-related amplifiers and risk factors, particularly if physical examination reveals diminished pulses or if the patient has symptoms. Currently, we do not recommend screening for asymptomatic patients, as the US Preventive Services Task Force has not endorsed this.

However, it’s important to note that being asymptomatic doesn’t mean a patient isn’t at risk. It just means they haven’t reached what we call the ischemic threshold required to trigger symptoms. If a patient is asymptomatic, the benefit is putting them on a treadmill to see if exercise precipitates symptoms. If symptoms appear during this test, the patient qualifies for screening.