Peripheral artery disease (PAD) affects people whose leg arteries have narrowed from plaque buildup, reducing blood flow to the lower limbs. Your risk rises sharply with age, but smoking, diabetes, high blood pressure, and high cholesterol are the major modifiable factors that drive the disease. Around 6.5 million Americans over 40 have PAD, and many don’t know it because symptoms can be subtle or absent entirely.
Age Is the Strongest Single Risk Factor
PAD prevalence climbs steeply with every decade of life. Among non-Hispanic White individuals, roughly 1.9% of people in their 50s have PAD. By the 60s, that number rises to about 5.4%. After age 80, nearly 1 in 4 (22.6%) are affected. The 2024 guidelines from the American College of Cardiology and American Heart Association flag everyone 65 and older as being at increased risk, regardless of other health factors.
For adults 50 to 64, screening is recommended when at least one additional risk factor is present, such as diabetes, a history of smoking, high cholesterol, high blood pressure, chronic kidney disease, or a family history of PAD. Adults under 50 generally aren’t screened unless they have diabetes plus another cardiovascular risk factor.
Smoking Multiplies Your Risk Three to Four Times
Smoking is the single most potent lifestyle risk factor for PAD. Current smokers face a three- to four-fold increase in risk compared to people who have never smoked. Tobacco damages artery walls directly, accelerates plaque formation, and promotes blood clotting. The relationship is dose-dependent: the more pack-years you accumulate, the higher your risk.
Quitting does help. Former smokers carry less risk than current smokers, though their risk remains elevated above that of never-smokers for years after stopping. Of all the modifiable factors for PAD, eliminating tobacco exposure offers the largest single reduction in risk.
Diabetes and PAD Reinforce Each Other
About 20% of people with diabetes over age 40 have PAD, and that figure climbs to 29% for those over 50. The relationship runs both ways: diabetes accelerates artery damage, and poor circulation from PAD worsens diabetic complications in the feet and legs. Chronically elevated blood sugar injures the inner lining of blood vessels and promotes inflammation that speeds plaque growth.
People with diabetes also tend to develop PAD in smaller, more distal arteries (further down toward the ankles and feet), which makes the disease harder to detect and treat. This pattern partly explains why diabetes is a leading contributor to lower-limb amputations.
High Blood Pressure and High Cholesterol
Hypertension and elevated cholesterol are independent risk factors for PAD, meaning each one raises your risk on its own even after accounting for smoking and diabetes. A large study of men published in JAMA found that these four factors together, smoking, diabetes, high blood pressure, and high cholesterol, account for the majority of clinically significant PAD cases. Bringing blood pressure and LDL cholesterol into normal ranges is associated with lower rates of complications and death in people who already have the disease.
Chronic Kidney Disease Raises Risk Sixfold
People with moderate to advanced kidney disease (a filtration rate below 60) have PAD at roughly six times the rate of people with normal kidney function. National survey data found that 24% of people with at least moderate kidney disease had PAD, compared to just 4% of those with healthy kidneys. The connection likely involves shared mechanisms: kidney disease increases inflammation, disrupts calcium and phosphorus metabolism in artery walls, and often coexists with diabetes and high blood pressure.
Racial and Ethnic Disparities
PAD does not affect all racial and ethnic groups equally. Black Americans carry a substantially higher burden. Among Black men, PAD prevalence reaches about 5% in the 50s, 13.2% in the 60s, and a striking 59% after age 80, roughly two to three times the rates seen in non-Hispanic White individuals at every age bracket. The reasons are partly biological (higher rates of diabetes and hypertension) and partly structural (disparities in access to preventive care and early diagnosis).
Outcomes also differ. When hospitalized for PAD, Black patients face 71% higher odds of major amputation compared to non-Hispanic White patients. Hispanic and Native American patients also have elevated amputation rates (36% and 48% higher, respectively). These gaps reflect differences in disease severity at the time of diagnosis, access to vascular specialists, and rates of limb-saving procedures.
Men and Women Face Different Patterns
Overall PAD prevalence is similar in men and women, but the disease often looks different. Women are more likely to be asymptomatic or to experience atypical symptoms during exercise rather than the classic cramping leg pain (claudication) that prompts evaluation. This means PAD in women is frequently underdiagnosed.
Men are more likely to present with severe complications like rest pain, non-healing ulcers, and gangrene. Yet some studies suggest women are actually more prone to developing critical limb ischemia, the most advanced stage of PAD, with up to twice the prevalence seen in male patients. The mismatch between symptom reporting and disease severity in women makes screening especially important for women who carry other risk factors.
Genetics and Family History
A family history of PAD or other forms of cardiovascular disease raises your risk independently of lifestyle factors. Research on identical and fraternal twins found that roughly 48% of the variation in ankle-brachial index scores (the standard PAD screening measurement) could be attributed to genetic factors, even after accounting for shared environmental exposures. The Framingham Offspring study and other large cohorts have confirmed that PAD has a significant heritable component.
The 2024 ACC/AHA guidelines specifically list family history of PAD as a reason to consider screening in adults aged 50 to 64. If a parent or sibling was diagnosed with PAD, you carry meaningful additional risk even if your other numbers look good.
Chronic Inflammation as an Underlying Driver
People with higher baseline levels of systemic inflammation face roughly double the risk of developing PAD, even when they appear healthy by other measures. A landmark study from the Physicians’ Health Study tracked men over years and found that those in the highest quarter of C-reactive protein levels (a blood marker of inflammation) had about twice the risk of developing symptomatic PAD compared to those in the lowest quarter. Conditions that promote chronic inflammation, including autoimmune diseases, obesity, and sedentary lifestyles, may contribute to PAD risk through this pathway.
Existing Cardiovascular Disease
If you already have atherosclerosis in one part of your body, the odds are high that it exists elsewhere. People with coronary artery disease, carotid artery narrowing, or an abdominal aortic aneurysm are flagged as high-risk for PAD in current guidelines regardless of age. Atherosclerosis is a systemic process, and plaque in the heart’s arteries strongly predicts plaque in the legs. Anyone with established cardiovascular disease in any vascular territory should be evaluated for PAD.