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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 June 11, 2024 e1327 additional diagnostic value of exercise ABI is limited, a retrospective case series showed the highest sensitivity and specificity for the diagnosis of PAD in patients with resting ABI ≥0.90.18 Various criteria for significant decrease in ABI with exercise have been reported.18 7 In patients with objectively confirmed PAD and an abnormal ABI (≤0.90), treadmill exercise ABI testing can be used to objectively assess functional status and walking performance, including documentation of time to onset of symptoms, nature of symptoms, and maximal walking time, as well as postexercise ABI. Among patients with chronic symptomatic PAD, this exercise assessment can be used as a baseline measure of functional status and for evaluation of response to therapy, including medical therapy (see Section 5, “Medical Therapy and Preventive Foot Care for Patients With PAD”), structured exercise therapy (see Section 6, “Exercise Therapy for PAD”), and revascularization (see Section 7, “Revascularization for Asymptomatic PAD”). Exercise ABI performance is used as an outcome measure to evaluate therapies for chronic symptomatic PAD in RCTs22,25 and has been shown to correlate with subjective symptoms. 8. Segmental limb pressure measurements with PVR, Doppler waveforms, or both are obtained in the vascular laboratory setting. Blood pressure gradients between cuffs placed on the leg (either 3 or 4 cuffs from thigh to ankle), along with corresponding qualitative changes in the appearance of PVR or Doppler waveforms, are used to localize PAD anatomically (ie, aortoiliac, femoropopliteal, and/or infrapopliteal disease), although the precise definition of location, severity, and characteristics of arterial lesions requires further imaging (see Section 3.2, “Imaging for PAD”).26,27 Segmental studies are particularly relevant in clinical situations in which delineation of anatomic level of PAD may impact the management of the patient (eg, in considering patients for revascularization). Standardized nomenclature for Doppler waveforms from lower extremity arteries has recently been proposed.62 9 The ABI alone may be inadequate to assess patients with suspected CLTI.28 The ABI may be 0.90 to 1.40 in nearly one-quarter of patients with CLTI, and 29% of patients have an ABI between 0.70 and 1.40.28,29 Additionally, the concordance between ABI and toe pressure/TBI among patients with CLTI is poor, with only 58% of patients who meet the criteria for abnormal toe pressures Table 8. Alternative Diagnoses for Nonhealing Lower Extremity Wounds With Normal Physiological Testing (Not PAD Related) Condition Location Characteristics and Causes Autoimmune injury Toes, foot, leg With blisters (eg, pemphigoid, pemphigus, epidermolysis bullosa) Without blisters (eg, dermatomyositis, lupus, scleroderma) Infection Toes, foot, leg Bacterial (eg, Pseudomonas, necrotizing Streptococcus) Fungal (eg, blastomycosis, Madura foot, chromomycosis) Mycobacterial Parasitic (eg, Chagas, leishmaniasis) Viral (eg, herpes) Inflammatory ulcer Toes, foot, leg Necrobiosis lipoidica Pyoderma gangrenosum Granuloma annulare Local injury Toes, foot, leg Trauma Insect or animal bite Burn Malignancy Toes, foot, leg Primary skin malignancy Metastatic malignancy Malignant transformation of ulcer Medication-related ulcer Toes, foot, leg Drug reactions (eg, erythema multiforme) Medication direct toxicity (eg, doxorubicin, hydroxyurea, some tyrosine kinase inhibitors) Neuropathic ulcer Pressure zones of foot Hyperkeratosis surrounds the ulcer Diabetes with peripheral neuropathy Peripheral neuropathy without diabetes Leprosy Venous ulcer Distal leg, especially above medial malleolus Develops in regions of skin changes due to chronic venous disease and local venous hypertension Typically wet (ie, wound drainage) rather than dry lesion PAD indicates peripheral artery disease. Modified with permission from Gerhard-Herman et al.69 Copyright 2017 American Heart Association, Inc., and American College of Cardiology Foundation. Downloaded from http://ahajournals.org by on October 7, 2026