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8.1.1.1.1. Diagnostic tests. Vascular assessment: ABI, TBI, TcPO2 measurements (refer to Section 5.3) Ankle–brachial index is the proposed initial non-invasive diagnostic test to confirm lower-limb decreased perfusion status90,436,437 and needs to be reported separately for each leg (see Recommendation Table 2). An ABI ≤0.90 confirms PAD diagnosis.90,436,437 In cases of an ABI >0.90 and clinical suspicion of PAD, post-exercise ABI measurements should be considered, along with imaging studies (preferably by treadmill). A post-exercise ABI decrease of >20% may serve as a PAD diagnostic criterion.438,439 In cases of abnormally high ABI values (ABI >1.4; see Recommendation Table 2) and patients with CLTI and diabetes440 (see Recommendation Table 11), TP measurements, the calculation of TBI and TcPO2, as well as pulse volume recordings or analysis of distal arterial Doppler waveforms, should be considered,90,91,132,133,441 and ABI can be estimated from distal Doppler waveforms independent of diabetes and media sclerosis.124 Apart from the assessment of limb perfusion, ABI serves as a surrogate marker for CV and all-cause mortality.88,442,443 A diagnostic PAD algorithm is depicted in Figure 9. 4–5x increased risk of CV events compared with patients without PAD Cardiac disease (MACE): Cerebrovascular disease Lower limb disease (MALE): CV mortality Myocardial infarction Coronary revascularization Hospitalization for heart failure Amputation Chronic or acute lower limb ischaemia Lower limb revascularization Increased death and vascular amputation risk Figure 8 Cardiovascular risk in patients with peripheral arterial disease. CV, cardiovascular; MACE, major adverse cardiac event; MALE, major adverse limb event; PAD, peripheral arterial disease. ESC Guidelines 3575 Downloaded from academic.oup.com/eurheartj/article/45/36/3538/7738955 by guest on 07 October 2026