Should all adults with diabetes, including those who are asymptomatic, be screened for peripheral vascular disease (PAD)?

According to Shihchen Kuo, RPh, PhD, associate research scientist of internal medicine at the University of Michigan Medical School in Ann Arbor, Michigan, the answer is no. Screening asymptomatic adults with diabetes for PAD isn’t supported by the evidence, has potential harms, and won’t change treatment, said Kuo, who debated the question at the American Diabetes Association (ADA) 2026 Scientific Sessions.

Taking the opposite side, Naomi Hamburg, MD, MS, the Joseph A. Vita Professor of medicine and chief of vascular biology at Boston University Chobanian & Avedisian School of Medicine in Boston, argued that testing for PAD would absolutely change outcomes for patients and that currently all stages of PAD are underdiagnosed.

The ADA’s current Standards of Care in Diabetes recommend: “In asymptomatic individuals with diabetes and age ≥ 65, microvascular disease in any location, or foot complications, or any end-organ damage from diabetes, screening for PAD with ankle-brachial index (ABI) testing is recommended if a PAD diagnosis would change management.”

Guidance from the American College of Cardiology (ACC) is similar.

The two speakers also had different take on these recommendations.

Truly Asymptomatic?

Kuo began by expressing skepticism that there would be many people who fit the ADA’s criteria who are truly asymptomatic, and whether a PAD diagnosis would change management in asymptomatic individuals.

The ADA document cites a cross-sectional German study that found the prevalence of PAD among primary care patients with diabetes aged 65 years or older was 26%; however, 24% were already symptomatic with claudication or had a history of peripheral revascularization or amputation, Kuo pointed out. Others may have had symptoms or signs of PAD that weren’t reported, he added.

Moreover, a recent review concluded that to date, no randomized study has compared ABI screening for PAD to unscreened controls, and pointed out that it is unknown whether PAD screening improves limb outcomes, he said.

Even the ADA’s document states that prospective, randomized, studies are needed to address whether PAD screening in people with diabetes improves cardiovascular event rates or long-term limb outcomes, Kuo noted.

In fact, the only evidence cited by the 2026 ADA guidance comes from the VIVA randomized controlled trial that compared a “triple” screening for hypertension, abdominal aortic aneurysm, and PAD to no screening in over 50,000 Danish men aged 65-75 years. Screening and subsequent interventions yielded a small but significant 7% risk reduction in all-cause mortality over a median 4.4 years, but there were no differences in cardiovascular mortality or PAD surgery rates, said Kuo.

And because ABI was bundled with two other proven interventions, “it is difficult to determine how much of the benefit was related to ABI screening,” he said, adding that the population was all-Danish, male, and older, and only 10% had diabetes, making the broader applicability questionable.

While the ADA, ACC, and American Heart Association (AHA) all recommend PAD screening with a resting ABI, this comes from nonrandomized studies. An expert ACC analysis noted that PAD is most often suspected based on symptoms or signs, and the assumption that finding PAD in asymptomatic people will lead to treatment changes to lower cardiovascular risk is “speculative,” Kuo said.

Interpreting ABI Results

Kuo also noted that it’s not entirely clear how ABI results should be interpreted, as the ADA standards don’t mention cutoff points for defining an abnormal test.

Results of ABI could be misleading in people with diabetes or advanced chronic kidney disease, because medial calcification can cause ankle arteries to become incompressible, resulting in a high ABI. But in those with restricted flow, ABI is low. Thus, “having both may result in a seemingly normal ABI in a patient with PAD,” Kuo said.

Follow-up diagnostic testing such as CT angiography or magnetic resonance angiography may be necessary, but ADA doesn’t provide follow-up recommendations.

In the VIVA trial, those with cutoffs of < 0.9 or ≥ 1.4 had repeated ABIs performed within a week.

Meanwhile, potential harms and costs of ABI screening of asymptomatic adults include anxiety, and expense if follow-up testing is ordered. The national average Medicare reimbursement for ABI testing (Current Procedural Terminology code 93922) ranges from $79 to $127, and only when submitted with an International Classification of Diseases-10 code supporting medical necessity based on symptoms and signs.

Treatment of PAD has two potential benefits: preventing cardiovascular disease (CVD) and reducing morbidity and mortality from lower-limb ischemia. But Kuo noted, “interventions to prevent CVD apply to all people with diabetes regardless of PAD.” And recommendations to reduce morbidity and mortality from lower-limb ischemia, such as antiplatelet therapy, vasodilators, and revascularization, all focus on treating symptomatic patients and don’t depend on screening for PAD in asymptomatic people, Kuo said.

Indeed, the value of antiplatelet and antithrombotic therapies in asymptomatic PAD is uncertain because the risk for bleeding could offset any lowering of risk for ischemic events. There is also no evidence to support early revascularization in people with asymptomatic PAD, he added.

Too Many People Are Being Missed

Hamburg said she prefers the word “testing” to “screening” because people with diabetes are already at increased risk.

She began by showing a photo of Gertrude Campbell, the first Black woman postmaster in Starkville, Mississippi, who developed diabetes in her 50’s and lost both her legs to PAD-related amputation, having never been screened for PAD despite receiving prolonged wound care. Campbell went on to become a vocal advocate for PAD awareness.

“I think this is really an emblematic story about how many people who need to be tested for PAD are not being tested,” Hamburg said.

Between 20% and 50% of adults with diabetes have comorbid PAD, and 20% of those undergo incident amputation. According to the ADA’s Amputation Prevention Alliance, a limb is amputated due to diabetes in the US every 3 minutes and 30 seconds, she said.

Rates of amputation among people with diabetes rose by 50% from 2009 to 2015 compared with a 22% drop among those without diabetes. And among those who undergo amputations, 50% never had any diagnostic test for vascular disease prior to the amputation.

“Unrecognized and untreated PAD in patients with diabetes drives preventable amputation,” Hamburg said.

She questioned the “asymptomatic” designation, noting that many people with PAD who report burning or numbness in the legs are told “your leg pain is just neuropathy,” and aren’t evaluated for PAD. Therefore, many who are classified as “asymptomatic,” actually have functional impairment.

In addition, only about 15% of people with PAD have classic claudication, while atypical symptoms are common. These include leg pain that starts at rest and continues, functional impairment, and multiple types of leg pain, particularly if they also have neuropathy.

Because the distribution of PAD in people with diabetes is often more distal, a pulse examination alone may be insufficient. As Kuo said, the sensitivity of ABI may be lower in people with diabetes due to the medial calcification, at about 50%-60%, Hamburg said. However, the sensitivity of a toe-brachial index is better, at 74%. “So there are ways to evaluate for the presence of PAD, even in people with diabetes,” she added.

Treatments for PAD and Cardiovascular Events

Diagnosing PAD does change management, Hamburg asserted. “We live in an exciting time for PAD….There’s a lot that’s new, both for the treatment of the walking difficulty that people with PAD have, and also for the prevention of cardiovascular events.” The former includes cilostazol for the treatment of intermittent claudication, supervised or home-based exercise, and revascularization. And for the latter, there is strong evidence for statins, ramipril, clopidogrel, GLP-1 agonists, and SGLT2 inhibitors.

In one noteworthy trial called STRIDE, semaglutide significantly improved walking time in people with PAD and T2D. “This is the first treatment that has shown an improvement in walking time other than exercise therapy and cilostazol,” Hamburg commented.

Based, in part, on the COMPASS trial, the ACC and AHA now recommend a combination of low-dose (2.5 mg twice daily) rivaroxaban and low-dose (81-100 mg) aspirin for people with PAD and high ischemic risk and with low bleeding risk, she said. “Of course, this is in patients with symptomatic PAD, but I would argue that if you’re not looking for it and asking fully about it and testing for it, you’re not going to be able to find the people who are most appropriate for getting these treatments,” she added.

Hamburg concluded with another photo of Campbell, testifying before Congress.

“There is strong evidence that testing for PAD in your patients with diabetes is going to change how they do. You need to ask about any leg symptoms and have a low threshold for sending the people who talk about leg pain for formal testing, just like you would for a patient who tells you about chest pain, where you’re doing some simple tests,” she said. “It provides you an important opportunity to intensify therapy to lower the risk of amputation and cardiovascular events.”

Kuo has no disclosures. Hamburg reported having consulting for Fukuda and receiving fund from the AHA and the National Institutes of Health.

Miriam E. Tucker is a freelance journalist based in the Washington DC area. She is a regular contributor to Medscape, with other work appearing in The Washington Post, NPR’s Shots blog, and diaTribe. She is on X @MiriamETucker and BlueSky @miriametucker.bsky.social.