Physician Update: AHA Special Edition
Read more articles from our most relevant research presented at the 2025 AHA Scientific Sessions.
Comprehensive Heart and Vascular Center
Microvascular Function and Peripheral Artery Disease
By Joshua A. Beckman, M.D., M.S.
Professor of Internal Medicine
Chief of Vascular Medicine
Each year, the AHA Scientific Sessions remind us that progress in cardiovascular medicine depends on questioning what we think we already know. This year, my focus was on one of the most underestimated contributors to functional impairment in vascular disease, microvascular dysfunction (MVD), and its profound impact on outcomes in patients with peripheral artery disease (PAD).
Historically, our attention has centered on the large conduit arteries that can be imaged and stented. Yet, as new data reveal, microcirculation plays a crucial role in determining limb perfusion, tissue health, and, ultimately, whether a patient keeps or loses a limb. In analyses from the Veterans Aging Cohort Study, patients with both PAD and evidence of MVD experienced dramatically higher risks of amputation and impaired ambulation. These findings reinforce that macrovascular repair alone cannot fully restore function.
“Microcirculation is not invisible – it is simply waiting for us to look closer.”
Joshua A. Beckman, M.D., M.S.
Recent imaging advances further reveal this physiology. MRI perfusion mapping and BOLD flow imaging reveal impaired microvascular reactivity in ischemic muscle that associate with reductions in the six-minute walk test. Moreover, improvements in microvascular reactivity after exercise or revascularization suggest the centrality of the microvasculature in ambulatory function in PAD.
Encouragingly, emerging therapies are showing promise. In the STARDUST trial, the GLP-1 receptor agonist liraglutide improved transcutaneous oxygen pressure and microvascular blood flow, echoing results from larger cardiovascular outcome trials such as LEADER. These data suggest that medications initially designed for diabetes and weight control may improve vascular resilience at the microvascular level.
As clinicians and scientists, we must begin to view PAD not only as a disease of blocked arteries but as a disorder of impaired perfusion at every scale. Microcirculation is not invisible – it is simply waiting for us to look closer.
