A 55-year-old man who is a smoker, comes in with a complaint of pain in his right calf. He says that it comes and goes and happens when he walks up a flight of stairs.
What is the next step to diagnose your suspicion of intermittent claudication?
Correct Answer D:
Intermittent claudication, the most common symptom of peripheral arterial disease, results from gradual narrowing of a leg artery. It is a painful, aching, cramping, or tired feeling in the muscles of the leg, not in the joints. Intermittent claudication occurs regularly and predictably during physical activity but is always relieved promptly by rest. The muscles ache when a person walks, and the pain begins more quickly and is more severe when the person walks quickly or uphill.
Usually, after 1 to 5 minutes of rest (sitting is not necessary), the person can walk the same distance already covered, although continued walking will again provoke the pain at a comparable distance. Most commonly, the pain occurs in the calf, but it can also occur in the thigh, hip, or buttock, depending on the location of the blockage.
The ankle-brachial index is an effective screening tool. The ankle-brachial index is calculated by dividing the ankle pressure (the higher of the posterior tibial artery pressures) by the brachial systolic pressure (the higher of the two arm pressures).
An ankle-brachial index below 0.95 at rest or following exercise is considered abnormal. An ankle-brachial index between 0.8 and 0.5 is consistent with intermittent claudication, and an index of less than 0.5 indicates severe disease.
Which of the following is the most important step in the management in order to alter the progression of peripheral arterial disease?
Peripheral arterial disease (PAD) is a common circulatory problem in which narrowed arteries reduce the blood flow to the limbs.
Risk factors for PVD include smoking, hyperlipidemia, diabetes mellitus, and hyperviscosity. Other etiologies for developing PVD may include phlebitis, injury or surgery, and autoimmune disease, including vasculitides, arthritis, or coagulopathy.
Most people with PAD can be treated with lifestyle changes, medications or both. Lifestyle changes to lower the risk include: stop smoking (single most important modifiable cause of PAD; smokers have a particularly strong risk of PAD), control diabetes, control blood pressure, be physically active (including a supervised exercise program), eat a low saturated-fat, low-cholesterol diet.
A 74-year-old white male complains of pain in the right calf that recurs on a regular basis. He smokes 1 pack of cigarettes per day and is hypertensive. He has a history of previous heart attack but is otherwise in fine health.
Which one of the following findings would support a diagnostic impression of peripheral vascular disease?
Peripheral vascular disease (PVD) is a clinical manifestation of artherosclerotic disease and is caused by occlusion of the arteries to the legs. Patients with significant arterial occlusive disease will have a prominent decrease in the ankle-brachial index from baseline following exercise, and usually a 20-mm Hg or greater decrease in systolic blood pressure. Typical symptoms of peripheral artery disease include pain in the legs with walking that goes away with rest. This is called intermittent claudication.
> Pain during rest and exercise and the presence of swelling and soreness behind the knee and in the calf (choice A) is found in those with Baker’s cysts.
> Peripheral nerve pain commonly begins immediately upon walking and is unrelieved by rest (choice B).
> Doppler waveform analysis is useful in the diagnosis of PVD and will reveal attenuated waveform at a point of decreased blood flow (choice C).
> Employment of the ankle-brachial index (choice E) is encouraged in daily practice as a simple means to diagnose the presence of PVD. Generally, ankle-brachial indices in the range of 0.91-1.30 are thought to be normal.
A 76-year-old white male with a history of type 2 diabetes mellitus presents with a well-demarcated ulcer on the lateral aspect of his right ankle. Because of associated edema, you are unable to palpate pulses in his feet.
The most appropriate next step in the care of this patient would be to:
Correct Answer E: Since palpation of the dorsalis pedis pulse on the affected limb is difficult in this patient due to edema, further diagnostic evaluation to rule out associated arterial insufficiency is warranted. Compression therapy in patients with underlying arterial disease may cause limb ischemia. Noninvasive diagnostic procedures, such as determining the ankle-brachial index or performing transcutaneous oxygen measurement, are simple methods for detecting arterial disease. Venography is usually reserved for investigation before surgery, if indicated. Aspirin and pentoxifylline may improve healing but would not be started until a diagnosis has been established.
A 62-year-old white male presents with symptoms of intermittent claudication. The patient smokes 1 pack of cigarettes per day and says he has been told in the past that he has diabetes mellitus, high cholesterol, and high blood pressure. He has not followed up on these problems with a physician because he has been “too busy”.
On examination his blood pressure is 140/105 mm Hg, and he has findings consistent with peripheral artery disease. A laboratory workup reveals moderate hyperglycemia and elevated total and LDL cholesterol.
Which one of the following would have the most significant effect on improving the outcome of intermittent claudication?
Cigarette smoking is the most important risk factor for intermittent claudication, which is the most common symptom of peripheral vascular disease (PVD). Intermittent claudication is described as cramping pain in the muscles of the legs with exercise, and is experienced by 2% of adults over 65 years of age. In one multi-site study of nearly 7,000 adults over 50 years of age, 29% had PVD, defined by an ankle-brachial index (ABI) of ≤ 0.9. As many as 90% of those with PVD may be asymptomatic.
Cigarette smoking increases the odds for PVD by 1.4 for every 10 cigarettes smoked/day. In addition to smoking, risk factors include diabetes mellitus, hypertension, and hyperlipidemia. Lifestyle modification is important in the management of PVD, with smoking cessation as the single most important intervention. Exercise training can increase functional capacity by increasing walking time up to 150%. Medical management of comorbid conditions is necessary to optimize control and decrease morbidity and mortality from PVD and its complications, e.g., leg ulcers, osteomyelitis, acute limb ischemia, and amputation.
The Heart Outcome Prevention Evaluation (HOPE) trial demonstrated that use of ramipril reduced cardiovascular morbidity and mortality in PVD patients by 25%, regardless of the need for control of hypertension. However, data are insufficient to support the use of an ACE inhibitor in patients with PVD who are not hypertensive.
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