A 69-year-old woman comes to the physician with right calf pain when walking. The pain has been present for several months but is now starting to limit her daily walks and shopping. It is described as a deep ache or cramp. The pain initially occurred after the patient walked 6 blocks, but now occurs after 2 blocks. It dissipates rapidly with rest. She has no chest pain or leg edema. The patient has a history of hypertension, hyperlipidemia, diet-controlled type 2 diabetes mellitus, and cigarette use. She has reduced her smoking to about 10 cigarettes a day. Her medications include simvastatin, ramipril, aspirin, calcium, and vitamin D.
The patient's blood pressure is 128/77 mm Hg and pulse is 72/min. Cardiac, lung, and abdominal examinations are unremarkable. Her femoral pulses are 2+ and symmetrical. Popliteal and dorsalis pedis pulses on the right feel diminished relative to the left. Her ankle-brachial index is 0.7 on the right and 0.9 on the left.
Electrocardiogram shows normal sinus rhythm and non-specific ST-segment and T-wave changes.
After smoking cessation, aggressive risk factor modification, and a supervised incremental walking program, which of the following would be the best next step in management if life-style-limiting claudication persists?

Question

A 69-year-old woman comes to the physician with right calf pain when walking.  The pain has been present for several months but is now starting to limit her daily walks and shopping.  It is described as a deep ache or cramp.  The pain initially occurred after the patient walked 6 blocks, but now occurs after 2 blocks.  It dissipates rapidly with rest.  She has no chest pain or leg edema.  The patient has a history of hypertension, hyperlipidemia, diet-controlled type 2 diabetes mellitus, and cigarette use.  She has reduced her smoking to about 10 cigarettes a day.  Her medications include simvastatin, ramipril, aspirin, calcium, and vitamin D.
The patient's blood pressure is 128/77 mm Hg and pulse is 72/min.  Cardiac, lung, and abdominal examinations are unremarkable.  Her femoral pulses are 2+ and symmetrical.  Popliteal and dorsalis pedis pulses on the right feel diminished relative to the left.  Her ankle-brachial index is 0.7 on the right and 0.9 on the left.
Electrocardiogram shows normal sinus rhythm and non-specific ST-segment and T-wave changes.
After smoking cessation, aggressive risk factor modification, and a supervised incremental walking program, which of the following would be the best next step in management if life-style-limiting claudication persists?

Quizplus · Accepted Answer

11ec193a_9734_0917_853d_97eeffa12e73_MD0002_00 This patient has claudication suggestive of peripheral artery disease (PAD). Modifying risk factors (especially smoking cessation) and adding graded exercise therapy can improve symptoms and decrease the progression of disease. In addition to these lifestyle changes, medical therapy is a reasonable option in most patients. Antiplatelet therapy is the preferred initial therapy for PAD, and aspirin is the preferred drug due to cost and efficacy. Clopidogrel is typically used in patients who cannot tolerate aspirin. Patients who are still symptomatic on antiplatelet therapy require second-line agents such as cilostazol, a phosphodiesterase inhibitor and vasodilator that inhibits platelet aggregation and significantly increases maximal and pain-free walking distances. Cilostazol is normally used in patients who do not meet criteria for revascularization, such as this patient whose ankle-brachial index (ABI) is >0.5. Cilostazol is contraindicated in patients with heart failure due to increased mortality in these patients. (Choice B) Pentoxifylline is indicated as a second-line treatment for PAD symptom relief, but controlled trials regarding efficacy are inconsistent and show limited benefit in improving walking capacity. (Choice C) Current guidelines recommend revascularization therapy (either surgical or percutaneous) for patients who fail all exercise and medical therapy, for those with significant disabling claudication preventing daily activities, and those with limb-threatening ischemia (ABI usually ~0.5). This patient should receive further medical therapy before considering revascularization as she does not meet the above criteria. (Choice D) Verapamil is an arterial vasodilator that modestly increases walking distance but has no effect on ABI, peripheral leg temperature or blood pressure, or PAD progression. Educational objective: Risk factor modification and graded exercise are effective in improving exercise capacity in patients with claudication and peripheral arterial disease (PAD). If lifestyle-limiting claudication persists, medical therapy with antiplatelet agents (aspirin or clopidogrel) is recommended to improve pain-free walking distance and prevent PAD progression. Patients who fail antiplatelet therapy and do not meet criteria for revascularization can be prescribed cilostazol to improve pain-free walking distances. __________ References: A comparison of cilostazol and pentoxifylline for treating intermittent claudication. (http://www.ncbi.nlm.nih.gov/pubmed/11063952) Meta-analysis of results from eight randomized, placebo-controlled trials on the effects of cilostazol on patients with intermittent claudication. (http://www.ncbi.nlm.nih.gov/pubmed/12480040) A randomized, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. (http://www.ncbi.nlm.nih.gov/pubmed/8918275)

A 69-Year-Old Woman Comes to the Physician with Right Calf