A 57-year-old man complains of right-sided leg and thigh pain and fatigue while walking. He has no chest pain, syncope, nausea, or abdominal pain. He has developed moderate erectile dysfunction over the past year. The patient's other medical problems include chronic kidney disease, hypertension, hyperlipidemia, gout, and gastroesophageal reflux disease. He also has a 40-pack-year smoking history and continues to smoke.
His blood pressure is 144/92 mm Hg, pulse is 67/min, and body mass index is 29 kg/m². A bruit is heard over the right carotid artery. Peripheral pulses are palpable bilaterally. There is a small ulcer at the tip of the right big toe. The ankle-brachial index is 1.0 bilaterally (normal 0.9-1.3) . Laboratory results are significant for serum creatinine of 1.6 mg/dL and HbA1c of 7.5%.
Which of the following is the most appropriate next step in management of this patient's leg pain?

Question

Quizplus · Accepted Answer

11ec193a_9769_2317_853d_dd0c72516f4b_MD0002_00 This patient has several risk factors, clinical symptoms, and signs (eg, intermittent claudication, erectile dysfunction, toe ulceration) that suggest occlusive peripheral arterial disease (PAD). Measurement of ankle-brachial index (ABI) is recommended in such patients to confirm the diagnosis of PAD. An ABI of <0.90 has 90% sensitivity and 95% specificity for occlusive PAD in symptomatic patients. Some patients with typical symptoms of intermittent claudication can have normal ABI values at rest. Those with a high likelihood of PAD should be evaluated further with exercise testing with repeat ABI. A normal ABI after exercise excludes the diagnosis of occlusive PAD; an ABI that decreases by >20% following exercise is diagnostic of occlusive PAD. (Choice A) Antiplatelet therapy with aspirin or clopidogrel is recommended in all patients with symptomatic PAD to reduce the risk of ischemic stroke, myocardial infarction, and vascular death. Cilostazol may be considered in those who continue to have persistent PAD symptoms despite antiplatelet therapy and an adequate supervised exercise program. However, the diagnosis of PAD should be confirmed in this patient prior to initiating medication. (Choice B) Computed tomography angiography or other noninvasive vascular imaging of the lower extremities is recommended for patients with abnormal ABI who are being considered for therapeutic intervention. However, it is less sensitive and specific than ABI for the initial diagnosis of PAD. In addition, it exposes patients to intravenous contrast agents, which can cause nephrotoxicity in those with impaired baseline renal function. (Choice D) Glycemic control (HbA1c goal <7%) is recommended in most patients with diabetes mellitus to reduce microvascular complications. However, it has not been shown to improve claudication symptoms or have a significant impact on the risk of PAD. (Choice E) Diabetic neuropathy usually presents with bilateral lower-extremity paresthesias; decreased sensation to light touch, pain, and temperature; and loss of vibration sense and proprioception. This patient's symptoms are more consistent with claudication than diabetic neuropathy. Educational objective: The first step in evaluating a patient with suspected peripheral artery disease (PAD) is to obtain an ankle-brachial index (ABI) to confirm the diagnosis. Patients with typical claudication symptoms and normal ABI should undergo exercise testing with repeat ABI to confirm the diagnosis of occlusive PAD. Vascular imaging studies are most useful in patients being considered for specific interventional procedures. __________ References: Using the ankle-brachial index to diagnose peripheral artery disease and assess cardiovascular risk. (http://www.ncbi.nlm.nih.gov/pubmed/22949346) Usefulness of postexercise ankle-brachial index to predict all-cause mortality. (http://www.ncbi.nlm.nih.gov/pubmed/21247542)

A 57-Year-Old Man Complains of Right-Sided Leg and Thigh Pain