A 55-year-old man comes to the office due to several months of worsening cramping in his left leg that he has noted during morning exercise. The patient has no chest discomfort, shortness of breath, palpitations, or syncope. Medical history is unremarkable, and he takes no medications. He is an ex-smoker with a 20-pack-year history. The patient does not use alcohol or illicit drugs. He exercises twice a week and follows a low-fat diet. His father had a myocardial infarction at age 60 and died from a second myocardial infarction at age 65. Blood pressure is 145/95 mm Hg and pulse is 85/min. Cardiac, pulmonary, and abdominal examinations are within normal limits. Peripheral pulses are decreased in the left leg. Ankle-brachial index is 0.65 in the left and 1.1 in the right. ECG is within normal limits. Fasting laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

Question

A 55-year-old man comes to the office due to several months of worsening cramping in his left leg that he has noted during morning exercise.  The patient has no chest discomfort, shortness of breath, palpitations, or syncope.  Medical history is unremarkable, and he takes no medications.  He is an ex-smoker with a 20-pack-year history.  The patient does not use alcohol or illicit drugs.  He exercises twice a week and follows a low-fat diet.  His father had a myocardial infarction at age 60 and died from a second myocardial infarction at age 65.  Blood pressure is 145/95 mm Hg and pulse is 85/min.  Cardiac, pulmonary, and abdominal examinations are within normal limits.  Peripheral pulses are decreased in the left leg.  Ankle-brachial index is 0.65 in the left and 1.1 in the right.  ECG is within normal limits.  Fasting laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d361_ee4f_bc81_2b360353d0d6_MD0003_00 This patient's intermittent claudication and ankle-brachial index results (ie, <0.9) are consistent with peripheral artery disease (PAD) in the left lower extremity. A supervised graded exercise program is the most useful intervention to improve functional capacity and reduce claudication in PAD patients. Other measures for treating PAD include smoking cessation, aggressive diabetes control (ie, hemoglobin A1c <7%), and blood pressure control. PAD is a manifestation of atherosclerotic cardiovascular disease (ASCVD). Statins reduce the risk of cardiovascular events in patients with ASCVD, and current guidelines recommend the initiation of both low-dose aspirin and statin therapy (eg, daily atorvastatin) for secondary prevention in all patients with known ASCVD. In addition to PAD, other manifestations of ASCVD include myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, and stroke or transient ischemic attack. (Choice A) Aspirin does not consistently reduce claudication symptoms, but it is indicated in combination with a statin to reduce cardiovascular risk in patients with clinically significant PAD. (Choice C) Fibrates (eg, fenofibrate) are highly effective in lowering serum triglycerides and have more modest efficacy in raising HDL and lowering LDL. However, statins provide superior cardiovascular benefit and are first-line therapy for both secondary and primary prevention of ASCVD. (Choice D) Surgical revascularization is reserved for patients with limb-threatening complications (eg, nonhealing ulcers), significant limitation in activities of daily living, or failure to respond to exercise and pharmacologic therapy. (Choice E) Heparin is used for acute thrombotic occlusions related to PAD. However, chronic warfarin therapy has not been shown to improve outcomes in PAD patients. Educational objective: Both low-dose aspirin and statin therapy are indicated for secondary prevention of cardiovascular events in all patients with known atherosclerotic cardiovascular disease (ASCVD). Peripheral artery disease is a manifestation of ASCVD, as is myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, and stroke or transient ischemic attack. References: Statin prescription is essential in peripheral vascular disease. (http://www.ncbi.nlm.nih.gov/pubmed/20123204) 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/30879355)

A 55-Year-Old Man Comes to the Office Due to Several