A 64-year-old nondiabetic man complains of cramping pain in his right thigh after walking 2 blocks. The pain goes away once he stops and rests for several minutes. He is an ex-smoker with 35-pack-year history. He has no history of heart disease or stroke. On physical examination, the femoral pulses are normal, but the popliteal and dorsalis pedis pulses are diminished on the right leg. His ankle brachial index is 0.98 on the left and 0.72 on the right. He is started on low-dose aspirin and lipid-lowering therapy. Which of the following is the best initial management for this patient?

Question

A 64-year-old nondiabetic man complains of cramping pain in his right thigh after walking 2 blocks.  The pain goes away once he stops and rests for several minutes.  He is an ex-smoker with 35-pack-year history.  He has no history of heart disease or stroke.  On physical examination, the femoral pulses are normal, but the popliteal and dorsalis pedis pulses are diminished on the right leg.  His ankle brachial index is 0.98 on the left and 0.72 on the right.  He is started on low-dose aspirin and lipid-lowering therapy.  Which of the following is the best initial management for this patient?

Quizplus · Accepted Answer

The patient's clinical presentation is consistent with the presence of peripheral artery disease (PAD) involving the right lower extremity. PAD is a coronary artery disease risk equivalent, and the medical therapy for such patients should include aggressive risk factor modification with counseling for smoking cessation, lipid-lowering therapy, and evaluation and treatment for hypertension and diabetes mellitus. This patient is started appropriately on low-dose aspirin and statin therapy. The next step is to enroll the patient in a supervised exercise program. Exercise therapy for a minimum of 12 weeks, with 30-45 minutes of exercise at least 3 times a week, is recommended for all patients with claudication. The goal is to reproduce the claudication symptoms during each session. Supervised exercise programs have been shown in multiple clinical trials to reduce symptoms and improve the maximum walking distance in these patients. (Choices A and B) Percutaneous or surgical revascularization is generally reserved for patients who have persistent symptoms despite initial exercise and/or pharmacologic therapy. (Choice D) Pentoxifylline has not been shown to provide any significant symptomatic improvement and is not recommended for use in patients with intermittent claudication. Cilostazol should be considered in patients who have persistent symptoms despite antiplatelet therapy and adequate supervised exercise programs. (Choice E) Warfarin has not been shown to improve claudication symptoms or cardiovascular outcomes in patients with PAD and is not recommended. Educational objective: A supervised exercise program should be recommended as a part of an initial treatment regimen in all patients with intermittent claudication. Pharmacologic therapy with cilostazol and percutaneous or surgical revascularization should be reserved for those with persistent symptoms despite adequate supervised exercise therapy. References: Supervised exercise versus primary stenting for claudication resulting from aortoiliac peripheral artery disease: six month outcomes from the claudication exercise versus endoluminal revascularization (CLEVER) study. (http://www.ncbi.nlm.nih.gov/pubmed/22090168) Systematic review of exercise training or percutaneous transluminal angioplasty for intermittent claudication. (http://www.ncbi.nlm.nih.gov/pubmed/21928409) 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline). (http://www.ncbi.nlm.nih.gov/pubmed/21959305)

A 64-Year-Old Nondiabetic Man Complains of Cramping Pain in His