A 72-year-old man comes to a rural health clinic due to intermittent leg pain. The patient reports a dull discomfort in his left lower calf with activity, causing him to stop and rest on the way to his mailbox, which is approximately 150 m (492 ft) from his house. The pain improves with rest and does not occur at night when he is lying in bed. Medical history is significant for hypertension and gout. Current medications include lisinopril and allopurinol. The patient has a 40-pack-year smoking history, but quit 5 years ago. Family history is significant for a stroke in his father and breast cancer in his mother. Blood pressure is 130/78 mm Hg and pulse is 75/min. The patient's left foot is shiny and devoid of hair, but there are no lower extremity ulcerations. Strength and sensory examination of the left lower extremity is normal. The ankle-brachial index is 0.76 on the left and 1.05 on the right (normal: 1.0-1.4). Laboratory results are as follows:

In addition to aspirin, which of the following medications is the most appropriate to add to this patient's pharmacologic regimen?

Question

A 72-year-old man comes to a rural health clinic due to intermittent leg pain.  The patient reports a dull discomfort in his left lower calf with activity, causing him to stop and rest on the way to his mailbox, which is approximately 150 m (492 ft) from his house.  The pain improves with rest and does not occur at night when he is lying in bed.  Medical history is significant for hypertension and gout.  Current medications include lisinopril and allopurinol.  The patient has a 40-pack-year smoking history, but quit 5 years ago.  Family history is significant for a stroke in his father and breast cancer in his mother.  Blood pressure is 130/78 mm Hg and pulse is 75/min.  The patient's left foot is shiny and devoid of hair, but there are no lower extremity ulcerations.  Strength and sensory examination of the left lower extremity is normal.  The ankle-brachial index is 0.76 on the left and 1.05 on the right (normal: 1.0-1.4).  Laboratory results are as follows:
 
In addition to aspirin, which of the following medications is the most appropriate to add to this patient's pharmacologic regimen?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be5c_b58b_8f63_ebaae085cb0c_MD0005_00 This patient's reduced ankle-brachial index and symptoms of calf pain with walking are consistent with claudication due to peripheral artery disease (PAD). PAD is the result of atherosclerotic narrowing that most commonly occurs toward the proximal end of large peripheral arteries (eg, iliac, popliteal). Typical cardiovascular risk factors (eg, advancing age, diabetes mellitus, smoking, hypertension) increase the risk of developing PAD. Depending on the severity of disease, patients can have pain with exertion (claudication), rest pain, tissue ulceration, or gangrene. PAD is a representation of atherosclerotic cardiovascular disease (ASCVD) and denotes an increased risk of future cardiovascular events (eg, myocardial infarction, stroke). The initiation of aspirin has demonstrated decreased incidence of stroke in patients with PAD and is recommended at the time of diagnosis. In addition, patients age ≤75 should be initiated on high-intensity statin therapy (eg, atorvastatin 40-80 mg daily, rosuvastatin 20-40 mg daily), regardless of baseline cholesterol levels; this lowers the risk of cardiovascular events and may in some cases improve claudication symptoms. (Choice A) Although amlodipine blocks dihydropyridine calcium channels in peripheral arteries, resulting in peripheral artery dilation, the drug is not helpful for PAD likely because arteries with atherosclerotic disease are unable to undergo significant dilation. Control of hypertension is recommended in patients with PAD, but this patient's blood pressure is already under control on lisinopril alone. (Choice B) Cilostazol is a phosphodiesterase-3 inhibitor that provides symptomatic improvement in some patients with claudication due to PAD; however, initiation of the drug is not recommended until lifestyle modifications (eg, smoking cessation, exercise) have failed. (Choice C) Some evidence suggests that clopidogrel may be superior to aspirin in reducing the risk of cardiovascular events in patients with PAD; however, aspirin is considered first-line therapy due to a lower bleeding risk. Dual antiplatelet therapy is not recommended due to increased bleeding risk and lack of additional benefit. (Choice E) Warfarin is not recommended in patients with PAD as it does not provide benefit over aspirin and increases the risk of bleeding complications. Educational objective: Peripheral artery disease (PAD) results from atherosclerotic narrowing of peripheral arteries and represents established atherosclerotic cardiovascular disease. Patients with PAD should be initiated on antiplatelet and high-intensity statin therapy for secondary prevention of cardiovascular events. References: Medical therapy in peripheral artery disease and critical limb ischemia. (http://www.ncbi.nlm.nih.gov/pubmed/27181397)

A 72-Year-Old Man Comes to a Rural Health Clinic Due