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:
Following medication adjustment, the patient is sent for CT angiography that shows 90% stenosis of the left superficial femoral artery and 80% stenosis of the left popliteal artery. Which of the following is the best additional recommendation for this patient?

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:
 Following medication adjustment, the patient is sent for CT angiography that shows 90% stenosis of the left superficial femoral artery and 80% stenosis of the left popliteal artery.  Which of the following is the best additional recommendation for this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be5d_51ce_8f63_3f45e461126f_MD0005_00 In addition to cardiovascular risk factor management (eg, smoking cessation), a supervised exercise program is the best initial management for claudication due to peripheral artery disease (PAD). Patients should participate in 30-45 minutes of supervised walking >3 times a week for >3 months. Once the walking time required to develop claudication is determined, the sessions are gradually increased until the patient can walk for a longer period without developing symptoms. Patients may experience moderate increases in symptom-free walking distance. For patients with persistent symptoms despite smoking cessation, antiplatelet and statin therapy, and supervised exercise therapy, the addition of twice-daily cilostazol may lead to improvement in symptoms. (Choice A) Daily intermittent pneumatic compression therapy may improve symptoms in some patients with severe PAD or critical limb ischemia, but it should not be attempted until exercise therapy has failed. (Choice B) A healthy diet low in fat is important in all patients with cardiovascular disease but is unlikely to result in significant improvement in claudication symptoms. (Choices C and E) Revascularization via percutaneous stent placement or surgical bypass grafting is generally reserved for patients with critical limb ischemia or for those who continue to have claudication symptoms despite cardiovascular risk factor management, exercise, and pharmacologic therapy. Educational objective: A supervised exercise program should be recommended for patients with intermittent claudication due to peripheral arterial disease. Cilostazol can be added for patients with persistent symptoms despite cardiovascular risk factor management and exercise therapy, followed by revascularization if necessary. 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)

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