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Treating Intermittent Claudication Caused by Peripheral Arterial Disease
Case Presentation
A 75-year-old woman visits her physician because of a 3-month history of muscle pain in her left calf after walking two blocks. The pain is relieved by rest, and she reports no other symptoms. The patient smoked one pack of cigarettes daily for 35 years, but she quit smoking 5 years before her current presentation.
On physical examination, the patient’s blood pressure is 128/78 mm Hg, her body mass index is 25 kg/m2, and all findings are normal except for reduced pulses in her left popliteal, posterior tibial, and dorsal pedis arteries. The patient’s right ankle-brachial index (ABI) is 0.95, and her left ABI is 0.60. An electrocardiogram reveals no abnormalities. The results of her complete blood count, estimated glomerular filtration rate, serum electrolytes, and liver function tests are within normal limits. Laboratory values out of normal ranges include a fasting blood glucose of 155 mg/dL (normal, 70-100 mg/dL), hemoglobin A1c (HbA1c) of 8% (normal, 4%-7%), serum total cholesterol of 295 mg/dL (high, ≥240 mg/dL), serum low-density lipoprotein (LDL) cholesterol of 160 mg/dL (high, 160-189 mg/dL), and serum high-density lipoprotein cholesterol of 35 mg/dL (ideal, >60 mg/dL). Her serum triglycerides are 100 mg/dL (normal, <150 mg/dL).
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Q: How should the case patient’s intermittent claudication from peripheral arterial disease (PAD) be treated?
A: As with the case patient, individuals who have PAD of the lower extremity often present with the classic symptom of intermittent claudication, which is pain or weakness while walking that is relieved by rest. In addition to a low ABI (<0.90), an ABI of 1.4 or higher is also associated with PAD in older patients with stiff arteries (Table). The case patient’s left ABI of 0.60 is low. The lower the ABI, the more severe the restriction of arterial blood flow, and the more serious the ischemia.
Risk factors for PAD in women include older age, active or passive cigarette smoking, diabetes mellitus, dyslipidemia, and hypertension.1,2 The case patient has dyslipidemia and diabetes mellitus, which need to be treated. Her diabetes mellitus can be managed through diet and metformin to reduce her HbA1c to less than 7%. Her dyslipidemia can be managed with a diet that is low in cholesterol and saturated fat, and with high-dose statin therapy to reduce her serum LDL cholesterol level to less than 100 mg/dL.3
Women with PAD have a high prevalence of coexisting coronary artery disease and history of ischemic stroke,4,5 and are at increased risk for all-cause mortality, cardiovascular mortality, and cardiovascular events.6-8 A stress test should be performed to rule out myocardial ischemia in the case patient. To reduce her risk of cardiovascular events and mortality, she should be treated with an antiplatelet drug (eg, aspirin or clopidogrel), an angiotensin-converting enzyme inhibitor, and a statin.1-3,9-12
Exercise is crucial in patients with PAD to improve both walking endurance and quality of life. The American College of Cardiology/American Heart Association guidelines recommend a supervised exercise program for individuals with intermittent claudication.1 According to a 1995 study, the optimal exercise program for improving claudication pain distances uses intermittent walking to near-maximal pain during a program of at least 6 months.13 In 2009, a randomized trial that included 156 patients with PAD showed similar findings, with exercise performance improving following a 6-month program of supervised treadmill exercise or lower-extremity resistance training. These improvements were observed regardless of whether the patient had claudication.14 To increase the case patient’s walking distance and capacity for exercise, cilostazol, a phosphodiesterase inhibitor that can alleviate symptoms of intermittent claudication, can be administered.15 Statins have also been shown in placebo-controlled studies to improve walking performance in persons with intermittent claudication.16,17
In addition, proper foot care is essential and should be discussed with the patient.1,2 Patients with PAD must wear properly fitted shoes. Careless nail clipping or injury from walking barefoot must be avoided. Feet should be washed daily and the skin kept moist with topical emollients to prevent cracks and fissures, which may serve as portals for bacterial infection. Fungal infection of the feet must be treated. Socks made of wool or other thick fabrics should be worn, and padding or shoe inserts may be used to prevent pressure sores. When a wound of the foot develops, specialized foot gear, including casts, boots, and ankle foot orthoses may be helpful in unweighting the affected area.
Indications for lower-extremity percutaneous transluminal angioplasty with stent placement or for lower-extremity bypass surgery in persons with PAD are: (1) incapacitating claudication interfering with work or lifestyle despite optimal medical management; and (2) limb salvage in persons with limb-threatening ischemia as manifested by rest pain, nonhealing ulcers, infection, gangrene, or a combination of these findings.18 Because the case patient does not yet fulfill criteria for revascularization, aggressive medical management accompanied by lifestyle changes is appropriate for this patient.
The author reports no relevant financial relationships.
Dr. Aronow is clinical professor of medicine, Divisions of Cardiology and Geriatrics, New York Medical College, Valhalla, NY.
References
1. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. https://circ.ahajournals.org/cgi/reprint/113/11/e463. Accessed November 9, 2010.
2. Aronow WS. Management of peripheral arterial disease in the elderly. In: Aronow WS, Fleg JL, Rich MW, eds. Cardiovascular Disease in the Elderly. 4th ed. New York, NY: Informa Healthcare; 2008:749-768.
3. Grundy SM, Cleeman JI, Merz CN, et al; National Heart, Lung, and Blood Institute; American College of Cardiology Foundation; American Heart Association. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines [published correction appears in Circulation. 2004;110(6):763]. Circulation. 2004;110(2):227-239.
4. Aronow WS, Ahn C. Prevalence of coexistence of coronary artery disease, peripheral arterial disease, and atherothrombotic brain infarction in men and women ≥62 years of age. Am J Cardiol. 1994;74(1):64-65.
5. Ness J, Aronow WS. Prevalence of coexistence of coronary artery disease, ischemic stroke, and peripheral arterial disease in older persons, mean age 80 years, in an academic hospital-based geriatrics practice. J Am Geriatr Soc. 1999;47(10):1255-1256.
6. Criqui MH, Langer RD, Fronek A, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326(6):381-386.
7. Vogt MT, Cauley JA, Newman AB, et al. Decreased ankle/arm blood pressure index and mortality in elderly women. JAMA. 1993;270(4):465-469.
8. Aronow WS, Ahmed MI, Ekundayo OJ, et al. A propensity-matched study of the association of peripheral arterial disease with cardiovascular outcomes in communitydwelling older adults. Am J Cardiol. 2009;103(1):130-135.
9. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet. 1996; 348(9038):1329-1339.
10. Ostergren J, Sleight P, Dagenais G, et al; HOPE Study Investigators. Impact of ramipril in patients with evidence of clinical or subclinical peripheral arterial disease. Eur Heart J. 2004;25(1):17-24.
11. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomized placebo-controlled trial. Lancet. 2002;360(9326):7-22.
12. Aronow WS, Ahn C. Frequency of new coronary events in older persons with peripheral arterial disease and serum low-density lipoprotein cholesterol ≥125 mg/dL treated with statins versus no lipid-lowering drug. Am J Cardiol. 2002;90(7):789-791.
13. Gardner AW, Poehlman ET. Exercise rehabilitation programs for the treatment of claudication pain. A meta-analysis. JAMA. 1995;274(12):975-980.
14. McDermott MM, Ades P, Guralnik JM, et al. Treadmill exercise and resistance training in patients with peripheral arterial disease with and without intermittent claudication: a randomized controlled trial. JAMA. 2009;301(2):165-174.
15. Thompson PD, Zimet R, Forbes WP, Zhang P. Meta-analysis of results from eight randomized, placebo-controlled trials on the effect of cilostazol on patients with intermittent claudication. Am J Cardiol,/i>. 2002;90(12):1314-1319.
16. Aronow WS, Nayak D, Woodworth S, Ahn C. Effect of simvastatin versus placebo on treadmill exercise time until the onset of intermittent claudication in older patients with peripheral arterial disease at six months and at one year after treatment. Am J Cardiol. 2003;92(6):711-712.
17. Mohler ER 3rd, Hiatt WR, Creager MA. Cholesterol reduction with atorvastatin improves walking distance in patients with peripheral arterial disease. Circulation. 2003;108(12):1481-1486.
18. Weitz JI, Byrne J, Clagett GP, et al. Diagnosis and treatment of chronic arterial insufficiency of the lower extremities: a critical review [published correction appears in Circulation. 2000;102(9):1074]. Circulation. 1996;94(11):3026-3049.
