Managing Asymptomatic Peripheral Artery Disease in Patients with Coronary Artery Disease
History Present Illness:
A 53-year-old male accountant with hypertension, hyperlipidemia, prior tobacco use and a recent inferior ST elevation myocardial infarction (STEMI) with preserved left ventricular systolic function presents for initial follow-up in the cardiovascular medicine clinic. He denies recurrent angina or dyspnea and is tolerating his medical regimen. He has refrained from tobacco use but remains sedentary. He has not begun cardiac rehabilitation and is not participating in regular aerobic exercise. He has not had claudication and denies transient ischemic attack or stroke symptoms.
Past Medical History:
- Coronary artery disease-inferior ST elevation myocardial infarction s/p percutaneous coronary intervention (PCI) of the right coronary artery (RCA)
Married. Lives independently. 40 pack-year smoking history, 1-2 beers per day, no illicit drug use.
No history of premature coronary artery disease, aneurysm or sudden cardiac death.
General: Well-appearing middle-aged male in no acute distress
HR 65 BP Right arm 140/90 Left arm 118/80 RR 20 Pox 100% on room air
Neck: Normal carotid upstroke bilaterally. No bruits.
Lungs: Clear to auscultation bilaterally
Cardiac: Regular rate rhythm nlS1S2 no clicks, rubs, murmurs or gallop
Abdomen: Soft nontender nondistended normoactive bowel sounds. No bruit.
Extremities: No clubbing, cyanosis, edema. 1+ right and 2+ left radial. 1+ bilateral femoral, popliteal, posterior tibial, dorsalis pedis pulses. No femoral bruits appreciated.
Skin: No ulceration.
Neurological: No focal motor or sensory deficits
Aspirin 81 mg PO QD
Clopidogrel 75 mg PO QD
Atorvastatin 80 mg PO QD
Metoprolol tartrate 25 mg PO BID
Losartan 50 mg PO QD
LDL 110 HDL 45
Which of the following is the most appropriate diagnostic test for peripheral artery disease in this patient?