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
The correct answer is: A. Ankle brachial index (ABI) with or without segmental limb pressures.
The patient described above is at risk for peripheral artery disease (PAD) given his history of tobacco use, hypertension and hyperlipidemia.1 Although currently asymptomatic, the patient leads a sedentary lifestyle and does not participate in an exercise program. His vascular exam demonstrates diminished pulses in his lower extremities suggestive of aortoiliac or 'inflow' disease. Furthermore, a systolic blood pressure difference of greater than 20 mmHg between both arms indicates a high likelihood of subclavian artery disease. The 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease recommends a comprehensive medical history and review of symptoms to assess for exertional limb symptoms.2 Furthermore, patients at increased risk of PAD (Table 1) should undergo vascular examination including palpation of lower extremity pulses. Patients with a history or physical examination findings suggestive of PAD should undergo non-invasive testing by measuring ankle-brachial pressure index with or without segmental pressures. In this patient, abnormal vascular testing could have implications with regards to counseling, initiation of peripheral artery disease rehabilitation and medical therapy with cilostazol were the patient to become symptomatic with exercise. Should exertional symptoms remain refractory to medical therapy, revascularization may be appropriate.
Table 1: Patients at Increased Risk of PAD
Age 50-64 years, with risk factors for atherosclerosis (e.g., diabetes mellitus, history of smoking, hyperlipidemia, hypertension) or family history of PAD
Age <50 years, with diabetes mellitus and one additional risk factor for atherosclerosis
Individuals with known atherosclerotic disease in another vascular bed (e.g., coronary, carotid, subclavian, renal, mesenteric artery stenosis or AAA)
- Joosten MM, Pai JK, Bertoia ML, et al. Associations between conventional cardiovascular risk factors and risk of peripheral artery disease in men. JAMA 2012; 308:1660-7.
- Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2017;69:1465-1508.