A 68-year-old man presents to the clinic with pain in the left calf that starts after walking two blocks on the way to his neighborhood grocery store. After 5-10 minutes of rest, he feels relief and can walk another block to the store. His medical history is positive for type 2 diabetes mellitus (T2DM), hypertension (HTN), and chronic kidney disease (CKD). His medications include an angiotensin-receptor blocker, calcium channel blocker, simvastatin, and sodium-glucose cotransporter-2 inhibitor.
His blood pressure is 136/85 mm Hg, heart rate is 76 bpm, and oxygen saturation on room air is 95%. Complete blood count values are within the reference ranges, creatinine level is 1.2 mg/dL, hemoglobin A1c concentration is 7.3%, and low-density lipoprotein level is 74 mg/dL. An ankle-brachial index is performed, which reveals values of 0.68 on the left leg and 0.89 on the right.
Aspirin is added to his medications and simvastatin is replaced with rosuvastatin.
The correct answer is: B. Prescribing supervised exercise therapy.
This patient's history of T2DM, HTN, and CKD increases the risk of complications from peripheral artery disease (PAD). In the case of claudication, noninvasive treatments such as exercise therapy should be the first-line option.
Cilostazol can also be used to treat claudication but should only be considered if supervised exercise therapy is not successful and in the absence of contraindications (heart failure and phosphodiesterase 5 inhibitor use). PTA and endovascular stenting are invasive therapies that should be considered in cases of more severe PAD, such as critical limb ischemia, that mainly present with resting pain or unhealing wounds.1,2 Hyperlipidemia treatment is indicated according to the guidelines and starts with statin therapy.2
References
- Criqui MH, Matsushita K, Aboyans V, et al.; American Heart Association Council on Epidemiology and Prevention, Council on Arteriosclerosis, Thrombosis and Vascular Biology, Council on Cardiovascular Radiology and Intervention, Council on Lifestyle and Cardiometabolic Health, Council on Peripheral Vascular Disease, Stroke Council. Lower extremity peripheral artery disease: contemporary epidemiology, management gaps, and future directions: a scientific statement from the American Heart Association. Circulation 2021;144:e171-e191.
- Grundy SM, Stone NJ. 2018 American Heart Association/American College of Cardiology/Multisociety guideline on the management of blood cholesterol-secondary prevention. JAMA Cardiol 2019;4:589-91.
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