-History and Physical, above.
-Patient with symptomatic PAD with intermittent claudication.
–ABI measurements show:
-Start a daily dose of either aspirin or clopidogrel (to prevent cardiovascular events such as an MI or stroke).
–ASCVD score:
-Smoking cessation.
-Start a walking program.
-Will start Cilostazol (a phosphodiesterase inhibitor with both antiplatelet and arterial vasodilatory activity)
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Cilostazol improves claudication symptoms by 50% compared to placebo.
Pentoxifylline is a 2nd line agent. It works for PAD but is not as effective as cilostazol.
-Cilostazol (Pletal) is recommended as initial treatment for peripheral artery disease (PAD). It increases walking distance and improves health-related quality of life.
Neither aspirin nor clopidogrel improves claudication symptoms, however, antiplatelet therapy is recommended to reduce the risk of MI, stroke, or vascular death in patients with symptomatic PAD.
Consider atherosclerosis risk factors & nonatherosclerotic causes. Order ABI if lower extremity sx suggestive of PAD; if asymptomatic but (+)physical findings, consider ABI. Cilostazol may improve max walking distance in pts w/ intermittent claudication. Refer pts refractory to medical tx to vascular specialist for consideration of revascularization.
Differentiate between neurogenic & vascular claudication.
Neurogenic claudication assoc w/ spinal stenosis; characterized by low back & lower extremity pain when standing/walking; pain persists until pt leans forward or sits down
Vascular claudication occurs w/ activity & resolves w/in 10 min of rest regardless of position.
A key difference is that vascular claudication is worse when walking uphill and is not relieved by bending forward.
Consider other causes of claudication
Popliteal artery entrapment syndrome
Neuropathic causes: DM, renal failure, EtOH use
Venous claudication: Thigh/leg pain & tightness on vigorous exercise that subsides with rest; primarily associated w/ iliofemoral venous outflow impairment.
Reference
http://www.aafp.org/afp/2013/0901/p306.html
http://www.aafp.org/afp/2012/0515/p1000.html