From the Guidelines
The next step in managing this 70-year-old patient with hypertension, cardiac disease, and symptoms of peripheral arterial disease (PAD) is to perform an ankle-brachial index (ABI) measurement to confirm the diagnosis and assess disease severity. This non-invasive test compares blood pressure in the ankle to that in the arm, with a ratio below 0.9 indicating PAD 1. The patient's symptoms of claudication after walking 100 yards in the left lower limb, weak inferior popliteal pulse, and absent dorsalis pedis pulse are suggestive of PAD.
Following confirmation, the management plan should include:
- Initiation of antiplatelet therapy with aspirin 75-100 mg daily or clopidogrel 75 mg daily to reduce cardiovascular events
- Starting a high-intensity statin such as atorvastatin 40-80 mg daily regardless of baseline cholesterol levels to improve claudication symptoms and reduce cardiovascular risk
- Optimizing blood pressure control to targets below 140/90 mmHg using antihypertensives that don't exacerbate PAD symptoms, such as ACE inhibitors or ARBs
- Referring the patient to a supervised exercise program involving 30-45 minute walking sessions 3-5 times weekly, encouraging them to walk to near-maximal pain before resting
- Smoking cessation is essential if the patient smokes
- For more severe symptoms, referring to a vascular specialist for consideration of revascularization procedures such as angioplasty, stenting, or bypass surgery 1.
This comprehensive approach addresses the underlying atherosclerotic disease process while improving functional capacity and reducing the risk of limb loss and cardiovascular events. The ABI measurement is a crucial initial step in this process, as it provides a non-invasive and accurate assessment of PAD severity 1.
From the Research
Next Steps in Management
The patient presents with symptoms of intermittent claudication, weak inferior popliteal pulse, and absent dorsalis pedis pulse, which are indicative of peripheral arterial disease (PAD). The next step in managing this patient would be to confirm the diagnosis and assess the severity of the disease.
Diagnostic Tests
- Ankle Brachial Index (ABI) measurement: This is a non-invasive test that can be used to diagnose PAD 2, 3, 4, 5, 6. It is a simple and inexpensive test that can be performed in a clinical setting.
- Vascular Doppler: This test can be used to assess blood flow in the affected limb, but it is not as sensitive as ABI measurement 2.
- Conventional angiography: This is an invasive test that can be used to visualize the blood vessels and diagnose PAD, but it is not typically used as a first-line diagnostic test 2, 4.
- Embolectomy: This is a surgical procedure that is used to remove a blood clot from a blood vessel, but it is not a diagnostic test 6.
Recommended Next Step
Based on the evidence, the recommended next step in managing this patient would be to perform an ABI measurement to confirm the diagnosis of PAD and assess the severity of the disease 2, 3, 4, 5, 6. This test is non-invasive, inexpensive, and can be performed in a clinical setting. If the ABI measurement is abnormal, further testing such as vascular Doppler or conventional angiography may be warranted to assess the severity of the disease and guide treatment.
Key Points to Consider
- PAD is a common condition that affects millions of people worldwide 6.
- The diagnosis of PAD can be confirmed with ABI measurement, which is a non-invasive and inexpensive test 2, 3, 4, 5, 6.
- The treatment of PAD typically involves lifestyle modifications, medical therapy, and possibly revascularization 4, 6.