What is the appropriate management for a 61-year-old patient with a significant history of cardiovascular disease, including coronary artery bypass grafting (CABG) and valve replacement, hypercholesterolemia, hypertension (HTN), multiple sclerosis, previous deep vein thrombosis (DVT), and osteoarthritis (OA) of the knee, presenting with bilateral leg tenderness and weakness?

From the Guidelines

This patient requires immediate evaluation for peripheral artery disease (PAD) and other potential causes of bilateral leg tenderness and weakness, given their significant cardiovascular history and risk factors. The initial assessment should include a thorough history, physical examination, and resting ankle-brachial index to detect PAD, as recommended by the 2024 lower extremity peripheral artery disease guideline-at-a-glance 1. Given the patient's history of previous DVT, CABG, valve replacement, high cholesterol, HTN, and multiple sclerosis, a comprehensive evaluation is necessary to determine the underlying cause of their symptoms. Basic laboratory tests including CBC, comprehensive metabolic panel, lipid profile, and inflammatory markers (ESR, CRP) should be ordered to rule out other potential causes of their symptoms. The patient's medication regimen should also be reviewed to ensure optimal management of their cardiovascular conditions, multiple sclerosis, and osteoarthritis, and to consider the use of antiplatelet and antithrombotic therapy, lipid-lowering therapy, and antihypertensive therapy as recommended by the guideline 1. Additionally, a comprehensive neurological examination should be performed to determine if the symptoms are related to multiple sclerosis exacerbation. Physical therapy evaluation may be beneficial for addressing weakness and maintaining mobility while the underlying cause is being treated. It is also important to consider the potential for health disparities in PAD and their impact on limb and cardiovascular outcomes, as highlighted in the guideline 1. The use of rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin (81 mg daily) may be effective in preventing major adverse cardiovascular events and major adverse limb events in patients with PAD, as recommended by the guideline 1. However, the patient's individual risk factors and medical history should be taken into account when making treatment decisions. The 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases also emphasize the importance of clinical assessment and physical examination in detecting PAD, and recommend the use of antiplatelet and antithrombotic therapy, as well as lipid-lowering and antihypertensive therapy 1. In terms of osteoarthritis management, the American College of Rheumatology 2012 recommendations suggest the use of acetaminophen, oral or topical NSAIDs, tramadol, or intraarticular corticosteroid injections for the initial management of knee OA, but do not recommend the use of nutritional supplements or topical capsaicin 1. However, these recommendations are not directly relevant to the patient's current presentation, and the primary focus should be on evaluating and managing their potential PAD and other cardiovascular risk factors.

From the Research

Initial Assessment

The patient presents with tenderness and weakness in both legs, which could be indicative of peripheral arterial disease (PAD) given their significant cardiovascular history, including CABG, valve replacement, high cholesterol, HTN, and previous DVT. The absence of ulcers and the warmth of the legs to touch are noted.

Diagnostic Approach

• Noninvasive vascular testing is recommended to confirm the diagnosis of PAD and determine its severity and extent 2.
• The ankle-brachial index (ABI) is a commonly used noninvasive test for diagnosing PAD, although it has been found to have low sensitivity in screening populations 3.
• Other noninvasive tests such as segmental limb pressures, pulse volume recordings, duplex ultrasonography, computed tomography angiography, and magnetic resonance angiography may also be considered 2.

Management Considerations

• Effective medical management is key in reducing the risk of major adverse cardiovascular events and major adverse limb events in patients with PAD 4.
• This includes management of modifiable risk factors through the prescription of anti-platelet and anticoagulation drugs, medications to control low-density lipoprotein cholesterol, blood pressure, and diabetes, and aid in smoking cessation 4.
• Vascular surgery services may be essential for patients requiring intervention, especially in cases of limb ischemia or significant vascular complications 5.

Urgency of Care

• The patient's presentation and history suggest the need for prompt evaluation and possible urgent care, given the potential for underlying PAD or other vascular conditions that could lead to severe complications 6.
• After-hours consultations for vascular issues can often result in urgent patient care, highlighting the importance of timely assessment and intervention 6.