Cardiovascular Patient E

The term peripheral arterial disease refers to disorders affecting the arteries that are outside the heart and cranium. The usual cause is atherosclerosis (although there also are various other inflammatory and non-inflammatory arterial disorders). Most frequently, pain arises in the legs during walking, as blood flow is unable to keep up with the energy requirements of muscles. For example, a patient may feel pain in the calves after walking a block or two. This condition, in which walking causes pain in the legs due to insufficient blood flow (ischemia), is called claudication. Pain in gastrocnemius is most common because it uses the most energy in walking. But pain in other muscles, such as in the hip or thigh, sometimes occur, depending on the regions in which the arteries are narrowed by atherosclerosis.

In one type, the disease is more proximal, affecting arteries such as the aorta, iliacs, femoral or popliteal. The second pattern is more distal, with arteries below the knee affected. Or both could be involved.

Doctors's Comments

The patient is a 62-year-old woman who for more than two years has had discomfort in the right thigh when she attempts, for example, to walk her dog around the block. She has to stop before she is even halfway. But recently her symptoms have begun affecting here right calf as well.

She had a myocardial infarction 4 years ago, followed by cardiac bypass surgery. She takes atorvastatin at a dose of 40 mg daily. Previously she smoked nearly a pack of cigarettes a day, but after her myocardial infarction managed to cut back to 8 per day.

She takes a thiazide diuretic for hypertension and her blood pressure on her previous visit was 122/79 mm Hg. A bruit was heard over the right femoral artery, and pulses are less than expected in the posterior tibial artery and dorsalis pedis artery in the right leg.

QUESTION: What risk factors for claudication are present in this patient?


QUESTION: What is a bruit?


QUESTION: What symptoms would cause you to say she has claudication?


Since the symptoms in the patient are consistent with claudication, the next step was to measure her ankle-brachial index for each leg. A continuous wave Doppler analysis of the waveform of the flow in her arteries was included. An ankle-brachial index of 0.9 or less is consistent with peripheral artery disease. (For the brachial pressure, the higher of the right and left brachial artery pressures is used. Then for each leg, the higher of the posterior tibial artery or dorsal pedis artery is used.)

R brachial artery 124 mm Hg L brachial artery 121 mm Hg
R popliteal artery 84 L popliteal artery 94 mm Hg
R posterior tibial artery 65 L posterior tibial artery 98 mm Hg
R dorsalis pedis artery 68 L dorsal pedis artery 105 mm Hg

She was counseled regarding smoking cessation and started a supervised and a home-based exercise program. She began taking cilostazol at a dose of 100 mg twice daily. This is a selective phosphodiesterase inhibitor. It was also suggested that she increase the dose of atorvastatin to 80 mg daily.

If her symptoms continue to limit her activity despite these interventions, the recommendation will be for angiography and revascularization. An endovascular approach would be considered for proximal disease, whereas surgical revascularization would be considered for distal (infrapopliteal) disease.

QUESTION: What is the ankle-brachial index for each leg?


QUESTION: Why is cilostazol taken to inhibit a certain type of phosphodiesterase?


QUESTION: What is angiography?


QUESTION: What is endovascular revascularization?


QUESTION: What is surgical revascularization?