Assessment and management of intermittent claudication: importance of secondary prevention

Abstract

Atherosclerotic peripheral arterial disease (PAD) is a common disorder with a steep age-related incidence that affects 5-10% of the over 55-year age group. Because of the association with atherosclerotic disease elsewhere, particularly coronary heart disease (CHD), the ankle-brachial pressure index (ABPI) correlates inversely with survival. Clinical management centres around detection, assessment, symptom relief and prevention of secondary cardiovascular complications. Non-invasive ultrasound and colour duplex techniques have revolutionised the detection of PAD, and the long-term surveillance of disease progression, while antiplatelet therapy coupled with risk factor modification (lipids, blood pressure and glycaemic control and smoking cessation) are aimed at reducing direct or indirect vascular complications, e.g. amputation or CHD death. The natural history of intermittent claudication, although troublesome and disabling, often runs a stable, fairly benign course, so the majority of patients (73%) are treated medically. Selecting patients for surgical revascularisation (angioplasty, bypass or endarterectomy) is guided principally by the severity of clinical symptoms, but discrete, proximal, short-segmental lesions are the most amenable to surgical intervention. In general, surgery is indicated to relieve disabling symptoms when medical therapy had failed; for treatment of symptoms of limb-threatening ischaemia, including rest pain, ischaemic ulceration and gangrene; and to remove or bypass sources of thrombo-embolism. Thus, medical therapies for symptom relief and secondary prevention of complications form the mainstay of treatment for three-quarters of patients with uncomplicated intermittent claudication.