Peripheral arterial disease/intermittent claudication
John M. Saxton in Exercise and Chronic Disease, 2011
PAD comprises a wide clinical spectrum ranging from individuals with asymptomatic arterial narrowing to those with the common symptom of intermittent claudication and, at the severe end of the spectrum, those with critical limb ischaemia. The ankle-to-brachial systolic blood pressure index (ABPI) is commonly used to help diagnose PAD. An ABPI of 0.7–0.9 is considered mild disease, 0.5–0.69 moderate, and <0.5 severe. Intermittent claudication is a cramplike leg pain that occurs during walking (and is relieved by rest), when the ability to deliver and utilise oxygen is inadequate to meet the metabolic requirement of the active skeletal muscles. It causes a marked reduction in functional capacity (Regensteiner and Hiatt, 1995) and quality of life (Regensteiner et al., 2008).
Answers
Andrew Schofield, Paul Schofield in The Complete SAQ Study Guide, 2019
Intermittent claudication (from the Latin claudicare, to limp) is a chronic disease caused by atherosclerosis in the peripheral vasculature and is characterised by progressive burning limb pain on exertion. Diagnosis is based on clinical evaluation, and imaging such as angiography is only indicated if medical treatment has failed or surgery is planned. Medical management involves treatment of such cardiovascular risk factors as hypertension, hyperlipidaemia, diabetes and smoking. As this is a vascular disease, it may coexist with other vascular diseases, such as ischaemic heart disease or cerebral vascular disease. Surgical treatment involves angioplasty with insertion of stents or open bypass surgery of the affected segment. Bypasses include aortobifemoral and femoral-femoral crossover. Distal disease is harder to manage with bypass, with a higher rate of graft occlusion or failure. Claudication may progress to critical ischaemia, which involves rest pain and intolerance of lying leg flat. Critical ischaemia should prompt urgent surgical referral.
The cardiovascular system
Peter Kopelman, Dame Jane Dacre in Handbook of Clinical Skills, 2019
Patients with mild chronic arterial occlusive disease may have no symptoms. Those who do develop symptoms usually present with intermittent claudication. The pain of intermittent claudication is most commonly felt in the calf muscles because the most common site for chronic arterial occlusive disease is the superficial femoral artery, which provides the blood supply to the calf; however, occlusive disease of the iliac arteries, or even the aorta, may give rise to claudication pain in the thighs or buttocks. Ischaemic rest pain is felt in the foot, is typically worst in bed at night, causes sleep deprivation and may make the patient hang the leg out of bed or get up and hobble about. Patients presenting with ulceration or soft tissue necrosis on the foot or ankle often have a history of claudication and/or rest pain. The onset of rest pain or tissue loss indicates that the survival of the limb is threatened.
Echocardiographic assessment at rest and during stress in patients with intermittent claudication
Published in Scandinavian Cardiovascular Journal, 2019
Joakim Nordanstig, Odd Bech-Hanssen, Per Skoog, Lennart Jivegård
Intermittent claudication symptoms are mainly driven by a mismatch between oxygen supply and demand in the working muscle during walking exercise. However, the extent of walking impairment is not solely explained by the distribution and extent of the peripheral atherosclerotic vascular lesions, suggestive of other possible pathophysiologic mechanisms contributing to IC symptoms [25]. In theory, ischemic cardiac disease in patients with lowered ABI may also mimic IC symptoms during exercise, or at least contribute to an impairment of walking capacity beyond what the peripheral atherosclerotic burden would explain. The secondary hypothesis investigated in this study was that a subset of IC patients demonstrates impaired left ventricular function that is only evident during stress and that this may contribute to IC symptom presentation. This hypothesis could not be confirmed, as no single patient in the study demonstrated significant cardiac dysfunction during dobutamine provocation that was not also evident when examined with echocardiography at rest.
The FlowOx device for the treatment of peripheral artery disease: current status and future prospects
Published in Expert Review of Medical Devices, 2021
Henrik Hoel, Jonny Hisdal
In a recent randomized controlled trial of 72 patients with intermittent claudication, we showed that treatment with FlowOx for 1 hour twice daily for 12 weeks increased pain-free walking distance compared with sham treatment [16]. For the patients with the most symptomatic disease, there was an increase in both pain-free and maximal walking distance. This was the first double-blind, randomized sham-controlled trial to show that INP treatment increases walking capacity in patients with intermittent claudication, and the first randomized controlled trial that documented the clinical effects of FlowOx treatment. In patients with intermittent claudication, cardiovascular prevention and exercise therapy are the first-line treatment. Participation in supervised exercise therapy (SET) programs has positive effects on leg symptoms, general health, and cardiovascular risk. However, the use of SET in the management of patients with intermittent claudication is limited by low accessibility and poor compliance. A systematic review from 2016 concluded that only one third of the patients with PAD were suitable for and willing to undertake SET [17]. Hence, treatment with FlowOx might be a relevant adjunct to standard care for patients with intermittent claudication. Especially for patients with disabling claudication and a high risk of complications from endovascular or open surgical treatment, FlowOx treatment seems to be a reasonable alternative.
Current and emerging drug treatment strategies for peripheral arterial disease
Published in Expert Opinion on Pharmacotherapy, 2020
Hani Essa, Francesco Torella, Gregory Y. H. Lip
Prognosis in PAD can be divided into outcomes for the affected limb and outcomes for the patient generally. Overall PAD can be viewed as a proxy for global atherosclerotic disease elsewhere, including CVD and CAD. Patients with PAD have increased rates of ischemic stroke, myocardial infarction (MI), and cardiovascular death [21,22]. Within five years of diagnosis, 10–15% of patients with intermittent claudication will die from cardiovascular disease [23]. Some 60% of patients with PAD suffer from co-existent ischemic heart disease and 30% from CVD [24]. The long-term prognosis of PAD has been shown to be worse than CAD (Hazard ratio, HR: 2.4, P = 0.01) [25]. Untreated, PAD can progress to locally compromised arterial blood supply resulting in severe pain, ulcers or gangrene, and acute limb ischemia necessitating urgent revascularisation therapy to prevent limb loss [26]. The natural history of critical limb ischemia (CLI) is well documented. At 1 year, 25% of patients will be dead, 30% will have undergone amputation, and 45% will be alive with both limbs [23]. More than 60% of patients with CLI will be dead at 5 years [27]. Currently, there are no predictive formulae that allow the clinician to estimate the level of risk of an individual patient with intermittent claudication to progress to CLI or the timescale in which this is likely to occur [28]. Some patients even develop CLI as a first presenting symptom of PAD without ever having suffered intermittent claudication. Pharmacological therapy has been demonstrated to reduce the risk of asymptomatic PAD becoming symptomatic and improve overall prognosis once symptomatic.
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