I
Pathological finding at physical examination; patient without symptoms, also during exercise
II
Claudication intermittents: symptoms during exercise
IIa
Pain-free walking distance, > 200 m
IIb
Pain-free walking distance, < 200 m
III
Pain at rest: mostly during the night, relieve of pain by position change or getting up
IV
Acral lesion, gangrene
What is the evidence regarding a supervised or non-supervised exercise training programme with risk factor intervention in patients with lower extremity PAD?
A programme of supervised exercise training is recommended as an initial treatment modality for patients with intermittent claudication (Class I, Level of Evidence: A) [1, 2].
Supervised exercise training should be performed for a minimum of 30–45 min, in sessions performed at least three times per week for a minimum of 12 weeks (Class I, Level of Evidence: A) [3]. The usefulness of unsupervised exercise programmes is not well established as an effective initial treatment modality for patients with intermittent claudication (Class IIb, Level of Evidence: B) [3]; however, non-supervised exercise therapy is indicated when supervised exercise therapy is not feasible or available [1].
Twelve years ago, the patient was also diagnosed a three-vessel coronary artery disease and had to undergo coronary artery bypass surgery with a left internal mammarial artery–left anterior descending artery graft and venous grafts on the right coronary artery, circumflex artery and the first diagonal branch of the left anterior descending artery. Figure 15.1 shows the ECG at rest. The left ventricle at that time showed a concentric hypertrophy with an infero-lateral hypokinesia and a slightly reduced left ventricular systolic function with an ejection fraction of 48 %. Actually, the patient does not complain about cardiac symptoms. An exercise stress test 3 years ago was electrically positive but clinically negative.
Fig. 15.1
Resting ECG. Sinus rhythm, 60/min
As further diagnosis, arthrosis of the left knee with condition after meniscectomy 5 years ago and a condition after hip replacement on the right side due to coxarthrosis 15 years ago are known.
Cardiovascular Risk Factors
Arterial hypertension treated for more than 30 years, dyslipidaemia (treated since 12 years), condition after smoking (stopped 12 years ago, 40 pack-years)
The results of a screening blood sample are as follows: glucose, 5.2 mmol/L (94 mg/dL); total cholesterol, 4.9 mmol/L (190 mg/dL); LDL-C, 3.4 mmol/L (130 mg/dL); HDL-C, 0.9 mmol/L (35 mg/dL); and triglycerides, 1.2 mmol/L (105 mg/dL).
Actual Medication
Aspirin 100 mg/d, lisinopril/hydrochlorothiazide 20/12,5 mg/d, nebivolol 10 mg/d, simvastatin 40 mg/d
What are the key points of history taking in a patient with PAD?
Is there any exertional limitation quickly relieved at rest of the lower extremity muscles or any history of walking impairment, i.e. fatigue, aching, numbness or pain?
Any pain at rest localized to the lower leg or foot and its association with the upright or recumbent positions?
Primary site(s) of discomfort: buttock, thigh, calf or foot?
Upper extremity exertional pain, particularly if associated with dizziness or vertigo?
Any transient or permanent neurological symptoms?
History of hypertension or renal failure?
Post-prandial abdominal pain and diarrhoea, particularly if related to eating and associated with weight loss?
Erectile dysfunction?
15.2 Clinical Assessment
75-year-old patient in good general condition, obese (172 cm, 90 kg, BMI 30.4 kg/m2). The patient describes classical intermittent claudication with crampy pain of his right calf. The pain-free walking distance in the plain is between 200 and 300 m; in uphill, symptoms occur already after 50–100 m.
Cardiopulmonary auscultation is normal. Blood pressure is 130/75 mmHg on both sides. Heart rate is 60/min., regular. Hip flexion at the right side is limited. No blood flow murmurs are noted over the carotid, subclavian, ilio-femoral or renal arteries. Palpation of the abdominal aorta is normal.
The pulse over the femoral arteries was palpable at both sides, attenuated on the right. Distally, only the posterior tibialis artery on the left side was weakly palpable (c.f. Fig. 15.3). The other examination findings were normal, especially no skin lesions of the legs or feet.
What are the key points of the clinical assessment of a patient with PAD?
Measurement of bilateral arm BP, auscultation and palpation of the cervical and supraclavicular fossae areas, peripheral arteries and abdominal aorta with annotation of any bruits and inspection of the feet for trophic defects.
Any poorly healing wounds of legs or feet?
Reduced muscle mass, strength and endurance?
Ankle–brachial index measurement (cf. Fig. 15.2).
Functional capacity?
Fig. 15.2
Measurement of the ankle–brachial index (ABI). Systolic blood pressure is measured by Doppler ultrasonography in each arm and in the dorsalis pedis (DP) and posterior tibial (PT) arteries in each ankle [4]
The oscillogram measured at the big toe shows a moderately abnormal graph with a flat peak, an equal upslope and downslope time and a missing dicrotic notch. This finding is confirmed by the ABI which is 0.77 on the right side and 0.92 on the left side (c.f. Fig. 15.3).
Fig. 15.3
Measurement of the ankle–brachial index and arterial pulse volume plethysmography (oscillogram) of the 75-year-old patient with intermittent claudication, Fontaine stage IIa
How is the ABI correctly measured and which are the pathologic ranges?
ABI Measurement (Fig. 15.2): Systolic blood pressure is measured by Doppler ultrasonography in each arm and in the dorsalis pedis and posterior tibial arteries in each ankle [4]. The higher of the two arm pressures is selected, as is the higher of the two pressures in each ankle. The right and left ankle–brachial index values are determined by dividing the higher ankle pressure in each leg by the higher arm pressure [5]. The ranges of the ankle–brachial index values are shown, with a ratio greater than 1.30 suggesting a non-compressible, calcified vessel. In this condition, the true pressure at that location cannot be obtained, and additional tests are required to diagnose peripheral arterial disease. Patients with claudication typically have ankle–brachial index values ranging from 0.41 to 0.90, and those with critical leg ischaemia have values of 0.40 or less.
Segmental limb plethysmographic waveform analysis is based on evaluation of waveform shape and signal amplitude (Figs. 15.4 and 15.5). Standardized criteria relating waveform changes to anatomic site and hemodynamic severity of disease are used in diagnostic interpretation. Pulse volume recordings are typically performed by injecting a standard volume of air into pneumatic cuffs. The volume of air injected into the cuff is enough to occlude the venous circulation but does not occlude the arterial circulation. Volume changes in the limb segment below the cuff are translated into a pulsatile pressure, which is detected by a transducer and then displayed by a pressure pulse contour.
Fig. 15.4
Pulse volume plethysmography: Pulse volume recording contour with increasing vascular disease severity [14]
Fig. 15.5
Pulse volume plethysmography: Determination of the site of occlusion by pulse volume plethysmography
A normal pulse volume recording, similar to the arterial waveform, is composed of a systolic upstroke with a sharp systolic peak followed by a downstroke that contains a prominent dicrotic notch. If a haemodynamically significant stenosis is present, dissipation of energy occurs because of arterial narrowing; this is reflected in a change in the pulse volume recording contour, indicating a proximal arterial obstruction. The amount of variation in the pulse volume recording contour is reflective of disease severity, as shown in Fig. 15.4.
15.3 Functional Capacity
For assessment of the functional capacity and possible exercise-induced ischaemia, a symptom-limited exercise stress test on a bicycle (15 W/min. Ramp protocol) was effectuated. The patient performed 102 W, corresponding to 74 % of the predicted value. Blood pressure increased from 130/75 mmHg to 190/80 mmHg, heart rate from 60/min. up to 117/min. (80 % of the predicted). Rate pressure product was 22′230. The reason for test termination was right calf pain. The test was clinically and electrically negative (Fig. 15.6).
