A 64-year-old nondiabetic man complains of cramping pain in his right thigh after walking 2 blocks. The pain goes away once he stops and rests for several minutes. He is an ex-smoker with 35-pack-year history. On physical examination, the distal pulses are diminished on the right leg. His ankle brachial index is 0.98 on the left and 0.75 on the right. Which of the following is this patient most likely to suffer over the next 5 years?
The patient's clinical presentation, with symptoms of intermittent claudication, diminished pulses, and abnormal (<1) ankle brachial index, is suggestive of peripheral artery disease (PAD) involving the right lower extremity. Multiple studies assessing the natural history of patients with PAD have found intermittent claudication as a strong predictor of the future risk of cardiovascular morbidity and mortality.
Patients with PAD and intermittent claudication have an estimated 20% 5-year risk of nonfatal myocardial infarction and stroke and a 15%-30% 5-year risk of death due to cardiovascular causes. The risk rises exponentially with progression of PAD, with an estimated 25% 1-year risk of cardiovascular mortality in patients with critical limb ischemia. The presence of PAD is a coronary artery disease risk equivalent, and these patients should be managed with aggressive risk factor modification for prevention of cardiovascular morbidity and mortality.
(Choice A) Abdominal aortic aneurysm (AAA) can be detected in approximately 10% of patients with PAD. The risk of AAA rupture is increased in patients with large aneurysm diameter (>5.5 cm), aortic expansion rate >0.5 cm/year, male sex, and current ongoing smoking. This patient has no symptoms or signs suggestive of AAA and therefore is not at increased risk of rupture.
(Choices B and C) The majority of patients (70%-80%) with intermittent claudication continue to have stable claudication symptoms at 5 years. Approximately 10%-20% of patients progress to worsening claudication, and only 1%-2% progress to develop critical limb ischemia with rest pain, nonhealing ulcer, and tissue gangrene that may require limb amputation.
(Choice D) The presence of PAD is not associated with an increased risk of intracranial hemorrhage.
Educational objective:
Cardiovascular disease is the major cause of morbidity and mortality in patients with peripheral artery disease (PAD). Patients with PAD and intermittent claudication have an estimated 20% 5-year risk of nonfatal myocardial infarction and stroke and a 15%-30% risk of death due to cardiovascular causes. Only 1%-2% of patients with PAD progress to develop critical limb ischemia with risk of limb amputation.