Review Question - QID 100586

This patient is presenting with burning bilateral leg pain that is worse with exertion and relieved with rest suggesting a diagnosis of vascular claudication. The best initial and most effective treatment for vascular claudication is exercise and smoking cessation.

Vascular claudication is muscle pain that results from exercise and is relieved by rest. It is seen in high-risk patients such as patients with diabetes or dyslipidemia. It is generally the result of atherosclerosis which leads to the formation of atheromas. Atheromas are lipid-filled intimal plaques that cause stenosis of the vessels. The pain in claudication results from ischemia that is exacerbated by exertion. Smoking, a major vascular risk factor, hastens the progression of atherosclerosis and can predispose to vascular claudication. A regular exercise program may stimulate angiogenesis (new blood vessel formation) leading to collateral circulation pathways thus reducing ischemia. For this reason, the most effective and best initial treatment of vascular claudication is graded exercise and smoking cessation. Other important initial steps in the management of vascular claudication include administration of aspirin and control of blood lipids with statins.

Incorrect Answers:
Answer 1: Balloon angioplasty with stenting may be indicated in vascular claudication but is not the first step in management. This treatment might be used in a patient who fails risk factor modification and medical management.

Answer 3: Femoral-popliteal bypass might be used in a patient who fails risk factor modification, medical management, and balloon angioplasty. This is the last-line therapy and generally is reserved for refractory and non-compliant patients.

Answer 4: Lisinopril and atorvastatin certainly should be started in this patient with hypertension, diabetes, dyslipidemia, and vascular claudication. These treatments would be less effective in treating his condition when compared to exercise and smoking cessation.

Answer 5: Lovenox and atorvastatin are inappropriate management of vascular claudication. Rather, appropriate medical management would involve an anti-platelet agent such as aspirin in combination with atorvastatin; however, both of these treatments are less effective than graded exercise and smoking cessation.

Bullet Summary:
The best initial and most effective treatment for vascular claudication is smoking cessation and graded exercise.