Review Question - QID 104070

The patient's clinical picture, especially the intermittent claudication, suggests peripheral arterial disease (PAD), a manifestation of systemic atherosclerosis. Atherosclerosis, a systemic condition, affects not only the peripheral arteries but also other vascular territories, including the coronary arteries. Given that PAD is essentially a marker for atherosclerosis elsewhere in the body, patients with PAD are at a significantly increased risk of coronary artery disease (CAD) and, consequently, acute myocardial infarction (MI).

PAD serves as a warning sign, indicating widespread arterial disease. These patients have a higher risk of cardiovascular morbidity and mortality. Therefore, comprehensive cardiovascular risk management, including lifestyle modifications and medications to treat hypertension, hyperlipidemia, and other risk factors, is crucial. Although symptoms of lower leg claudication may be the first to manifest, coronary artery and cerebrovascular disease are often concurrent, even if they have yet to exhibit symptoms such as angina, TIA, etc. Overall prognosis is correlated with the severity of PAD present, which is quantified by ankle-brachial index (ABI). An abnormal ABI should lead the physician to pursue lower extremity doppler ultrasound and/or angiography to confirm the diagnosis.

Hennion and Siano discuss the diagnosis and management of peripheral artery disease. Ankle-brachial index (ABI) is used to screen for and diagnose PAD, with an ABI < 0.9 associated with a 2-4 times increased risk of experiencing a cardiovascular event. There are conflicting opinions on the appropriateness for screening for PAD; however, patients presenting with symptoms suggestive of claudication should certainly undergo screening.

Criqui et al. studied mortality in patients suffering from peripheral artery disease. They found a relative risk of death from cardiovascular disease of 5.5 and a relative risk of death from coronary artery disease of 6.6 compared to patients without peripheral artery disease. Peripheral artery disease that is classified as severe and significantly symptomatic is associated with a 15-fold risk of mortality from cardiovascular and coronary heart disease.

Illustration A depicts the pathophysiology of PAD and its relation to coronary artery disease. Illustration B summarizes outcomes associated with PAD; note the extremely high risk of cardiovascular events and mortality. Illustration C lists interpretations of ABI values, with ABI < 0.9 indicative of PAD.

Incorrect Answers:
Answer 1: Chronic venous insufficiency causes symptoms like edema, varicosities, and venous stasis ulcers, but it's not directly linked to atherosclerosis or PAD.
Answer 2: Deep vein thrombosis is a clotting disorder and isn't a direct complication of atherosclerosis or PAD.
Answer 3: While PAD does increase the risk of ischemic stroke due to the systemic nature of atherosclerosis, the risk of acute myocardial infarction is more directly associated given the patient's presentation.
Answer 4: Restless leg syndrome is a neurologic disorder and isn't linked to PAD or atherosclerosis.

Bullet Summary:
Patients presenting with symptoms of peripheral arterial disease (PAD) are at heightened risk for other manifestations of atherosclerosis, including coronary artery disease and its complications such as acute myocardial infarction.