Assessment and management of intermittent claudication: importance of secondary prevention

Atherosclerotic peripheral arterial disease (PAD) is a common disorder with a steep age-related incidence that affects 5-10% of the over 55-year age g roup. Because of the association with atherosclerotic disease elsewhere, pa rticularly coronary heart disease (CHD), the ankle-brachial pressure index (ABPI) correlates inversely with survival. Clinical management centres arou nd detection, assessment, symptom relief and prevention of secondary cardio vascular complications. Non-invasive ultrasound and colour duplex technique s have revolutionised the detection of PAD, and the ions-term surveillance of disease progression, while antiplatelet therapy coupled with risk factor modification (lipids, blood pressure and glycaemic control and smoking ces sation) are aimed at reducing direct or indirect vascular complications, e. g. amputation or CHD death. The natural history of intermittent claudicatio n, although troublesome and disabling, often runs a stable, fairly benign c ourse, so the majority of patients (73%) are treated medically Selecting pa tients for surgical revascularisation (angioplasty, bypass or endarterectom y) is guided principally by the severity of clinical symptoms, but discrete , proximal, short-segmental lesions are the most amenable to surgical inter vention. In general, surgery is indicated to relieve disabling symptoms whe n medical therapy has failed for treatment of symptoms of limb-threatening ischaemia, including rest pain, ischaemic ulceration and gangrene; and to r emove or bypass sources of thrombo-embolism. Thus, medical therapies for sy mptom relief and secondary prevention of complications form the mainstay of treatment for three-quarters of patients with uncomplicated intermittent c laudication.