Pharmacotherapy Case 16: Peripheral Artery Disease (PAD) Management by Dr. Nehad Ahmed

 

Chief Complaint:

A 70-year-old male presents to the clinic for a follow-up appointment to discuss the management of his peripheral artery disease (PAD). He reports intermittent claudication in his left calf with walking, which has become progressively worse over the past few months. He is concerned about his symptoms worsening and seeks advice on managing his condition.

Subjective Data:

History of Present Illness (HPI):
The patient is a 70-year-old male with a history of peripheral artery disease (PAD) diagnosed 2 years ago. He reports worsening symptoms of intermittent claudication over the past 3 months, particularly in the left calf, occurring after walking about 200 meters. The pain is relieved by rest but returns after walking again. The patient denies rest pain or ulcers but is concerned that his symptoms are worsening. He has not experienced any major changes in lifestyle, diet, or physical activity recently.

Past Medical History (PMH):

Peripheral artery disease (PAD), diagnosed 2 years ago

Hypertension, diagnosed 15 years ago

Hyperlipidemia, diagnosed 10 years ago

Type 2 diabetes mellitus, diagnosed 5 years ago

Coronary artery disease (CAD), with a history of stable angina

Obesity (BMI: 34 kg/m²)

No history of major strokes, amputations, or major surgeries.

Medications:

Aspirin 81 mg daily (antiplatelet therapy for PAD and CAD)

Simvastatin 40 mg nightly (for hyperlipidemia)

Lisinopril 10 mg daily (for hypertension)

Metformin 1000 mg daily (for diabetes)

Amlodipine 5 mg daily (for blood pressure control)

No over-the-counter medications or herbal supplements.

Allergies:

No known drug allergies (NKDA).

Family History:

Father had a history of CAD and died of a myocardial infarction at age 65.

Mother had diabetes and hypertension.

Social History:

Smoking: Former smoker, quit 10 years ago after a 30-pack year history.

Alcohol: Drinks 1-2 glasses of wine per week.

Physical activity: Sedentary lifestyle, walks only short distances due to calf pain.

Diet: High-fat, low-fiber diet with limited fruits and vegetables.

Lives alone, independent in activities of daily living.

 

Review of Systems:

Cardiovascular: Occasional chest discomfort with exertion, no recent chest pain, or shortness of breath.

Neurological: No dizziness, lightheadedness, or weakness.

Gastrointestinal: No nausea, vomiting, or abdominal pain.

Musculoskeletal: Intermittent calf pain with walking; no swelling, redness, or ulcers.

Psychiatric: Occasional mild anxiety, especially when walking long distances due to fear of worsening symptoms.

Objective Data:

Vital Signs upon Arrival:

Blood Pressure: 142/88 mmHg

Heart Rate: 75 bpm (regular rhythm)

Respiratory Rate: 18 breaths/min

Temperature: 36.7°C (98.1°F)

Oxygen Saturation: 97% on room air

Weight: 98 kg (BMI 34 kg/m²)

Height: 170 cm

Physical Exam:

General: Alert, oriented, and in no acute distress.

Cardiovascular: Regular rhythm, no murmurs, no jugular venous distension. Bilateral peripheral pulses are diminished in the femoral, popliteal, and posterior tibial arteries.

Respiratory: Clear lung fields bilaterally, no wheezes or crackles.

Abdomen: Soft, non-tender, no hepatomegaly or ascites.

Musculoskeletal: Left calf exhibits mild tenderness to palpation; no visible atrophy or redness. Distal extremities show no signs of ulcers or gangrene. No swelling or edema in the lower limbs.

Neurological: Intact sensation and motor function in both lower extremities. No focal deficits.

Ankle-Brachial Index (ABI):

Left ABI: 0.65 (indicative of moderate PAD)

Right ABI: 0.72 (indicative of mild PAD)

A normal ABI is between 1.0 and 1.4. Values below 0.9 are considered abnormal and indicative of PAD.

Laboratory Results:

Lipid Profile:

Total Cholesterol: 230 mg/dL

LDL: 140 mg/dL (target: <100 mg/dL for high-risk patients)

HDL: 38 mg/dL (goal: >40 mg/dL)

Triglycerides: 175 mg/dL (goal: <150 mg/dL)

Complete Blood Count (CBC): Normal

Electrolytes: Sodium 140 mEq/L, Potassium 4.1 mEq/L

Creatinine: 1.0 mg/dL (normal renal function)

Blood Glucose: 112 mg/dL (fasting, target: <130 mg/dL for diabetes)

Doppler Ultrasound of Lower Extremities:

Evidence of moderate stenosis in the left superficial femoral artery and mild stenosis in the right femoral artery, consistent with PAD.

Electrocardiogram (EKG):

Normal sinus rhythm, no evidence of ischemia or arrhythmias.

Assessment:

The patient is a 70-year-old male with a history of peripheral artery disease (PAD), hypertension, hyperlipidemia, and diabetes mellitus. His intermittent claudication has worsened over the past few months, with symptoms now occurring after walking short distances. The patient's ankle-brachial index (ABI) is consistent with moderate PAD on the left side and mild PAD on the right. His lipid profile reveals elevated LDL cholesterol (140 mg/dL) and triglycerides (175 mg/dL), both of which contribute to the progression of his vascular disease. His blood pressure is suboptimally controlled at 142/88 mmHg, and his diabetes is not optimally managed with a fasting glucose of 112 mg/dL.

The patient is at high risk for cardiovascular events due to his PAD, history of coronary artery disease (CAD), and uncontrolled hypertension and hyperlipidemia.

Plan:

Pharmacotherapy:

Antiplatelet Therapy:
Continue aspirin 81 mg daily to reduce the risk of cardiovascular events and thrombotic complications associated with PAD.

Lipid Management:

Increase simvastatin to 80 mg nightly to further reduce LDL cholesterol. The goal is to lower LDL cholesterol to <100 mg/dL.

If triglycerides remain elevated, consider adding fenofibrate to further lower triglyceride levels.

Blood Pressure Management:

Continue amlodipine 5 mg daily and lisinopril 10 mg daily.

Aim to achieve a blood pressure target of <130/80 mmHg. Consider increasing lisinopril to 20 mg daily if blood pressure control is insufficient.

Diabetes Management:
Continue metformin 1000 mg daily for diabetes management.
Educate the patient on the importance of maintaining blood glucose control (goal: <130 mg/dL fasting). Refer for diabetic education and dietary counseling.

Lifestyle Modifications:

Exercise Program:
Recommend supervised walking therapy to improve walking distance and reduce symptoms of claudication. Aim for 30 minutes of walking at least 3 times per week.
Encourage weight loss through a low-calorie, heart-healthy diet, focusing on reducing saturated fats and increasing fiber intake.

Smoking Cessation:
Reinforce the importance of smoking cessation, as smoking is a major risk factor for PAD progression. Provide resources for smoking cessation programs if needed.

Dietary Changes:
Encourage a heart-healthy diet, such as the DASH or Mediterranean diet, to improve lipid control, blood pressure, and overall cardiovascular health.

Monitoring:

Follow-up in 6-8 weeks for lipid profile, blood pressure, and ABI reassessment.

Monitor for any new or worsening claudication symptoms, ulcers, or signs of ischemia in the lower extremities.

Follow-up in 3-6 months for diabetes management and weight loss progress.

Referral:

Vascular surgery consult may be considered if symptoms of intermittent claudication significantly impact the patient’s quality of life despite optimal pharmacotherapy and lifestyle changes. Endovascular intervention or surgical revascularization might be indicated based on further evaluation.

Patient Education:

Educate the patient on the importance of adhering to prescribed medications, especially antiplatelet therapy and statins, to manage cardiovascular risk.

Discuss exercise therapy and the benefits of supervised walking to increase walking distance and reduce symptoms.

Emphasize the importance of smoking cessation in slowing the progression of PAD.

Provide educational materials about heart-healthy eating, managing diabetes, and blood pressure.

Discussion:

Management of peripheral artery disease (PAD) includes pharmacologic treatment, lifestyle changes, and sometimes surgical or interventional procedures. For this patient, the primary goal is to reduce symptoms (intermittent claudication), prevent progression of the disease, and lower cardiovascular risk. The increased statin dose aims to lower LDL cholesterol, while blood pressure and blood glucose control are essential in preventing complications. Supervised exercise is crucial in improving functional status and quality of life in PAD patients. Regular follow-up is necessary to assess progress and adjust treatment as needed.