Claudication, which means “to limp”, is defined as a pain or discomfort in the lower limb muscles [legs, thighs, or buttocks] that is made worse by walking and relieved with rest.

Although a number of medical problems can cause claudication, the most common cause is peripheral artery disease.

This results from deposits of cholesterol plaques (atherosclerosis) on the wall of the lower extremity arteries. These plaques may progress and produce narrowing or complete blockage of blood flow in these vessels.

PAD risk factors

The major risk factors for developing PAD include:

• Hypertension (high blood pressure)

• Hyperlipidemia (elevated blood levels of lipids, including cholesterol and triglycerides)

• Cigarette smoking

• Diabetes

Studies found that the above risk factors cause claudication in 70 per cent of PAD patients. Among these factors, cigarette smoking was the most important one.

PAD symptoms

The pain and discomfort associated with claudication vary from person to person.

Some people have severe, debilitating discomfort while others have minimal symptoms.

The severity of one’s symptoms depends upon how many arteries are affected, how narrowed the arteries are, the number of collateral (or “alternate” or “detour”) vessels available to provide blood when the damaged vessels cannot, how quickly one walks, and whether one walks on a flat surface or up an incline/stairs.

Pain location depends upon the site of blockages. A person may have foot, calf, thigh or buttock pain, either alone or in combination.

As an example, calf claudication is the most frequent location of pain and commonly results from blockage of the thigh vessels that are supposed to supply downstream blood flow to the legs.

PAD diagnosis

• The ankle-arm index. This measures the ratio of resting blood pressure at the ankle to that in the arm. A normal value is between 0.9 and 1.3.

If the test is normal at rest in a patient with symptoms of claudication, it is often repeated following exercise on a treadmill machine.

• Sequential blood pressures. Blood pressure can be measured serially at different levels in the lower extremities to determine the level and extent of PAD.

• Imaging. Ultrasonography is a non-invasive test that can be used to see the location and severity of the narrowing in the blood vessels.

Computed tomography (CT) and magnetic resonance angiography (MRA) are other non-invasive ways of looking at blood vessels.

• Arteriography. It is slightly invasive and so is usually reserved for when a procedure to open the vessel [by a stent or by surgery], called revascularisation, is planned.

Claudication treatment

Most people with claudication are treated medically, which includes reducing the risk factors listed above, exercise training and medications.

However, in spite of appropriate medical treatment, some people may have incapacitating claudication that prevents them from working or carrying on with daily tasks.

In that case, they may be candidates for revascularisation procedures, which either include balloon-mediated opening of the narrowed vessel coupled with stent placement, or a bypass surgery.

Risk reduction

• An LDL level below 100 mg/dL is recommended [LDL is the bad form of cholesterol]. Treatment may include lifestyle changes (diet and exercise) and/or a statin.

• A blood pressure level below 130/80 mmHg is recommended. Treatment may include lifestyle changes (diet and exercise) and/or antihypertension medications.

• Quitting smoking and improving control of diabetes may also cut claudication pain, but even more importantly, they help to reduce the risk of coronary artery disease.

Clinical data shows that patients with PAD have up to 50 per cent risk of harbouring coronary disease, and vice versa!

• Exercise. It involves walking on a treadmill or a track for 45 to 60 minutes at least three times a week.

Exercise programmes reduce the symptoms of claudication, including increasing the distance and the time that one can walk before developing leg pain.

Patients who respond to an exercise programme can expect improvement within two months. The benefits of exercise diminish when training stops.

Medications

• Antiplatelet agents. Like aspirin and clopidogrel, these are medications that reduce blood clotting. They are recommended for all patients with PAD.

While they may only modestly improve claudication symptoms, their use has been shown to reduce the need for surgery and the risk of death from PAD.

• Cilostazol. This is the most effective medication for treatment of claudication symptoms, particularly when combined with exercise.

• Unproven or ineffective treatments. These include pentoxifylline, herbal remedies (Ginkgo biloba, Padma 28) and chelation therapy.

Many other treatments such as Viagra and antioxidants are still investigational.

• Joe Yammine is a cardiologist at Bermuda Hospitals Board. He trained at the State University of New York, Brown University and Brigham and Women’s Hospital. He holds five American Board certifications. He was in academic practice between 2007 and 2014, when he joined BHB. During his career in the US, he was awarded multiple teaching and patients’ care recognition awards. The information herein is not intended as medical advice nor as a substitute for professional medical opinion. Always seek the advice of your physician. You should never delay seeking medical advice, disregard medical advice or discontinue treatment because of any information in this article.