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The natural history of claudication: risk to life and limb
1Department of Vascular Surgery, St George's Hospital Medical School, London, England, United Kingdom.
Insights
Intermittent claudication (IC) rarely leads to amputation, but significantly increases the risk of cardiovascular events and mortality. Early diagnosis and risk factor management are crucial for improving outcomes in patients with IC.
Area of Science:
- Vascular Medicine
- Cardiovascular Epidemiology
- Public Health
Background:
- Intermittent claudication (IC) is a common symptom of peripheral arterial occlusive disease (PAOD).
- Patients with IC often fear disease progression and amputation, but severe outcomes are relatively rare.
- IC is associated with a significantly increased risk of cardiovascular events and mortality.
Purpose of the Study:
- To analyze the natural history of intermittent claudication.
- To identify risk factors for disease progression and adverse outcomes.
- To highlight the cardiovascular risks associated with IC.
Main Methods:
- Review of evidence over the last 40 years regarding intermittent claudication outcomes.
- Analysis of amputation rates, symptom progression, and cardiovascular event incidence in claudicant populations.
- Comparison of mortality rates in claudicants versus the general population.
Main Results:
- Major amputation is rare (1-3% over 5 years); 50% of patients may become symptom-free.
- Significant disease deterioration affects about 25% of patients, primarily in the first year.
- Smoking is the strongest risk factor for amputation. Diabetes, male gender, and hypertension also increase progression risk.
- IC is a marker for increased risk of fatal and nonfatal cardiovascular events (CVD, CAD), with 2-4% experiencing events annually.
- Mortality rates for claudicants are substantially higher than the general population (30% at 5 years, 50% at 10 years, 70% at 15 years).
Conclusions:
- Intermittent claudication, while rarely leading to amputation, signifies a high risk for cardiovascular events and mortality.
- Aggressive management of risk factors, particularly smoking cessation, is critical for improving prognosis.
- Claudicants require comprehensive cardiovascular risk assessment and management beyond leg ischemia.
Abstract:
Although a patient with intermittent claudication (IC) will fear progression to severe disease and amputation, this is a relatively rare outcome of claudication, with only 1% to 3% of claudicants ever requiring major amputation over a 5-year period. Indeed, in one study, 50% of claudicants became symptom free during 5 years' follow-up. All the new evidence over the last 40 years has not altered the impression that only about one fourth of patients with IC will ever significantly deteriorate, and that deterioration is most frequent during the first year after diagnosis (6 to 9%) compared with 2% to 3% per annum thereafter. Smoking is the most important risk factor for the progression of local disease in the legs, with an amputation rate 11 times greater in smokers than nonsmokers. Diabetes, male gender, and hypertension are also important risk factors for progression. Because cerebrovascular disease (CVD), coronary artery disease (CAD), and peripheral arterial occlusive disease (PAOD) coexist, PAOD and IC should be regarded as a marker for increased risk from fatal and nonfatal cardiovascular event, and 2% to 4% of claudicants have a nonfatal cardiovascular event every year. The risk is higher in the first year after developing IC than in a long-standing stable claudicant, and the average claudicant is more likely to have a nonfatal myocardial infarction (MI) or stroke in the next year that of ever requiring a major amputation for his leg ischemia. The mortality in claudicants is 30% at 5 years, 50% at 10 years, and 70% at 15 years, without any clear decrease in these figures over the last 30 to 40 years. The mortality of claudicants is approximately two and a half times that of an age-matched general population.