Management of intermittent claudication: the importance of secondary prevention

Atherosclerotic peripheral arterial disease (PAD) is a common disorder usually associated with silent or symptomatic arterial disease elsewhere in the circulation and a cluster of cardiovascular risk factors inducing atheroma progression and/or thrombotic complications. Because of these strong clinical associations, especially with coronary heart disease, the ankle-brachial pressure index (ABPI) is of prognostic significance. The clinical management of IC should include relief of symptoms combined with prevention of secondary cardiovascular complications, e.g. acute thrombotic events causing limb- or life-threatening ischaemia, which are often due to atherosclerotic plaque rupture leading to thrombotic vessel occlusion. Many patients with PAD do not receive an optimum package of secondary prevention, tailored to include maximum cholesterol reduction, BP and glycaemic control, ACE inhibition and single or combination anti-platelet therapy. This review considers recent information from large secondary prevention trials, e.g. the PAD subgroups within the HOPE, CAPRIE and statin studies. Slowing progression of atherosclerosis, and inducing stabilisation and regression of atheromatous plaques, is now feasible using long-term combination drug therapy. The phrase angle quotation mark, leftangle quotation mark, leftconservative therapyangle quotation mark, rightangle quotation mark, right, popular among vascular surgeons, implies a passive minimal-intervention strategy of surveillance and lifestyle advice; such terminology is perhaps no longer appropriate since considerable improvements in survival are likely to accrue if all patients with PAD, especially those with low ABPI, receive vigorous, titrated medical therapies, tailored to individual patients, as part of an evidence-based secondary prevention regime.