A 69-Year-Old Woman Comes to the Physician with Right Calf

question 397

Multiple Choice

A 69-year-old woman comes to the physician with right calf pain when walking.  The pain has been present for several months but is now starting to limit her daily walks and shopping.  It is described as a deep ache or cramp.  The pain initially occurred after the patient walked 6 blocks, but now occurs after 2 blocks.  It dissipates rapidly with rest.  She has no chest pain or leg edema.  The patient has a history of hypertension, hyperlipidemia, diet-controlled type 2 diabetes mellitus, and cigarette use.  She has reduced her smoking to about 10 cigarettes a day.  Her medications include simvastatin, ramipril, aspirin, calcium, and vitamin D.
The patient's blood pressure is 128/77 mm Hg and pulse is 72/min.  Cardiac, lung, and abdominal examinations are unremarkable.  Her femoral pulses are 2+ and symmetrical.  Popliteal and dorsalis pedis pulses on the right feel diminished relative to the left.  Her ankle-brachial index is 0.7 on the right and 0.9 on the left.
Electrocardiogram shows normal sinus rhythm and non-specific ST-segment and T-wave changes.
After smoking cessation, aggressive risk factor modification, and a supervised incremental walking program, which of the following would be the best next step in management if life-style-limiting claudication persists?

• A)Cilostazol
• B)Pentoxifylline
• C)Revascularization therapy
• D)Verapamil
• E)Warfarin

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