Cardiovascular · Moderate
This case is fictional and exists for study. It describes no real patient.
64 years · male
A 64-year-old male presents to the primary care clinic complaining of progressive cramp-like pain in his right calf when walking more than 150 metres. The pain onset is predictable, worsens when walking uphill, and resolves completely within 5 to 10 minutes of standing still. He reports no pain at rest or while sleeping. He has a 30-pack-year smoking history and untreated hypertension. On examination, his right lower leg appears pale compared to the left, with shiny skin and reduced hair growth. Right popliteal pulse is weak, and right dorsalis pedis and posterior tibial pulses are non-palpable. Heart sounds are normal, and chest is clear.
Vital signs
- HR
- 76 bpm
- BP
- 148/88 mmHg
- RR
- 14/min
- Temp
- 36.6 °C
- SpO₂
- 97%
Examination findings
- Reduced lower extremity hair growth and shiny skin on the right calf
- Non-palpable right dorsalis pedis and posterior tibial pulses
- Right calf pain reliably reproduced by exercise and relieved by rest
Investigations
| Total Cholesterol | 6.2 mmol/L | reference: < 5.0 |
| HbA1c | 40 mmol/mol | reference: < 42 |
| eGFR | 82 mL/min/1.73m2 | reference: > 90 |
Question 1 of 3
Which of the following is the most appropriate initial non-invasive investigation to confirm the diagnosis of peripheral arterial disease?
Ankle-brachial pressure index (ABPI) measurement is the essential initial non-invasive test to diagnose peripheral arterial disease in primary care. Duplex ultrasound and CT angiography are second-line imaging modalities reserved for anatomical localization before invasive interventions (e.g., angioplasty or surgery). Venous Doppler ultrasound assesses venous thrombosis or insufficiency, which does not address the arterial clinical presentation.
Teaching point: ABPI is the first-line diagnostic investigation for suspected peripheral arterial disease in primary care.
Question 2 of 3
An ankle-brachial pressure index (ABPI) measurement is performed on the patient and yields a value of 0.65 on the right side. How should this finding be interpreted?
A normal ABPI ranges from 0.9 to 1.3. An ABPI of 0.7 to 0.89 indicates mild peripheral arterial disease (PAD), 0.5 to 0.69 indicates moderate PAD, and <0.5 indicates severe PAD (with <0.3 typically seen in critical limb ischaemia). Thus, a value of 0.65 indicates moderate PAD.
Teaching point: An ABPI value between 0.5 and 0.69 indicates moderate peripheral arterial disease.
Question 3 of 3
Which of the following is the most appropriate initial management strategy for this patient's intermittent claudication?
First-line management for stable intermittent claudication includes secondary prevention (smoking cessation, antiplatelet therapy such as clopidogrel, lipid-lowering with a statin, BP optimization) and participation in a supervised exercise programme. Revascularization (angioplasty or bypass) is reserved for refractory cases or critical limb ischaemia. Anticoagulation is not routinely indicated for PAD. Bed rest and leg elevation worsen arterial flow and promote functional decline.
Teaching point: First-line management of stable intermittent claudication involves a supervised exercise program and comprehensive cardiovascular risk optimization.
Key learning points
- Intermittent claudication is characterized by exertional leg muscle pain relieved by rest, diagnosed initially via ABPI.
- An ABPI value between 0.5 and 0.69 denotes moderate arterial compromise.
- Initial conservative management centers on supervised exercise, smoking cessation, statin therapy, antiplatelets, and blood pressure management.
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