From the University of York, York, UK, and the University Hospital of Angers, Angers, France.
Abstract
Objective: To provide an overview of therapies for improving functional outcomes in individuals with intermittent claudication due to lower-limb peripheral arterial disease (PAD).
Methods: Literature review.
Results: Treatment approaches that aim to improve functional outcomes (and walking performance specifically) in individuals with intermittent claudication include exercise training, lower-limb revascularization, and prescription of various drugs, including peripheral vasodilators. Supervised exercise training, particularly that which involves walking as the main exercise modality, is an effective treatment for improving walking performance in individuals with intermittent claudication; however, few supervised exercise programs exist specifically for these patients, limiting access to this therapy. Consequently, most patients with intermittent claudication do not participate in supervised exercise. The evidence for the effectiveness of unsupervised exercise programs is currently weak and mixed, and lack of motivation and pain have been cited as major barriers to participation in self-managed exercise. Lower-limb revascularization procedures (angioplasty or bypass surgery) can improve walking performance; however, such procedures are not feasible for some patients (eg, in the case of extensive multi-segmental disease) and are invasive and expensive. Medications used to treat PAD-related functional impairment (eg, cilostazol, pentoxifylline, inositol nicotinate, and naftidrofuryl oxalate [not approved in the US]) all have limited efficacy.
Conclusion: Supervised walking exercise is a cheap and effective approach for improving walking performance in individuals with intermittent claudication. Therefore, efforts should be made to provide patients with access to a supervised exercise program, or to promote self-managed walking when supervised exercise is not available or practical.
Peripheral arterial disease (PAD) is a chronic cardiovascular disease characterised by atherosclerotic narrowing or occlusion of the arteries supplying the legs. It is highly prevalent in older adults, affecting around 20% of adults aged > 70 years [1,2]. Around 10% to 35% of patients report the typical symptoms of intermittent claudication, which is specifically defined as lower-limb discomfort or pain on exertion that is relieved within 10 minutes of rest; however, a further 30% to 40% report other, atypical lower-limb symptoms [3]. Intermittent claudication impairs quality of life by limiting ambulation and activities of daily living [4] and is associated with a several-fold increased risk of cardiovascular and all-cause mortality compared with age-matched healthy controls [5,6]. The treatment of individuals with intermittent claudication has 2 main objectives: secondary prevention of cardiovascular disease and improvement of functional status (and, in turn, quality of life) [3,7,8]. The former objective is usually pursued through prescribing various medications to help manage cardiovascular risk factors (eg, antiplatelets, HMG-CoA reductase inhibitors, antihypertensive and antidiabetic medication) and promoting lifestyle changes such as smoking cessation, increased physical activity, and consumption of a healthy diet. This review focuses on the latter objective by providing an overview of the evidence for different treatments to improve functional outcomes in individuals with intermittent claudication. Patients with PAD often present with multiple comorbidities that may have independent adverse effects on functional capacity (eg, osteoarthritis, chronic heart failure, chronic obstructive pulmonary disease) [9]; therefore, concomitant treatment of comorbidities should be considered when attempting to optimize the functional status of patients.
