What is claudication at rest and what is its significance?

Claudication at rest occurs when blood flow is reduced below a level sufficient for supplying the metabolic needs of the tissue at rest. The pain is typically in the forefoot, often occurs at night when the feet are elevated, and is often relieved by placing the feet in a dependent position. Ulcers and gangrene often accompany claudication at rest.

What is the general approach to outpatient management of PVD?

First, treat other conditions that might adversely affect tissue oxygen delivery, such as congestive heart failure, anemia, and hypoxia. Modify risk factors. Smoking cessation has been shown to improve the morbidity and mortality in patients with PVD. Despite the lack of firm evidence, it is prudent to treat hypertension, control hyperglycemia, and lower cholesterol. In severe cases, especially in diabetics, meticulous local care of skin, feet, and nails is necessary if infection and limb loss are to be prevented. Have your patients take off their shoes and socks during the examination.

Can claudication be improved?

Exercise has been shown to improve pain-free walking time. The magnitude of the improvement has been up to 290% with an average of approximately 134%. Patients should be encouraged to walk to the point of claudication and then to rest until pain-free and then resume walking.

Pentoxifylline is presently the only medication for claudication. It is believed to improve erythrocyte deformability, platelet reactivity, and blood viscosity. The magnitude of improvement is less than with exercise (25-100%), and should be used when the response to exercise is inadequate.

What about anticoagulation, aspirin, and vasodilators?

None of these medications has been proved to reduce claudication or prevent progression of atherosclerosis in PVD patients. Aspirin should be prescribed routinely because it reduces the incidence of myocardial infarctions and strokes in patients with PVD.

When is surgery or angioplasty indicated?

Symptoms interfere with lifestyle

Failure to respond to medical interventions

Development of claudication at rest

Skin ulceration or gangrene

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