Correspondence

Intermittent Claudication

N Engl J Med 2007; 357:91-93July 5, 2007

Article

To the Editor:

In his review of intermittent claudication, White (March 22 issue)1 emphasizes that patients with this condition are at high risk for cardiovascular events, but he does not emphasize the role of statins in this population. There is good justification for the systematic prescription of statins for patients with peripheral arterial disease. The Heart Protection Study showed that in patients with peripheral arterial disease, aggressive lowering of low-density lipoprotein cholesterol was associated with a marked reduction in cardiovascular events,2 whether or not there was evidence of coronary disease at baseline; there was no apparent threshold cholesterol value below which statin therapy was not associated with a benefit. In addition, patients with peripheral arterial disease have endothelial dysfunction secondary to atherosclerosis that contributes to intermittent claudication and may be improved with statin therapy. Studies have shown a significant increase in exercise performance with statin use.3-5 This improvement is similar to that resulting from the use of vasodilator drugs such as cilostazol, which have not been shown to reduce deaths or cardiovascular events.

Joseph Emmerich, M.D., Ph.D.
Emmanuel Messas, M.D., Ph.D.
Jean-Noel Fiessinger, M.D.
INSERM Unité 765, Paris CEDEX 06, France
joseph.emmerich@egp.aphp.fr

5 References

1. 1

   White C. Intermittent claudication. N Engl J Med 2007;356:1241-1250
   Full Text | Web of Science | Medline

2. 2

   Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002;360:7-22
   CrossRef | Web of Science | Medline

3. 3

   Mohler ER, Hiatt WR, Creager MA. Cholesterol reduction with atorvastatin improves walking distance in patients with peripheral arterial disease. Circulation 2003;108:1481-1486
   CrossRef | Web of Science | Medline

4. 4

   Mondillo S, Ballo P, Barbati R, et al. Effects of simvastatin on walking performance and symptoms of intermittent claudication in hypercholesterolemic patients with peripheral vascular disease. Am J Med 2003;114:359-364
   CrossRef | Web of Science | Medline

5. 5

   Aronow WS, Nayak D, Woodworth S, Ahn C. Effect of simvastatin versus placebo on treadmill exercice time until the onset of intermittent claudication in older patients with peripheral vascular disease at six months and at one year after treatment. Am J Cardiol 2003;92:711-712
   CrossRef | Web of Science | Medline

To the Editor:

White recommends percutaneous transluminal angioplasty (PTA) in young patients because they have a higher risk of graft failure after surgical therapy than do older patients. However, there is no evidence that femoropopliteal PTA provides more durable results than surgical revascularization or optimal medical treatment in young patients. Young people with intermittent claudication may require repeated vascular interventions. Since each intervention leaves fewer possibilities for intervention in the future, interventions should be deferred as long as possible.

No intervention should be performed before optimal noninvasive treatment has been tried for a sufficient period of time without success. Eighteen months of such treatment may be needed to obtain the maximum effect.1,2

Einar Dregelid, M.D.
Haukeland University Hospital, 5021 Bergen, Norway
eidreg@yahoo.com

2 References

1. 1

   Perkins JM, Collin J, Creasy TS, Fletcher EW, Morris PJ. Exercise training versus angioplasty for stable claudication: long and medium term results of a prospective, randomised trial. Eur J Vasc Endovasc Surg 1996;11:409-413
   CrossRef | Web of Science | Medline

2. 2

   Gardner AW, Katzel LI, Sorkin JD, Goldberg AP. Effects of long-term exercise rehabilitation on claudication distances in patients with peripheral arterial disease: a randomized controlled trial. J Cardiopulm Rehabil 2002;22:192-198
   CrossRef | Medline

Author/Editor Response

Emmerich et al. point out that statin therapy is an important component of the total effort to reduce the risk of atherosclerosis in patients with peripheral arterial disease. This recommendation is consistent with the most current guidelines of the American College of Cardiology and the American Heart Association (class I recommendation, level of evidence B).1 There is evidence of improvement in symptoms of claudication with statin therapies; however, the magnitude of the benefit of lipid-lowering therapies for walking distance remains unclear.

Dregelid emphasizes that patients with claudication should be given an opportunity to have a response to pharmacologic therapy and lifestyle modification before undergoing revascularization; this approach is consistent with the current guidelines.1 A prolonged (18-month) trial of conservative therapy may not be appropriate, however, for persons with vocation-limiting claudication. In these patients, PTA can both improve their symptoms and speed their return to work.

I agree that there is no evidence that the results of PTA are more durable than those of surgery, but I would point out that in patients with claudication or patients who have chronic critical limb ischemia, PTA is not inferior to surgery, making the procedure associated with less morbidity the treatment of choice.2 Furthermore, a failed lower-extremity bypass is more likely to lead to tissue or limb loss than restenosis after PTA.3 Unlike surgery, PTA can be repeated at no increased risk to the patient or limb,4 and promising endovascular strategies to prevent restenosis may be used to maintain patency of the treated femoral popliteal segment.

Christopher White, M.D.
Ochsner Medical Center, New Orleans, LA 70121
cwhite@ochsner.org

4 References

1. 1

   Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary of a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. J Am Coll Cardiol 2006;47:1239-1312
   CrossRef | Web of Science | Medline

2. 2

   Adam DJ, Beard JD, Cleveland T, et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet 2005;366:1925-1934
   CrossRef | Web of Science | Medline

3. 3

   Baldwin ZK, Pearce BJ, Curi MA, et al. Limb salvage after infrainguinal bypass graft failure. J Vasc Surg 2004;39:951-957
   CrossRef | Web of Science | Medline

4. 4

   Schillinger M, Mlekusch W, Haumer M, Sabeti S, Ahmadi R, Minar E. Angioplasty and elective stenting of de novo versus recurrent femoropopliteal lesions: 1-year follow-up. J Endovasc Ther 2003;10:288-297
   CrossRef | Web of Science | Medline