Ep 189 – Intermittent claudication

Intermittent claudication is a hallmark symptom of peripheral arterial disease (PAD) and reflects widespread atherosclerosis. It presents as predictable exertional leg pain caused by inadequate blood flow during exercise. The pain location helps localise arterial stenosis and diagnosis relies on history, examination and the ankle–brachial index (ABI), with imaging reserved for intervention planning. Management focuses on cardiovascular risk reduction, smoking cessation, supervised exercise therapy, antiplatelet treatment and statins. Revascularisation is considered only when symptoms continue to limit lifestyle despite optimal therapy. Although limb loss is uncommon, cardiovascular mortality is high, making systemic risk management essential. In this episode, Dr Roger Henderson gives an overview of the condition and looks at how best to diagnose and manage it.

Key take-home points

• Intermittent claudication is a symptom of PAD and a marker of systemic atherosclerosis.
• Claudication pain is predictable, exertional and relieved by rest, reflecting an oxygen supply/demand mismatch in muscle cells.
• The pain occurs when exercise triggers anaerobic metabolism, producing metabolites that stimulate pain receptors.
• The pain location localises disease: buttocks/thighs (aortoiliac), thigh (common femoral), calf (superficial femoral), foot (tibial/popliteal).
• Leriche’s syndrome occurs in aortoiliac occlusion, causing bilateral buttock claudication, impotence and absent femoral pulses.
• Major risk factors mirror those of coronary disease: smoking (strongest), diabetes, hyperlipidaemia, hypertension and age.
• The history should assess walking distance, quality of pain, pattern of relief and the presence of rest pain or other vascular symptoms.
• Examination may show skin changes, hair loss, ulcers and reduced or delayed pulses. Buerger’s test and bruits provide additional clues.
• The ABI is the key initial test; a reading <0.9 confirms PAD, while a reading >1.3 suggests calcified, incompressible arteries.
• An exercise ABI helps when symptoms are typical, but resting ABI is normal.
• Imaging such as duplex vascular ultrasound, computed tomography angiography, magnetic resonance angiography and angiography is used when planning revascularisation and not for routine diagnosis.
• Core management principles include smoking cessation, statins, blood pressure control, diabetes optimisation and antiplatelet therapy.
• Supervised exercise therapy is a cornerstone, improving walking distance and functional capacity.
• Revascularisation (endovascular or surgical) is reserved for lifestyle-limiting symptoms after optimal medical therapy.
• Prognosis: limb loss is rare, but cardiovascular mortality is high, making systemic risk reduction essential.
• Endovascular options (angioplasty, stenting, drug-coated balloons, atherectomy) are less invasive but may require repeat interventions due to restenosis.
• Open surgical bypass offers superior long-term patency for extensive disease compared to minimally invasive options, but carries a higher perioperative risk, making patient selection critical.

Key references

1. Mazzolai L, et al. Eur Heart J. 2024;45(36):3538-3700. doi: 10.1093/eurheartj/ehae179.
2. Gornik HL, et al. Circulation. 2024;149(24):e1313-e1410. doi: 10.1161/CIR.0000000000001251.
3. NICE. 2020. https://www.nice.org.uk/guidance/cg147/chapter/recommendations.
4. Patel SK, Surowiec SM. StatPearls [Internet]. 2023. https://www.ncbi.nlm.nih.gov/books/NBK430778/.