Management of Intermittent Claudication

Initial Treatment

The American College of Cardiology recommends supervised exercise training for 30-45 minutes at least 3 times weekly for a minimum of 12 weeks as the cornerstone of initial treatment, combined with aggressive cardiovascular risk factor modification and antiplatelet therapy 1, 2
Exercise should be of sufficient intensity to bring on claudication pain, followed by rest periods, repeated throughout the session, and improves maximal walking distance by 40-100% and provides systemic benefits including lowered blood pressure, improved glycemic control, and improved lipid profiles 2
The American College of Cardiology recommends initiating antiplatelet therapy immediately with aspirin 75-325 mg daily or clopidogrel 75 mg daily to reduce risk of MI, stroke, and vascular death 1
Smoking cessation is mandatory, and statin therapy should target LDL <100 mg/dL (or <70 mg/dL for very high-risk patients) for all patients with LDL ≥100 mg/dL 1, 3
Blood pressure control should target <140/90 mmHg for nondiabetics or <130/80 mmHg for diabetics and chronic kidney disease patients, and glycemic control in diabetics should target hemoglobin A1C <7% to reduce microvascular complications 1, 3

Cilostazol 100 mg orally twice daily should be started simultaneously with exercise therapy or if exercise alone is inadequate, provided the patient does not have heart failure of any severity, and improves pain-free walking distance by 59% and maximal walking distance by 40-60% after 12-24 weeks 3, 4
Pentoxifylline 400 mg orally three times daily with meals should only be considered when cilostazol is contraindicated or not tolerated, but has marginal and not well-established clinical effectiveness compared to cilostazol 3, 4

Step 1 (Weeks 0-12) involves initiating supervised exercise training 3 times weekly, starting aspirin or clopidogrel immediately, implementing aggressive risk factor modification, and adding cilostazol 100 mg twice daily if no heart failure present 1, 2, 3, 4
Step 2 (Weeks 12-24) involves continuing exercise training even if symptoms improve, and considering endovascular intervention for lifestyle-limiting disability if inadequate response after 12-24 weeks of optimal medical therapy 3
Step 3 (After 3-6 months) involves considering endovascular procedures only for patients with lifestyle-limiting disability despite adequate trial of exercise and pharmacological therapy, and preferring endovascular intervention for TASC type A iliac and femoropopliteal lesions 3

Never prescribe cilostazol without screening for heart failure first, as it is an absolute contraindication regardless of severity 4
Do not proceed to invasive management before completing a minimum 3-6 month trial of exercise and pharmacotherapy unless critical limb ischemia is present 3
Do not consider pentoxifylline equivalent to cilostazol, as its benefit is marginal at best and should only be used when cilostazol is contraindicated 3, 4
Do not use warfarin in addition to antiplatelet therapy, as it provides no benefit and increases bleeding risk (Class III: No Benefit) 1, 3

L-arginine, propionyl-L-carnitine, and ginkgo biloba have insufficient evidence for intermittent claudication, and chelation therapy is contraindicated and potentially harmful 3, 5
Homocysteine-lowering drugs (folic acid and B12 supplements) are not well established even in patients with elevated homocysteine >14 micromoles/L 1

Daily foot inspection, skin cleansing, and topical moisturizing creams should be encouraged, and skin lesions and ulcerations must be addressed urgently 1
Target hemoglobin A1C <7% to reduce microvascular complications 1