H.J.P Fokkenrood

Innovative strategies for
intermittent claudication

towards a stepped care approach and new outcome measures



 Several international guidelines (the American College of Cardiology/ American Heart Association (ACC/AHA) and the Trans-Atlantic Inter-Society Consensus on Management of Peripheral Arterial Disease (TASC II) describe an overall strategy and basic treatment for patients with symptomatic PAOD.2,4 Treatment of PAOD should consist of a multi-component therapy of cardiovascular risk reduction by pharmacology interventions and lifestyle coaching (1) and symptomatic treatment (2).5


 The first component aims to prevent cardiovascular events (myocardial infarction, stroke) and related morbidity and mortality. The prevalence of cerebrovascular disease in patients with PAOD is about 25-50%.6 In a subgroup of

patients with severe and symptomatic PAOD a 15-fold increase in mortality rate was found.7 For IC, a 5-year mortality rate of 19.2% is described, of which 70% is due to cardiovascular causes. Cardiovascular risk reduction is important to prevent cardiovascular events (myocardial infarction or stroke) and related morbidity and mortality. The most important modifiable risk factors for atherosclerosis are smoking, hypertension, diabetes mellitus, hyperlipidaemia and obesity.8 According to international guidelines, all symptomatic patients with or without a history of cardiovascular disease are generally prescribed antiplatelet therapy in combination with a statin.


 The second component aims at relieving symptoms related to PAOD. An initial treatment modality is exercise therapy, first suggested by Erb in 1898.10 This approach was supported more than a century later by a Cochrane review. In this review, an overall improvement in maximal walking time with a mean difference of 5.12 minutes (CI 4.51 – 5.72) was found in favor of exercise therapy compared with usual care or placebo.11 In daily practice, lack of adequate individual supervision appears to be an important barrier for the initiation and continuation of exercise therapy in patients with PAOD. A Cochrane review by Bendermacher et al. and a RCT by Nicolai et al. showed that supervised exercise therapy (SET) was superior to a non-supervised program.12,13 In a cohort study, community-based SET appeared to be as effective as hospital-based SET.13 Community-based SET has the advantage of providing a larger capacity of care and is feasible in close proximity to the patient's home environment. With this body of evidence, it is clear that SET provided by a physical therapist (PT) in combination with cardiovascular risk management (CVRM) must be offered to all patients with IC.