Intermittent Claudication

  • People with intermittent claudication do not normally need referral
  • Control of risk factors is fundamental

Assessment

Signs and Symptoms

  • Pain in the calf on walking (+thigh/ buttock)
  • Never at rest or standing/weight bearing
  • Resolves completely with 1-5 minutes of rest: recurs after further walking
  • Worse hurrying and uphill

History and Examination

History:
  • Details of symptoms (see above) to differentiate from other cause of leg pain
  • Ask about other symptoms which limit walking (e.g. dyspnoea, arthritis)
  • Smoking history
  • Family history – especially for younger patients (e.g. less than 55 years)
Examination:
  • Pulse palpation and Doppler examination help to confirm the diagnosis
  • Ankle brachial pressure index is usually less than 1.0 (typically between 0.5 and 1.0). ABPI of more than 1.0 with normal Doppler sounds makes claudication unlikely, but still a possibility in the presence of a good history

Differential Diagnoses

  • Many other causes of leg pain – the symptoms bulleted above are the key to diagnosis

Red Flags

None.

Pain in the calf at night is not characteristic of ischaemic rest pain.

Investigations

  • Full blood count to check for anaemia or hyperviscosity
  • Serum lipids
  • Screen for diabetes

Management

  • Advice and help to stop smoking is of the greatest importance
  • Prescribe an antithrombotic (usually clopidogrel)
  • Prescribe a statin (even if cholesterol is not high)
  • Ensure good control of diabetes and hypertension, if present
  • Advise regular exercise. Walking to the limit of tolerance is beneficial

Joint formulary - Chapter 2, section 2.12 Lipid-regulating drugs - Statins

Joint formulary - Chapter 2, section 2.9 Antiplatelet drugs - Antiplatelet drugs

Referral

Referral Criteria

  • Referral is only indicated for patients whose symptoms have become a persistent and significant disability
  • Do not refer patients who are still smoking
  • Ensure good risk factor control before referral
  • It is reasonable to refer patients with troublesome leg pain when there is doubt about the diagnosis and when confirmation of arterial disease would change management
  • A low ABPI is not an indication for referral: referral should be based on the severity of symptoms and disability
  • A good history of claudication with a normal ABPI may be a reason for referral, for specialist advice to establish the diagnosis

Referral Instructions

Referral to vascular specialist

  • e-Referral service selection:
    • Specialty: Surgery - Vascular
    • Clinic Type: Not otherwise specified
    • Service: DRSS-Northern-Surgery Vascular- Devon CCG- 15N

Referral Forms

DRSS referral form

Supporting Information

Pathway Group

This guideline has been signed off by the Northern Locality on behalf of NEW Devon CCG.

Publication date: September 2015

 

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