Robert J. Hinchliffe, MD, MRCS, Clinical Lecturer in Vascular Surgery, St George’s Regional Vascular Institute, St George’s Hospital and St George’s University of London, London, UK.
William Jeffcoate, FRCP, Professor, Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, Nottingham University Hospitals, City Hospital Campus, Nottingham, UK.

Individuals with ulceration of the foot should be identified and referred urgently to a specialist. Unfortunately there is little formal health care education in diabetic foot ulceration and often no specialist referral pathway. We discuss the common modes of presentation of patients with diabetes and foot ulcer. The clinical implications of a range of symptoms and signs will be explained, including the most common diagnostic pitfalls in everyday primary care practice.
Key words: diabetes, peripheral vascular disease, ulcer, vascular surgery, peripheral arterial disease, diabetic foot.

Marc Schermerhorn, MD, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Kristina Giles, MD, Beth Israel Deaconess Medical Center, Boston, MA, USA.

Peripheral arterial disease (PAD) is a common disorder among older adults. Recognition of the signs and symptoms and appropriate referral of patients to a vascular surgeon can improve functional outcomes and limb salvage. Behavioural, medical, and percutaneous endovascular or open surgical therapies may all be used, depending upon the severity of symptoms and likelihood of limb loss. Cardiovascular comorbidities are common with PAD, and appropriate treatment to minimize cardiovascular mortality is important.
Key words: peripheral arterial disease, claudication, critical limb ischemia, endovascular treatment, lower extremity bypass.

To the Editor:
I have a question in regard to the article “An Older Woman with Peripheral Arterial Disease” by Dr. Wilbert Aronow from the May issue (Geriatrics & Aging 2006;9:378). The author writes “…Beta-blockers should be administered because she has a prior MI and an abnormal LVEF to reduce cardiovascular morbidity and mortality.” That’s true, but what happens with beta-blockers and PAD in this patient--are they not contraindicated?
Marilú Budinich Villouta, MD, Geriatrics Resident, Mayor University, Capredena La Florida Rehabilitation Centre, Santiago, Chile.

Dr. Aronow replies:
A meta-analysis of 11 randomized, controlled trials demonstrated that beta blockers do not adversely affect walking capacity or the symptoms of intermittent claudication in patients with mild to moderate peripheral arterial disease (PAD).¹

Of 490 men and women, mean age 80 years, with symptomatic PAD and prior myocardial infarction (MI) without contraindications to beta-blockers, 257 (52%) were treated with beta-blockers.² Adverse effects causing cessation of beta-blockers occurred in 31 of these 257 patients (12%). At 32-month follow-up, use of a beta-blocker was associated with a 53% significant independent reduction in the incidence of new coronary events in older patients with PAD and prior MI.²

In a vascular surgery clinic, 301 of 364 patients (83%), mean age 71 years, with PAD and coronary artery disease were being treated with beta-blockers.³
Finally, the American College of Cardiology/American Heart Association 2005 practice guidelines for the management of patients with PAD recommend beta-blockers as antihypertensive therapy in patients with PAD to reduce MI, stroke, congestive heart failure, and cardiovascular death with a Class I recommendation.⁴
Wilbert S. Aronow, MD, Clinical Professor of Medicine, New York Medical College, Valhalla, NY.

References

1. Radack K, Deck C. Beta-aderenergic blocker therapy does not worsen intermittent claudication in subjects with peripheral arterial disease: meta-analysis of randomized controlled trials. Arch Intern Med. 1991;151:1769-76.
2. Aronow WS, Ahn C. Effect of beta blockers on incidence of new coronary events in older persons with prior myocardial infarction and symptomatic peripheral arterial disease. Am J Cardiol 2001;87:1284-6.
3. Sukhija R, Yalamanchili K, Aronow WS, et al. Clinical characteristics, risk factors, and medical treatment of 561 patients with peripheral arterial disease followed in an academic vascular surgery clinic. Cardiol Rev 2005;13:107-9.
4. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary. Circulation 2006;113:1474-547.

From the Department of Medicine, Cardiology and Geriatrics Divisions, New York Medical College, Valhalla, NY, USA.
Wilbert S. Aronow, MD, CMD, Clinical Professor of Medicine, Divisions of Cardiology, Geriatrics, and Pulmonary/Critical Care Medicine;
Chief, Cardiology Clinic; Senior Associate Program Director and Research Mentor, Fellowship Programs, Department of Medicine, New York Medical College, Valhalla, NY, USA; Adjunct Professor of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York City, NY, USA.

A 73-year-old woman saw a physician because of a three-month history of pain on walking after two blocks, which was relieved by rest. She had no other symptoms and was not on any medications.

Ernane D. Reis, MD, Assistant Professor, Department of Surgery, Mount Sinai School of Medicine, New York, NY.
Nicholas Morrissey, MD, Assistant Professor, Department of Surgery, Mount Sinai School of Medicine, New York, NY.

Prevalence of peripheral arterial disease (PAD) increases with age. PAD is not only associated with disability (e.g., claudication, limb loss), but also with increased mortality from cardiac and cerebrovascular events. A thorough assessment of symptoms, risk factors and physical signs--including ankle-brachial indices--can be sufficient to determine whether PAD is present. Further testing--such as Duplex examination, magnetic resonance imaging and conventional arteriography--is often required to determine progression and accurate localization of lesions, as well as to direct therapeutic intervention. Early detection of PAD can help prevent functional impairment and death in the elderly.
Key words: atherosclerosis, peripheral arterial disease, ankle-brachial index, diabetes, claudication.