Case history and initial presentation

A 62-year-old male presents to his local GP with left calf pain. The pain has been a growing concern for the last 6 months and regularly occurs while playing tennis. He emphasises that the pain is relieved by rest and there is no pain while resting.

Apart from the calf pain, the patient is generally well and has no other complaints.

The patient has a 2-year history of Type 2 diabetes mellitus (T2DM), is a non-smoker and was diagnosed with hypertension in 2001. Of note, his father had T2DM, hypertension and suffered a fatal myocardial infarction at 73 years-of-age.

Current medications include aspirin, ramipril, metformin and a NSAID as required for the calf pain.

Physical examination and laboratory investigations

Physical examination reveals the following:

·Heart and lungs: no abnormalities on auscultation

·BP: 138/88 mmHg

·Radial pulse: regular 88 beats/min

·BMI: 29 kg/m²

Right lower limb:

·Artery pulsations present, including in foot arteries

Left lower limb:

·Femoral artery pulsations present in groin

·No pulsations in popliteal or distal pulse points

Ankle-Brachial Index (ABI) investigation - pressure gradients:

·Left ankle 80/138 (index = 0.58)

·Right ankle 104/138 (index = 0.75)

ECG:

The electrocardiogram shows regular sinus rhythm. Clear Q-waves were visible in Leads II, III, and aVF. These Q-waves consistent with a previous inferior infarction.

Laboratory investigations:

·Total cholesterol: 7.0 mmol/L

·LDL: 4.8 mmol/L

·HDL: 0.9 mmol/L

·Triglycerides: 5.0 mmol/L

·HbA1c: 7.9%

·FBE: Normal

·U&E: eGFR 61 mL/min, all other measures within reference range.

·LFT: all measures within reference range

The lipid profile targets for high-risk patients with existing coronary heart disease are:

·LDL-C

·HDL-C > 1.0 mmol/L.

·Triglycerides

Management

The patient is commenced on clopidogrel, and a low-dose statin. He continued to take ramipril and metformin. Felodipine and insulin were added to his regimen. He is referred to the multi-disciplinary diabetes centre for initial and ongoing patient education for self-management of his diabetes. He is also referred to an exercise physiology clinic for assessment and prescription of an exercise program to assist in self-management of his health. The NSAID and aspirin were discontinued.

Four months later, at his now regular monthly checkup, his symptoms have improved and progress towards lipid profile targets is evident. He will continue monthly appointments for the time being.

Question 3 (6 points)

 

To demonstrate your knowledge of cardiovasular disease, explain this statement:

Similar underlying alterations to the structure and function of arteries are probably responsible for this patient's calf pain and coronary heart disease.

Include basic principles and evidence from the scenario that may be relevant.

As always, reference as necessary.

 

Question 3 options:

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Question 4 (0.5 points)

 

Blood pressure targets are lower in patients with diabetes, compared to those who do not have diabetes.

Question 4 options:

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Â	False

Question 5 (4 points)

 

Explain the rationale for the addition of felodipine to the patient's medication regimen.

In your answer you should consider the patient's history and physical examination findings, the mechanism of action of the class of drug and the intended therapeutic outcome.

As always, reference as necessary.

Question 5 options:

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Question 6 (2 points)

 

Briefly explain why aspirin was discontinued.

 

Question 6 options:

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Question 7 (3 points)

 

With direct reference to information in the scenario, predict and justify two goals of an exercise program for this patient.

As always, reference as necessary.

Question 7 options: