The most common cause is atherosclerosis. Atherosclerosis is a fatty build-up and narrowing of the arteries. This leads to limited or completely blocked blood flow through the arteries. Risk factors include:

The pain of intermittent claudication has three (3) characteristics:

1. It is a cramping pain in the calves brought on by exertion.
2. Rest relieves it.
3. It is reproducible (i.e. it almost always occurs after having walked some distance)

Pain brought on by walking is less serious than pains occurring during sleep or while at rest. These are indications of disease progression and warrant therapy that is more aggressive.

The diagnosis of intermittent claudication begins with a through history and physical. There are three specific questions in the medical history, which is part of the assessment process:

• Do you get pain or cramping in the calf, thigh or buttock muscles when you walk?
  
• Does the pain or cramping go away when you rest or stop walking?
  
• Does the discomfort occur at approximately the same distance every time you walk?

Major physical findings upon examination may include:

• Arterial bruits (abnormal blood flow sound heard by stethoscope when placed over a major artery such as abdominal aorta or femoral artery)
  
• Decreased or absent leg pulses
  
• Decreased skin temperature
  
• Abnormal skin color (persistent areas of redness called dependent rubor)
  
• Shiny or hairless skin on the legs

The ankle-brachial index is an effective screening tool. It requires a blood pressure cuff and continuous wave Doppler. Blood pressure readings are compared between the upper extremities and ankle arteries. Dividing the "ankle" pressure by the "arm" pressure gives you the ankle-brachial index. An ankle-brachial index below 0.95 is considered abnormal. An ankle-brachial index between 0.8 and 0.5 is consistent with intermittent claudication. An ankle-brachial index less than 0.5 indicates severe disease.

Angiography or MRI assisted angiography may be necessary to determine the extent of the disease. However, these studies are not used to make the initial diagnosis.

"Conservative treatment" is indicated for patients who experience symptoms only upon exertion. In these cases, aggressive lifestyle modification is essential. These include:

• Stop Smoking
  
• Maintain good diabetic control
  
• Maintain good cholesterol levels
  
• Maintain normal blood pressure

In addition to lifestyle modifications, conservative treatment also includes anti-platelet medications (see below), a walking program and medical treatment of symptoms.

Anti-platelet medications

There are three (3) anti-platelet medications available for patients with intermittent claudication: aspirin, Ticlid and Plavix. Anti-platelet medications do more than prevent complications from intermittent claudication. The Antiplatelet Trialists’ Collaboration Study demonstrated that patients with intermittent claudication who were treated with anti-platelet therapy had a 17.8 percent relative reduction in the incidence of heart attacks, stroke and vascular death.

There are two (2) medications approved for the treatment of the symptoms of intermittent claudication: Trental and Pletal.

"Surgical treatment" of intermittent claudication may be necessary with patients whose arteries are blocked in localized areas or who have narrowed lengths of clogged arteries.

Surgical choices for localized blockages include "angioplasty" of the lesion or endarterectomy (replacing a blocked section of the artery).

The surgical procedure for clogged, narrowed lengths of leg arteries is bypass graft surgery.

Clients with a history of intermittent claudication present underwriting concerns for life insurance companies. Most carriers operate on the theory that the younger the client the higher the rating (i.e. clients 39 and younger had double the normal underwriting rating). Complicating factors such as smoking, high cholesterol, diabetes and high blood pressure can result in higher ratings or a declination. Clients with intermittent claudication and coronary artery disease or cerebral vascular disease are in the majority of cases uninsurable for individual coverage.

The following questions will help you screen clients with a history of intermittent claudication:

1) Does the client currently smoke?

Underwriting Comment: Claudication (pain in the leg while walking that is relieved by rest) is caused by hardening of the arteries (atherosclerosis) in the legs. It is essentially the same disease as coronary artery disease (hardening of the arteries of the heart). Factors that contribute to the development of claudication are the same as those that cause coronary artery disease:

• Smoking
  
• Hypertension (high blood pressure)
  
• Hyperlipidemia (high cholesterol levels or high cholesterol/HDL ratios)
  
• Family history of heart or vascular disease
  
• Diabetes
  
• Obesity

Clients with intermittent claudication who continue to smoke represent poor underwriting risks. However, clients with claudication who quit smoking have better medical and underwriting outcomes.

The term peripheral vascular disease refers to other vascular diseases in addition to claudication, which is a disease of the arteries of the legs. Other forms of peripheral vascular disease include carotid disease (primary blood supply to the brain), abdominal aorta disease (primary blood supply to the lower body) and renal artery disease (primary blood supply to the kidneys).


2) When was the client diagnosed with claudication, and how was it treated?

Underwriting Comment: The goal of treatment of claudication is to improve the symptoms and stop the progression of the disease. Medications can help symptoms, but lifestyle changes can successfully treat claudication. These lifestyle changes include stopping smoking, regular exercise, losing weight and a reduction in blood cholesterol. When lifestyle alone is not enough to treat the symptoms or stop the progression, angioplasty of the affected artery or an actual bypass graft around the blocked artery are treatment options. It is important to document the original date of diagnosis and the kind of treatment the client received for their claudication.


3) What medications is the client currently taking?

Underwriting Comment: Clients with claudication normally take an aspirin a day to reduce the chances of developing a blood clot at the blockage site. In addition, they may also take medications for high cholesterol, high blood pressure or diabetes. They may also take medications to reduce the symptoms of claudication (i.e. Trental and Pletal). It is important to document ALL the medications the client is taking.


4) What lifestyle changes has the client made to treat their claudication?

Underwriting Comment: As indicated above, lifestyle changes can be very effective in literally stopping the progression of peripheral vascular disease. It is important to document all the "positive" lifestyle changes the client has adopted to insure the client is given the appropriate "credit" in his or her underwriting assessment.


5) Does the client have a history of coronary artery disease?

Underwriting Comment: Statistics reported in the New England Journal of Medicine demonstrate a high death rate from heart disease among patients with even mild peripheral vascular disease. The study demonstrated that for patients with severe claudication the ten-year mortality for cardiovascular disease was 15 times higher than for persons who had no peripheral vascular disease. Clients who have claudication and coronary artery disease present underwriting problems that may preclude them from offers for individual coverage. It is important to ask all clients with known claudication if they have any history of any form of heart disease.

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