Considerations on a Case of Myocardial Infarction and Leriche Syndrome

We know from international registry data that approximately 5% of patients (pts) have both ischaemic heart disease (CAD) and obstructive peripheral artery disease (PAD). After adjusting for risk factors, this association was found to be associated with a doubling of mortality and a 60% increase in the risk of major adverse cardiac events (MACE). In the context of polyvascular disease, PAD therefore identifies a subgroup of pts who are at very high risk and require specific secondary prevention strategies: e.g. new antiplatelet and antithrombotic regimens, as well as more stringent lipid targets. This paper presents a case of polyvascular disease that was diagnosed and managed in an outpatient cardiac rehabilitation setting. A 46–year–old man who was a heavy smoker (26 pack–year) and had a family history of CAD, dyslipidaemia (LDL cholesterol 132 mg/dl), and impaired glucose tolerance (HbA1c: 6.3%) was referred to us following a recent anterior STEMI. The pt underwent prompt reperfusion therapy by means of primary angioplasty and implantation of two DES at the IVA–diagonal bifurcation. Upon admission to Cardiac Rehabilitation (CR) the pt was haemodynamically stable and asymptomatic for angina, with mild impairment of left ventricular systolic function (EF 50%). However, his ability to undertake aerobic training was limited by significant muscle weakness in his lower limbs, with a walking range of 300 m. Physical examination revealed that the arterial pulses in both lower limbs were reduced. On Doppler ultrasound, there was monophasic flow along the entire arterial axis bilaterally up to the distal level. A CT angiogram was requested due to suspected aortoiliac pathology. This led to a diagnosis of Leriche syndrome. Six months after STEMI, the aortoiliac pathology was corrected via an endovascular procedure. The pt managed to stop smoking. Dysglycaemia was corrected through nutritional measures. The target level of LDL cholesterol of ‹40 mg/dl was achieved. The pt was advised to follow a walking training programme. PAD does not always present with the typical symptom of intermittent claudication; sometimes it presents with non–specific symptoms in the lower limbs. It is easier to diagnose PAD in CR, where pts are supervised during physical reconditioning programmes. CAD pts must be carefully checked for PAD as clinically evident atherosclerosis in multiple arterial beds, is increasingly identified as a particularly malignant cardiovascular disease