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Management of Lower Limb Intermittent Claudication

Development of a Care Pathway

  • Section 1: A Global Approach to Vascular Disease
  • Published:
Disease Management & Health Outcomes

Summary

The natural history of lower limb intermittent claudication (LLIC) is relatively benign as regards the development of critical ischaemia and limb loss, but individuals with LLIC have a mortality rate at least double that of an age- and gender-matched population. Management of both the symptom complex and the risk factors is essential, and this has in the UK historically been undertaken by the vascular surgeon and the general practitioner, respectively. An integrated care pathway has been developed with particular reference to recent randomised trials from Oxford and Edinburgh, which have demonstrated that exercise may be, for many claudicants, as effective as angioplasty in improving maximum walking distance over a minimum 2-year follow-up. All risk factors are as effectively treated in primary care as they are in a hospital clinic. Unless critical ischaemia intervenes (an infrequent occurrence), the role of the vascular surgeon is now, arguably, that of a diagnostician.

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References

  1. Integrated care management. The path to success? In: Wilson J, editor. Oxford: Butterworth Heinemann: 1997

  2. Clinical Guidelines: using clinical guidelines to improve patient care within the NHS. 1996: NHS Executive, May

  3. Criqui MH, Fronek A, Barrett-Connor E. The prevalence of peripheral arterial disease in a defined population. Circulation 1985; 71: 510–5

    Article  PubMed  CAS  Google Scholar 

  4. Hale WE, Marks RG, May FE, et al. Epidemiology of intermittent claudication: evaluation of risk factors. Age Ageing 1988; 17: 57–60

    Article  PubMed  CAS  Google Scholar 

  5. Schroll M, Munck O. Estimation of peripheral arteriosclerotic disease by ankle blood pressure measurements in a population study of 60 year old men and women. J Chron Dis 1981; 34: 261–9

    Article  PubMed  CAS  Google Scholar 

  6. Hughson WG, Mann JI, Garrod A. Intermittent claudication: prevalence and risk factors. BMJ 1978; I: 1379–81

    Article  Google Scholar 

  7. Fowkes FGR, Housley E, Cawood EHH, et al. Edinburgh Artery Study: prevalence of asymptomatic and symptomatic peripheral arterial disease in the general population. Int J Epidemiol 1991; 20: 384–92

    Article  PubMed  CAS  Google Scholar 

  8. Kannel WB, Skinner JJ, Schwartz MJ, et al. Intermittent claudication: incidence in the Framingham Study. Circulation 1970; 41: 875–83

    Article  PubMed  CAS  Google Scholar 

  9. Kannel WB, McGhee DL. Update on some epidemiologic features of intermittent claudication: the Framingham Study. J Am Geriatr Soc 1985; 33: 13–8

    PubMed  CAS  Google Scholar 

  10. Leng GC, Fowkes FGR, Lee AJ, et al. Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study. BMJ 1996; 313: 1440–4

    Article  PubMed  CAS  Google Scholar 

  11. Skalkidis Y, Katsouyanni K, Petridou E, et al. Risk factors of peripheral arterial occlusive disease: a case control study in Greece. Int J Epidemiol 1989; 18: 614–8

    Article  PubMed  CAS  Google Scholar 

  12. Reunanen A, Takkunen H, Aromaa A. Prevalence of intermittent claudication and its effect on mortality. Acta Med Scand 1982; 211: 249–56

    Article  PubMed  CAS  Google Scholar 

  13. Fowkes FGR, Housley E, Riemersma RA, et al. Smoking, lipids, glucose intolerance and blood pressure as risk factors for peripheral atherosclerosis compared with ischemic heart disease in the Edinburgh Artery Study. Am J Epidemiol 1992; 135: 331–40

    PubMed  CAS  Google Scholar 

  14. Pomrehn P, Duncan B, Weissfeld L, et al. The association of dyslipoproteinemia with symptoms and signs of peripheral arterial disease. The Lipid Research Clinics Program Prevalence Study. Circulation 1986; 73 (1 Pt 2): I100–7

    Article  PubMed  CAS  Google Scholar 

  15. Haimovici H. Patterns of arteriosclerotic lesions of the lower extremity. Arch Surg 1967; 95: 918–22

    Article  PubMed  CAS  Google Scholar 

  16. Hell KM, Balzereit A, Diebold U, et al. Importance of blood viscoelasticity in arteriosclerosis. Angiology 1989; 40: 539–46

    Article  PubMed  CAS  Google Scholar 

  17. Ernst EE, Matrai A. Intermittent claudication, exercise and blood rheology. Circulation 1987; 76: 1110–4

    Article  PubMed  CAS  Google Scholar 

  18. Hertzer NR, Beven EG, Young JR, et al. Coronary artery disease in peripheral vascular patients — a classification of 1000 coronary angiograms and results of surgical management. Ann Surg 1984; 199: 223–33

    Article  PubMed  CAS  Google Scholar 

  19. Dormandy JA, Murray GD. The fate of the claudicant — a prospective study of 1969 claudicants. Eur J Vasc Surg 1991; 5: 131–3

    Article  PubMed  CAS  Google Scholar 

  20. Davey Smith G, Shipley MJ, Rose G. Intermittent claudication, heart disease risk factors, and mortality. Circulation 1990; 82: 1925–31

    Article  Google Scholar 

  21. O’Riordain DS, O’Donnell JA. Realistic expectations for the patient with intermittent claudication. Br J Surg 1991; 78: 861–3

    Article  PubMed  Google Scholar 

  22. Peabody NC, Kannel WB, McNamara PM. Intermittent claudication. Arch Surg 1974; 109: 693–7

    Article  PubMed  CAS  Google Scholar 

  23. Dormandy JA, Ray S. The natural history of peripheral arterial disease. In: Tooke JE, Lowe GDO, editors. A textbook of vascular medicine. London: Arnold, 1996: 162–75

    Google Scholar 

  24. Jelnes R, Gaardsting O, Hougaard Jenson K, et al. Fate in intermittent claudication: outcome and risk factors. BMJ 1986; 293: 1137–40

    Article  PubMed  CAS  Google Scholar 

  25. Chapuis PH, Dent OF, Fisher R, et al. A multivariate analysis of clinical and pathological variants on prognosis after resection of large bowel cancer. Br J Surg 1985; 72: 698–702

    Article  PubMed  CAS  Google Scholar 

  26. Schadt DC, Hines EA, Jurgens JL, et al. Chronic atherosclerotic occlusion of the femoral artery. JAMA 1961; 175: 937–400

    Article  PubMed  CAS  Google Scholar 

  27. Begg TB, Richards RL. The prognosis of intermittent claudication. Scott Med J 1962; 7: 341–52

    PubMed  CAS  Google Scholar 

  28. Peto R, Lopez AD, Boreham J, et al. Mortality from smoking worldwide. In: Doll R, Crofton J, editors. Tobacco and health. Br Med Bull 1996; 52(1): 12–21

    CAS  Google Scholar 

  29. Dormandy JA, Hoare E, Colley J, et al. Clinical, haemodynamic rheological and biochemical findings in 126 patients with intermittent claudication. BMJ 1973; 4: 576–81

    Article  PubMed  CAS  Google Scholar 

  30. Coffman JD, Javett SL. Blood flow in the human calf during tobacco smoking. Circulation 1963; 28: 932–7

    Article  PubMed  CAS  Google Scholar 

  31. Phillips AN, Wannamethee SG, Walker M, et al. Life expectancy in men who have never smoked and those who have smoked continuously: 15 year follow up of large cohort of middle aged men. BMJ 1996; 313: 907–8

    Article  PubMed  CAS  Google Scholar 

  32. Jonason T, Bergstrom R. Cessation of smoking in patients with intermittent claudication. Effects on the risk of peripheral vascular complications, myocardial infarction and mortality. Acta Med Scand 1987; 221: 253–60

    CAS  Google Scholar 

  33. Myers KA, King RB, Scott DF, et al. The effect of smoking on the late patency of arterial reconstruction in the legs. Br J Surg 1978; 65: 267–71

    Article  PubMed  CAS  Google Scholar 

  34. Austoker J, Sanders D, Fowler G. Smoking and cancer: smoking cessation. BMJ 1994; 308: 1478–82

    Article  PubMed  CAS  Google Scholar 

  35. Tang JL, Law M, Wald N. How effective is nicotine replacement therapy in helping people to stop smoking? BMJ 1994; 308: 21–25

  36. Kottke TE, Battista RN, DeFriese GH, et al. Attributes of successful smoking interventions in medical practices: a meta-analysis of 39 controlled trials. JAMA 1988; 259: 2883–9

    Article  PubMed  CAS  Google Scholar 

  37. Smith I, Franks PJ, Greenhalgh RM, et al. The influence of smoking cessation and hypertriglyceridaemia on the progression of peripheral arterial disease and the onset of critical ischaemia. Eur J Vasc Endovasc Surg 1996; 11: 402–8

    Article  PubMed  CAS  Google Scholar 

  38. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease. The Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344: 1383–9

    Google Scholar 

  39. Shepherd J, Cobbe SM, Ford I, et al., for The West of Scotland Coronary Prevention Study Group. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. N Engl J Med 1995; 333: 1301–7

    Article  PubMed  CAS  Google Scholar 

  40. Betteridge J, Bilous R, Cobbe S, et al. Identification and management of patients with raised serum lipids in general practice. Br J Cardiol 1996; 3 Suppl. I: S20–5

    Google Scholar 

  41. Krolewski AS, Warram JH, Rand LI, et al. Epidemiologic approach to the etiology of type I diabetes and its complications. N Engl J Med 1987; 317: 1390–8

    Article  PubMed  CAS  Google Scholar 

  42. Krolewski AS, Warram JH. Epidemiology of diabetes mellitus In: Marble A, Krall LP, Bradley RF, et al., editors. Joslins diabetes mellitus. 12th ed. Philadelphia: Lea and Febiger, 1985: 12–42

    Google Scholar 

  43. Robertson WB, Strong JP. Atherosclerosis in persons with hypertension and diabetes mellitus. Lab Invest 1968; 18: 538–51

    PubMed  CAS  Google Scholar 

  44. Zdanov VS, Vihert AM. Atherosclerosis and diabetes mellitus. Bull WHO 1976; 53: 547–53

    PubMed  CAS  Google Scholar 

  45. Sternby NH. Atherosclerosis in a defined population. An autopsy survey in Malmo, Sweden. Acta Pathol Microbiol Scand 1968; Suppl. 194: 5

    Google Scholar 

  46. Stout RW. Diabetes and atherosclerosis: the role in insulin. Diabetologia 1979; 167: 141–50

    Article  Google Scholar 

  47. Brownlea M, Cerami A, Vlassara H. Advanced glycolysation end products in tissue in the biochemical basis of diabetic complications. N Engl J Med 1988; 318: 1315–21

    Article  Google Scholar 

  48. Diabetes Drafting Group. Prevalence of large vessel and small vessel disease in diabetic patients from 14 centres. The World Health Organization Multinational Study of Vascular Disease in Diabetes. Diabetologica 1985; 28: 615–40

    Google Scholar 

  49. Beach KW, Bedford GR, Bergelin RO, et al. Progression of lower extremity arterial occlusive disease in type II diabetes mellitus. Diabetes Care 1988; 11: 464–72

    Article  PubMed  CAS  Google Scholar 

  50. Bild DE, Selby JV, Sinnock P, et al. Lower extremity amputation in people with diabetes. Epidemiology and prevention. Diabetes Care 1989; 12: 24–31

    CAS  Google Scholar 

  51. Nelson RG, Gohdes DM, Everhart JE, et al. Lower extremity amputations in NIDDM. 12yr follow up in Pima Indians. Diabetes Care 1988; 11:8–16

    Article  PubMed  CAS  Google Scholar 

  52. Edmonds ME. Experience in a multi disciplinary diabetic foot clinic. In: Connor H, Boulton AJM, Ward JD, editors. The foot in diabetes. Chichester: John Wiley & Sons Ltd, 1987: 121–33

    Google Scholar 

  53. Assal JP, Muhlhauser I, Pernet A, et al. Patient education as the basis for diabetic care in clinical practice and research. Diabetologica 1985; 28: 602–13

    Article  CAS  Google Scholar 

  54. Martin MJ, Hulley SB, Browner WS, et al. Serum cholesterol, blood pressure, and mortality: implications from a cohort of 361,662 men. Lancet 1986; III: 933–6

    Article  Google Scholar 

  55. Collins R, Peto R, McMahon S, et al. Blood pressure, stroke, and coronary heart disease. Part 2. Short-term reductions in blood pressure: overview of randomized drug trials in their epidemiological context. Lancet 1990; 335: 827–38

    CAS  Google Scholar 

  56. European Atherosclerosis Society Task Force for Prevention of Coronary Heart Disease. Prevention of coronary heart disease: scientific background and new clinical guidelines. Nutr Metabol Cardiovasc Dis 1992; 2: 113–56

    Google Scholar 

  57. Department of Health. The health of the nation: a strategy for health in England. London: HMSO, 1992

    Google Scholar 

  58. MRC Working Party. MRC trial of treatment of mild hypertension: principal results. BMJ 1985; 291: 97–104

    Article  Google Scholar 

  59. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the systolic hypertension in the elderly program (SHEP). JAMA 1991; 265: 3255–64

    Google Scholar 

  60. Dahlof B, Lindholm LH, Hansson L, et al. Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension). Lancet 1991; 338: 1281–5

    Article  PubMed  CAS  Google Scholar 

  61. MRC Working Party. Medical Research Council trial of treatment of hypertension in older adults: principal results. BMJ 1992; 304: 405–12

    Article  Google Scholar 

  62. Elliott H. Best buys for the formulary. Costs Options Hypertens 1996; 5: 15–7

    Google Scholar 

  63. Merrin PK, Elkeles RS. Anti-hypertensive and lipid-lowering therapy in diabetes. Hosp Update 1994; 20(1): 36–46

    Google Scholar 

  64. Jackson R, Barham P, Bills J, et al. Management of raised blood pressure in New Zealand: a discussion document. BMJ 1993; 307: 107–10

    Article  PubMed  CAS  Google Scholar 

  65. Sever P, Beevers G, Bulpitt C, et al. Management guidelines in essential hypertension: report of the second working party of the British Hypertension Society. BMJ 1993; 306: 983–7

    Article  PubMed  CAS  Google Scholar 

  66. Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. The fifth report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNCV). Arch Intern Med 1993; 153: 154–83

    Article  Google Scholar 

  67. Subcommittee of WHO/ISH Mild Hypertension Liaison Committee. Summary of 1993 World Health Organization — International Society of Hypertension guidelines for the management of mild hypertension. BMJ 1993; 307: 1541–6

    Article  Google Scholar 

  68. Meyers MG, Carruthers SG, Leenen FHH, et al. Recommendations from the Canadian Hypertension Society consensus conference on the pharmacologic treatment of hypertension. Can Med Assoc J 1989; 140: 1141–6

    Google Scholar 

  69. Fahey TP, Peters TJ. What constitutes controlled hypertension? Patient based comparison of hypertension guidelines. BMJ 1996; 313: 93–6

    Article  PubMed  CAS  Google Scholar 

  70. Khaira HS, Hanger R, Shearman CP. Quality of life in patients with intermittent claudication. Eur J Vasc Endovasc Surg 1996: 65–9

  71. Hunt SM, McEwen J, McKenna SP, et al. Subjective health of patients with peripheral vascular disease. Practitioner 1982; 226: 133–6

    PubMed  CAS  Google Scholar 

  72. Arfvidsson B, Karlsson J, Dahllof AG, et al. The impact of intermittent claudication on quality of life evaluated by the sickness impact profile technique. Eur J Clin Invest 1993; 23: 741–5

    Article  PubMed  CAS  Google Scholar 

  73. Johnson BF, Singh S, Evans L, et al. A prospective study of the effect of limb threatening ischaemia and its surgical treatment on the quality of life. Eur J Vasc Endovasc Surg 1997; 13: 306–11

    Article  PubMed  CAS  Google Scholar 

  74. Beattie DK, Golledge J, Greenhalgh RM, et al. Quality of life assessment in vascular disease towards a consensus. Eur J Vasc Endovasc Surg 1997; 13: 9–13

    Article  PubMed  CAS  Google Scholar 

  75. Housley E. Treating claudication in five words. BMJ 1988; 296: 1483–4

    Article  PubMed  CAS  Google Scholar 

  76. Idstron JP, Elander A, Soussi B, et al. Influence of endurance training on glucose transport and uptake in rat skeletal muscle. Am J Physiol 1986; 251: H903–6

    Google Scholar 

  77. Gollnich PD, Armstrong RB, Sambert CW, et al. Enzyme activity and fibre composition in skeletal muscle of untrained and trained men. J Appl Physiol 1972; 33: 312–6

    Google Scholar 

  78. Larsen OA, Larsen NA. Effect of daily muscular exercise in patients with intermittent claudication. Lancet 1966; II: 1093–6

    Article  Google Scholar 

  79. Ekroth R, Datilloff AG, Gundevale B, et al. Physical training of patients with intermittent claudication. Indications method and results. Surgery 1978; 84: 640–43

    CAS  Google Scholar 

  80. Perkins JMT, Collin J, Creasy TS, et al. Exercise training versus angioplasty for stable claudication. Long and medium term results of a prospective randomised trial. Eur J Vasc Endovasc Surg 1996; 11(4): 409–13

    Article  PubMed  CAS  Google Scholar 

  81. Creasy TS, McMillan PJ, Fletcher EWL, et al. Is percutaneous transluminal angioplasty better then exercise for claudication? — preliminary results from a prospective randomised trial. Eur J Vasc Surg 1990; 4: 135–40

    Article  PubMed  CAS  Google Scholar 

  82. Gardner AW, Poehlman ET. Exercise rehabilitation programs for the treatment of claudication pain — a meta-analysis. JAMA 1995; 274(12): 975–80

    Article  PubMed  CAS  Google Scholar 

  83. Antiplatelet Triallists’ Collaboration. Collaborative overview of randomised trials of antiplatelet therapy. I. Prevention of death, myocardial infarction and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ 1994; 308: 81–106

    Article  Google Scholar 

  84. Hirsh J, Dalen JE, Fuster V, et al. Aspirin and other platelet active drugs: the relationship between dose, effectiveness and side-effects. Chest 1995; 108 (4 Suppl.): S247–57

    Article  Google Scholar 

  85. Arean JC, Blanchard J, Boissel JP, et al. Multicentre double blind study of ticlopidine in the treatment of intermittent claudication and the prevention of its complications. Angiology 1988; 39: 802–11

    Article  Google Scholar 

  86. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996; 348: 1329–39

    Article  Google Scholar 

  87. Barradell LB, Brogden RN. Oral naftidrofuryl. A review of its pharmacology and therapeutic use in the management of peripheral occlusive arterial disease. Drugs Aging 1996; 8(4): 299–322

    CAS  Google Scholar 

  88. Heidrich H, Allenberg J, Cachovan M, et al. Guidelines for therapeutic studies on peripheral arterial occlusive disease in Fontaine stages II-IV. Vasa 1992; 21(4): 333–43

    PubMed  CAS  Google Scholar 

  89. Trubestein G, Böhme H, Heidrich H, et al. Naftidrofuryl in chronic arterial disease. Results of a controlled multicentre study. Angiology 1981; 35: 701–8

    Google Scholar 

  90. Adhoute G, Andreassian B, Buccalon H, et al. Treatment of stage II chronic arterial disease of the lower limbs with the serotonergic antagonist naftidrofuryl: results after six months of a controlled multicentre study. J Cardiovasc Pharmacol 1990; 16 Suppl. 3: 75–80

    Google Scholar 

  91. Adhoute G, Bacourt F, Barrai M, et al. Naftidrofuryl in chronic arterial disease. Results of a six month controlled multicentre study using naftidrofuryl tablets 200mg. Angiology 1986 Mar; 37 (3 Pt 1): 160–7

    Article  PubMed  CAS  Google Scholar 

  92. Kriessmann A, Neiss A. Clinical effectiveness of naftidrofuryl in intermittent claudication. Vasa Suppl 1988; 24: 27–32

    PubMed  CAS  Google Scholar 

  93. Lowe GDU. Drugs in cerebral and peripheral arterial disease. BMJ 1990; 300: 524–8

    Article  PubMed  CAS  Google Scholar 

  94. Whyman MR, Ruckley CV, Fowkes FGR. Angioplasty for mild intermittent claudication. Br J Surg 1991; 78: 643–5

    Article  PubMed  CAS  Google Scholar 

  95. Pell JP, Whyman MR, Fowkes FGR, et al. Trends in vascular surgery since the introduction of percutaneous transluminal angioplasty. Br J Surg 1994; 81: 832–5

    Article  PubMed  CAS  Google Scholar 

  96. Belli A-M, Cumberland DC, Knox AM, et al. The complication rate of percutaneous peripheral balloon angioplasty. Clin Radiol 1990; 41: 380–3

    Article  PubMed  CAS  Google Scholar 

  97. Johnston WK, Rae M, Hogg-Johnston SA, et al. 5 year results of a prospective study of percutaneous transluminal angioplasty. Ann Surg 1987; 206: 403–13

    Article  PubMed  CAS  Google Scholar 

  98. Toogood GJ, Torrie EPH, Magee TR, et al. Early experience with stenting of iliac occlusions. Br J Surg 1997; 84 Suppl. 1: 44

    Google Scholar 

  99. Chetter IC, Spark JI, Turton EPL, et al. Percutaneous transluminal angioplasty for intermittent claudication: evidence on which to base the medicine. Eur Soc Vasc Surg 11th Annual Meeting, Lisbon, September 1997

  100. Szilagyi DE, Elliott Jr JP, Smith RF, et al. A thirty year survey of the reconstructive surgical treatment of aorto-iliac occlusive disease. J Vasc Surg 1986; 3: 421–36

    PubMed  CAS  Google Scholar 

  101. Veith FJ, Gupta S, Daly V. Management of early and late thrombosis of expanded polytetrafluorethylene (PTFE) femoropopliteal bypass grafts — favourable prognosis with appropriate re-operation. Surgery 1980; 87: 581–7

    PubMed  CAS  Google Scholar 

  102. Moody AP, Gould DA, Harris PL. Vein graft surveillance improves patency in femoro-popliteal bypass. Eur J Vasc Surg 1990; 4: 117–21

    Article  PubMed  CAS  Google Scholar 

  103. Raptis S, Miller JH. Influence of a vein cuff on polytetrafluoroethylene grafts for primary femoropopliteal bypass. Br J Surg 1995; 82: 487–91

    Article  PubMed  CAS  Google Scholar 

  104. Whyman MR, Fowkes FGR, Kerracher EMG, et al. Is intermittent claudication improved by percutaneous transluminal angioplasty? A randomized controlled trial. Br J Surg 1997; 84 Suppl. 1: 1

    Google Scholar 

  105. Forum on Angiology. The challenge of change: new strategies for risk reduction in the claudicating patient. Dublin, April 1997

  106. Family Heart Study Group. Randomised controlled trial evaluating cardiovascular screening and intervention in general practice: principal results of British Family Heart Study. BMJ 1994; 308: 313–20

    Article  Google Scholar 

  107. Imperial Cancer Research Fund OXCHECK Study Group. Effectiveness of health checks conducted by nurses in primary care: final results of the OXCHECK Study. BMJ 1995; 310: 1099–104

    Article  Google Scholar 

  108. Lindholm LH, Ekbom T, Dash C, et al., on behalf of the CELL Study Group. The impact of health care advice given in primary care on cardiovascular risk. BMJ 1995; 310: 1105–9

    Article  PubMed  CAS  Google Scholar 

  109. Cupples ME, McKnight A. Randomised controlled trial of health promotion in general practice for patients at high cardiovascular risk. BMJ 1994; 309: 993–6

    Article  PubMed  CAS  Google Scholar 

  110. McGhee SM, Mclnnes GT, Hedley AJ, et al. Coordinating and standardizing long-term care: evaluation of the west of Scotland shared-care scheme for hypertension. Br J Gen Prac 1994; 44: 441–5

    CAS  Google Scholar 

  111. Field K, Thorogood M, Silagy C, et al. Strategies for reducing coronary risk factors in primary care: which is most cost effective? BMJ 1995; 310: 1109–

    Google Scholar 

  112. Toon PD. Health checks in general practice. BMJ 1995; 310: 1083–4

    Article  PubMed  CAS  Google Scholar 

  113. Raine R, Streetly A, Davis AM. Variation in local policies and guidelines for cholesterol management: national survey. BMJ 1996; 313: 1368–9

    Article  PubMed  CAS  Google Scholar 

  114. Consumers Association. Management of hyperlipidaemia. Drug Ther Bull 1996; 34(12): 89–93

    Article  Google Scholar 

  115. Sacks FM, Pfeffer MA, Moye LA, et al., for the Cholesterol and Recurrent Events Trial Investigators. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med 1996; 335: 1001–9

    Article  PubMed  CAS  Google Scholar 

  116. Neil HAW, Roe L, Godlee RJP, et al. Randomised trial of lipid lowering dietary advice in general practice: the effects on serum lipids, lipoproteins, and antioxidants. BMJ 1995; 310: 569–73

    Article  PubMed  CAS  Google Scholar 

  117. Pharoah PDP, Hollingsworth W. Cost effectiveness of lowering cholesterol concentration with statins in patients with and without pre-existing coronary heart disease: life table method applied to health authority population. BMJ 1996; 312: 1443–8

    Article  PubMed  CAS  Google Scholar 

  118. Jamrozik K, Vessey M, Fowler G, et al. Controlled trial of three different anti-smoking interventions in general practice. BMJ 1984; 288: 1499–503

    Article  PubMed  CAS  Google Scholar 

  119. Richmond RL, Austin A, Webster IW. Three year evaluation of a programme by general practitioners to help patients to stop smoking. BMJ 1986; 292: 803–6

    Article  PubMed  CAS  Google Scholar 

  120. Imperial Cancer Research Fund General Practice Research Group. Effectiveness of a nicotine patch in helping people stop smoking: results of a randomised trial in general practice. Br Med J 1993; 306: 1304–8

    Article  Google Scholar 

  121. Russell MAH, Stapleton JA, Feyerabend C, et al. Targeting heavy smokers in general practice: randomised controlled trial of transdermal nicotine patches. BMJ 1993; 306: 1308–12

    Article  PubMed  CAS  Google Scholar 

  122. Grimshaw JN, Russell IT. Achieving health gain through clinical guidelines. II. Ensuring that guidelines change clinical practice. Qual Health Care 1994; 3: 45–52

    CAS  Google Scholar 

  123. Thomson R, Lavender M, Madhok R. How to ensure that guidelines are effective. BMJ 1995; 311: 237–42

    Article  PubMed  CAS  Google Scholar 

  124. Promoting clinical effectiveness. A framework for action in and through the NHS. NHS Executive, 1996J, editor. Oxford: Butterworth Heinemann: 1997

    Google Scholar 

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  1. Consultant General and Vascular Surgeon, Countess of Chester Health Park, Liverpool Road, Chester, CH2 1UL, England

    Paul Edwards

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Edwards, P. Management of Lower Limb Intermittent Claudication. Dis-Manage-Health-Outcomes 2 (Suppl 1), 18–29 (1997). https://doi.org/10.2165/00115677-199700021-00005

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