Clinical Cardiologists works on diagnosis and treatment of pathologies of the human circulatory system. Lamentably, in many occasions we focus our efforts on the main organ (heart) and lose concentration on other sites of the arterial tree: Central Nervous System circulation and inferior members system.
Those regions are assumed as primary sector by Neurologists as well peripheral circulation is primary sector for surgeons.
Both regions received just secondary benefits of heart treatments (risk factors control) without a direct intervention.
The gold of these dissertation is make to cardiologists discover a cardiovascular system (different from cardiac), the peripheral vascular tree that feeds legs and which is affected by medical treatment diseases in most of it evolution, require surgery for revascularization or amputation just on few and severe cases. In United States there are 8 to 12 millions of patients with arterial peripheral disease (with 4.3% of prevalence on 40's and 14.5% after 70's) . 4 to 5 millions of them show intermittent claudicating, by year, 150.000 are amputated with high perisurgical mortality rate due to co-morbidities [2,3].
In no surgical treatment we will focus on therapeutic physical exercise and risk factors modifications (cardiovascular rehabilitation) to prevent serious circulatory events (Primary prevention) or attenuate active risks factors and avoid new presentations (Secondary prevention).
Peripheral Vascular pathologies Schema of inferior members :
We must have priority in the diagnosis of chronic peripheral arterial occlusion, an important generalized arteriosclerosis indicator.
This pathology presents as etiology the Arteriosclerosis Risk Factors such as arterial hypertension, sedentary, dyslipidemias, smoking, Diabetes Mellitus, Obesity, Male sex, elevated homocisteinury, premature arteriosclerosis familiar disease.
The symptoms and signs, we could find are:
- Intermittent claudication: pain, cramps; hip, thigh, and legs fatigue at walking, which starts at the same exercise level and relief when patient rests 5 minutes). In women, generates higher physical dysfunction than men [4,5].
- Erectile dysfunction or sexual impotence.
- Dry and scaly skin.
- Deficient nails and hair growth.
- Ulcers, necrosis and gangrene.
- No edemas.
- Absent or reduced beets.
- Foot: dependent rubor, pallor on elevation (1 at 2 minutes).
Based on the symptoms and alterations on the physical exam, there are many classifications of ischemic arterial vascular disease. The most famous is Fontaine Classification:
Other classification, more used by Vascular Surgeons is the published by Ruther Ford and col. 
Non invasive diagnostics
- Ankle-brachial Index (ABI). The ABI is defined as the ratio of the systolic blood pressure in the ankle divided by the systolic blood pressure at arm. The ABI is measured by placing the patient in a supine position for 5 min. Systolic blood pressure is measured in both arms, and the higher value is used as the denominator of the ABI. Systolic blood pressure is then measured in dorsalis pedis and posterior tibial arteries) by placing blood pressure cuff just above the ankle helped by a Doppler detector. The higher value is the numerator of the ABI in each limb. Depending on the measurements we may determinate:
Normal 0.91 to 1.3.
Mild Obstruction 0.7 to 0.9.
Moderate Obstruction 0.4 to 0.69.
Severe Obstruction < 0.4
Poorly compressible ankle artery (calcification) >1.30.
In the cases of doubt diagnosis, is possible to sensitize the measurement performing a graded treadmill (looking for inferior members muscle fatigue or intensive pain with intermittent claudicating) and compare the values before and after the effort (if it is detected a fall between the measurements of ankle pressures >20mmHg the diagnosis is Intermittent Claudicating.
Ankle pressures values < 55 mmHg in non diabetics and < 70 mmHg in diabetics indicates the patient has important difficulty for soft tissues cicatrisation. Many studies demonstrates that patients a symptomatic with ABI index < 0.90 has increasing cardiovascular morbid-mortality too [8,9]. Associations between ABI and function were stronger than associations between leg symptoms and function .
- Magnetic Resonance Angiogram (which is progressive replacing invasive methods but with high costs)
- Ultrasonography and Doppler with precise visualization of arteries and to analyze the wave shapes of the beets (which correlated with arterial pressure indicate diagnosis of the grade and severity of the disease, [11,3]; it is useful for to value therapeutic procedures with stents or revascularization.
- Transcutaneus measurement of partial Oxygen pressure. Values < 30 mmHg are associated with bad evolution of affected zone.
Invasives diagnotics method
Selective Arterial Catheterization Angiography and radiologic contrast liquid with or without image by digital subtraction is essential to perform revascularization or amputation surgery.
All clinical valuations and complementary methods are performed to be able to precise diagnosis and treat in correct way depending on the disease evolution.
Ten years ago, Jeffrey Weitz and col. published data about changes on time of the population with chronic peripheral arterial disease . Many Scientifics publications adapted schemes to represent this data:
By the certainty of which pathologies affects the inferior members cardiovascular system, and their evolution, there are two reasons for the importance of early diagnosis of peripheral vascular disease:
First, to identify high risk myocardial infarction patients or acute stroke, and then reduce their morbimortality (comparing those patients with subjects without disease, they have mortality risk due coronary disease of 6.5, general cardiovascular general mortality 5.9, and mortality for all causes 3.1  and half of them presents cerebral or coronary disease symptoms .
Second, to eliminate the symptoms that cause lost of different grades of function, improving life quality and lack the possibility of amputation. 
Those explanations justify the planning and application of Strategies of Prevention and Treatment.
Modifications of the Cardiovascular Risk Factors (CRF)
- Complete quit of Tobacco Habits (patients who reduce the number of daily cigarettes, just compliance for short term, until emotional disturbs presents.) It may be necessary psychological therapy and fundamentally, generate an appropriate medical-patient relationship, explaining about the risks at short and long term due to tobacco consume. It is a big hard task for both, but may always be done. A smoker (men or women) has double or triple possibilities to develop intermittent claudicating . By the quit of the smoking habit they will have better pain evolution on time  and long term permeability venous shunts [17,18].
- Adequate Diabetes Control, in conjugation with anterior item, are the most important risk factors to develop peripheral vascular disease. In diabetes disease, vascular lesions are localized on femoral, popliteal and tibial's artery, those are diffuse and distal, associated to neuropathy in which, is less intermittent claudicating; meanwhile, smoking and hypertension are associated to proximal disease, affecting abdominal aorta, iliac an femoral, with focal lesions, without neuropathy and hard presentation of intermittent claudication. Diabetes specific treatment based on tree pillars: pharmacological therapy (oral hypoglycemic and/or insulin) + diet + medically controlled physical activity.
- Combat obesity and excessive weight which integrates the Metabolic Syndrome and potenciates other risk factors, increasing sedentary tendency, higher joint exigencies and hard affectation of lymphatic and venous system.
- Arterial pressure maintenance between normal limits through low salt consume, physical activity and pharmacological therapy, if necessary.
- Normalize Lipid panel with diet, exercise and pharmacological therapy.
- Antiplatelet Therapy with aspirin, clopidrogel, ticlopidine, cilostazol, etc.
- Control of other possible risk factors: elevated levels of Reactive C Protein, Fibrinogen, homocisteyn, and plasmatic viscosity.
- Stress management from cardiologist, and if necessary, psychotherapy.
- Cardiovascular Rehabilitation (CR) in all patients with CRF for development of peripheral vascular disease (and obviously cardiogenic).
Reviewing the Evolution of Peripheral Vascular Disease scheme, the addition of Intermittent Claudicating patients and the patients which worsening on time, 89% of them are on medical treatment and rehabilitation, 11% of patient which goes on surgery may receive an important treatment complement trough exercise.
It is demonstrated the important role of cardiologist, specifically the ones specialized on CR.
The implementation of Physical Therapy on most of the patients who need CR is difficult because: a) low medical derivation rate, from specialists without own service on their center or no utilization of centers which count with it (mainly on women, old adults, whom needs to many exclamation of benefits). b) Inadequate medical cover for this services and c) important geographic distance to capacitated medical centers with this service [19,20]. For those reasons, this therapeutic resource keeps sub estimated and consistently non indicated to patient population. The estimation is that 10 to 20% of myocardial infarct or revascularization surgery patients participate on this therapy .
The low therapeutic application for medicals, do not take advantage from media communication about the benefits of CR a physical activity as valuable tool.
This situation is more discourage for peripheral vascular disease  even the existence of international normative recommending the therapy .
How and when will we perform CR in those patients?
When we detect modifiable riskier patients to perform CR, we must to value the evolution of the case, evaluate old diagnosis methods of peripheral disease, look for circulatory pathologic manifestations from central nervous system or peripheral stroke sequel and cardiopathy evidence.
On other way, must detect born, muscle or articulations affectation from vertebral column, hips, legs, taking care with the altered sensibility threshold of diabetic patients. It may be important the consideration of other area specialist intervention [22. Revascularizated patients have many possibilities to participate of CR, than Diabetic insulin-dependant patients or with low ABI index .
We should determinate effort capacity and pain threshold by an exercise testing to set up the work level we'll indicate. Treadmill is more convenient than bicycle ergometer. To determine the initiation of mild, moderate or severe pain must develop protocols with soft levels increasing (1.0 mile/hour, increasing velocity every 2 minutes  or by Weber Protocol). In cases with important peripheral neuropathy, laying bike is indicated to lack patient falls or lesions. When both methods are lack to been developed, arm exercise test will be performed, at least, to determine myocardial energetic consume. We must evaluate existence of myocardial ischemia, arrhythmia (continuous ECG monitory) and Arterial Pressure performance on effort.
On rehabilitation session, will be indicated tree minutes level effort on treadmill which generate mild to moderate pain. Starting with 30 minutes session, then, gradually increase duration to 50 minutes. Strength training is less effective than treadmill walking exercise . CR developed at office is effective than the one developed at home [27,28] with more improving on peripheral circulation and neuromuscular coordination [29,32]. On diabetic neuropathy patient is recommended to perform swimming, bike, sitting and lying exercises, without weight transportation instead slide strip, long walks or steps . Diabetic patients had worst legs function .
Why to do CR on those patients? Since 1966, scientific bibliography shows benefits of this therapy. Exercise rehabilitation increased treadmill distance walked to onset of claudicating by 134% and to maximal claudicating by 77 %, walking economy by 12 %, 6-minute walk distance by 12 % and maximal calf blood flow by 30 % after 6 month  . Four weeks later appear first results  and after 12 weeks of intervention [34,35]. Other authors shows good results [36-41,61,62], even, on patient without claudicating  The improvement on patient functional status allow him to develop high energy request exercises, with social reinsertion and improving of auto esteem. Those patients who not receive therapy experiment diminution of physical activity, stability and legs circulation; as was demonstrated by Gardner and col. .
Which changes improves the functional status of patients on CR? It is wrong to believe that ischemic regions must experiment surgical revascularization therapy. This concept just reduces necrosis develop and amputation on severe cases (7% of patients). The improvement will be reached trough medical treatment and exercise . Exercise optimizes the energy demand for oxygen extraction from arteries in legs.
It is demonstrated abnormal mitochondrial metabolism at legs skeletal muscles in peripheral vascular disease patients  which improves with exercises  accumulation of intermediates of oxidative metabolism (acylcarnitines)  fall in oxygen saturation and longer recovery times in comparison with normal person [49,50]. Exercise improves endothelial dependant vasodilatation and blood circulation on legs muscles , Type I and II fiber, capillary density, reduction on IIb fiber and better muscular resistance . After 6 month, fibrinolysis improves [53,43]. Venous and lymphatic disease improve with exercise too.
Cilostazol: primary and secondary antiplatelet by phosphodisterase III with thrombosys and platelet activation inhibition. Reduce smooth muscle proliferation, increases legs artery circulation flow, and reduces triglycerides and LDL, vasodilatation by lack calcium.
Generate a significant Absolute Claudicating Distance and Initial Claudicating increasing at 100mg/12h dose. Most frequently adverse event is: headache, diarrhea, peripheral edema and palpitations . Contraindicated in grave congestive cardiac insufficiency.
Pentofiline: approved in 1984 by FDA to intermittent claudicating treatment. Improves plasticity of red cells, reduce fibrinogen, and platelet aggregation. The improvement of the claudicating beginnings and absolute values. Otherwise, clinics benefits are not defined .
Propinil-l-carnitine: it is not clear the mechanism for the improvement on walking distance. Dose 2g/day .
Angiogenic Growth Factors: have shown preliminary success in patients with resting pain and ischemic ulcers .
Angioplastic therapy and by pass surgery 
- Incapacitating claudicating that interfere on patient work and life style.
- Limb salvage in persons with limb-threatening ischemia as manifested by rest pain, no healing ulcers, and/or infection or gangrene.
- Vasculogenic impotence.
- Tissue loss has progressed beyond the point of salvage.
- Surgery is too risky because for patient general status.
- Short life expectancy is very low.
- Functional limitations diminish the benefit of limb salvage.
Treatment costs and life quality
Disease severity determines cost treatment. Holler and col.  showed that annual costs for medical assistance on Fontaine IIa status disease patient is 1792 euros, IIb status 2551 euros, status III 4356 euros and status IV 6225 euros. The costs of the in-hospital treatment 44.4%, drug 33.4%, care costs 6.7%, rehabilitation 3.6%, adjuvant 1.9% and indirect costs 9.67%. Other authors showed in-hospital CR short program with adequate cost – benefit rate. .
The expected gain in effectiveness achieved with peripheral By Pass surgery is small compared with the costs. Angioplasty performed whenever feasible was more effective than was exercise alone, and the cost-effectiveness ratio was within the generally accepted range .
On peripheral vascular disease patients, CR helps to control CRF, because slow down severe disease evolution, patient develop high life autonomy, increases efforts level for claudicating pain. Otherwise, is economic and reduces other intervention necessity. Low percentage patients need surgery or pharmacological therapy.
In conclusion, physician should apply this therapeutic.
- Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999-2000.Circulation..2004;110(6):738-43.
- Treat-Jacobson D, Walsh ME. Treating Patients with peripheral arterial disease and claudication. J Vasc Nurs. 2003 ; 21(1):5-14; quiz 15-6.
- Halperin JL. Evaluation of patients with peripheral vascular disease. Thrombosis Research. 2002;106 (6)303-311
- Oka RK, Szuba A, Giacomini JC, Cooke JP. Gender differences in perception of PAD: a pilot study. Vasc Med..2003;8(2):89-94.
- Gardner AW. Sex differences in claudication pain in subjects with peripheral arterial disease. Med Sci Sports Exerc..2002;34(11):1695-8.
- Carter SA. The relationship of distal systolic pressures to healing of skin lesions in limbs with arterial occlusive disease, with special reference to diabetes mellitus. Scand J Clin Lab Invest.. 1973; 128:239-243.
- Ruther Ford RB, Baker JD, Ernst C, Et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg..1997;26:517-538.
- Newman AB, Sutton-Tyrrell K, Vogt MT, et al. Morbidity and mortality in hypertensive adults with a low anke/arm blood pressure index. JAMA..1993;270:487-489.
- Vogt MT, Cauley JA, Newman AB, et al. Decreased ankle/arm blood pressure index and mortality in elderly women. JAMA..1993;270:465-469.
- McDermott MM, Greenland P, Liu K, Guralnik JM, Celic L, Criqui Mh, Chan C, Martin Gj, Schneider J, Pearce WH, Taylor LM, Clark E. The ankle braquial index in associated with leg function and physical activity: the Walking and Leg Circulation Study. Ann Intern Med.. 2003;136(12):873-83.
- Rutherford RB. Lowenstein DH, Klein MF. Combining segmental systolic pressures and plethysmography to diagnose arterial disease of the leg. Am J Surg..1979;38:211-18.
- Weitz JI, Byrne J, Clagent G, Farkouh ME, Porter JM, Sacckett DL, Strandness DE, Taylor LM. Diagnosis and Treatment of Chronic Arterial Insufficiency of the Lower Extremities: A Critical Review. Circulation..94:3026-3049.
- Norman PE, Eikelboom JW, Hankey GJ. Peripheral arterial disease: prognostic significance and prevention of atherothrombotic complications. Med J Aust..2004;181(3):150-4.
- Brevetti G, Oliva G, Silvestro A, Scopacasa F, Chiariello M. Peripheral Arteriopaty and Cardiovascular Events (PACE) Study Group. Atherosclerosis..2004;175(1):131-8.
- Knnel WB, McGee DL, Update on some epidemiologic features of intermittent claudication: The Framingham study. J am Geriatr Soc..1985;33:13-18.
- Jonason T, Ringquist I, Factors of prognostic importance for subsequent rest pain in patients with intermittent claudication. Acta Med Scand..1985;218:27-33.
- Myers KA, King RB, Scott DF, et al. The effect of smoking on the late patency of arterial reconstructions in the legs. Br J Surg..1978;65:267-271.
- Herring M, Gardner A, Glover J, Seeding human arterial prostheses with mechanically derived endothelium. The detrimental effect of smoking. J Vasc Surg..1984:1:279-289.
- Ades PA. Cardiac rehabilitation and secondary prevention of coronary Herat disease. N Engl J Med. 2001;345:892-902.
- Allen JK, Scott LB, Stewart KJ, Young DR. Disparities in women´s referral to and enrollment in outpatient cardiac rehabilitation. J Gen Intern Med.. 2004;19:747-753.
- Regensteiner JG. Exercise rehabilitation for the patient with intermittent claudication: a highly effective yet underutilized treatment. Curr Drug Targets Cardiovasc Haematol Disord..204;4(3):233-9.
- Position Statement American Diabetes Association. Original Article. Preventive Foot Care in People With Diabetes. Diabetes Care..2003;26:S78-S79.
- Stewart HJ, Hiatt WR, Regensteiner JG, Hirsch AT. Exercise training for claudication. N Engl J Med.2002;347:1941-1951.
- Katzel LI, Sorkin J, Bradham D, Garner AW. Comorbilities and the entry of patients with peripheral arterial disease into an exercise rehabilitation program. J Cardiopulm Rehabil..2000;20(3):165-71.
- Riebe D, Patterson RB, Braun CM. Comparison of two progressive treadmill tests in patients with peripheral arterial disease. Vasc Med..2001;6(4):215-21.
- Hiatt WR. Wolfel EE, Meier RH, Regensteiner JG. Superiority of treadmill walking exercise versus strength training for patients with peripheral arterial disease. Implications for the mechanism of the training response. Circulation..1994;90(4):1866-74.
- Cheetham DR, Burgess L, Ellis M, Williams A, Greenhalgh RM, Davies AH. Does Supervised exercise offer adjuvant benefit over exercise advise alone for the treatment of intermittent claudication ? A randomized trial. Eur J Vasc Endovasc Surg..2004;27(1):17-23.
- Savage P, Ricci MA, Lynn M, Garner A, Knight S, Brochu M, Ades P. Effects of home versus supervised exercise for patient with intermittent claudication. J Cardiopulm Rehabil..2001;21(3):152-7.
- Alpert JS, Larsen OA, Lassen NA. Exercise an intermittent claudication. Blood flow in the calf muscle during walking studied by the xenon-133 clearance method. Circulation..1969;39:353-359.
- Position Statement. American Diabetes Association. Original Article. Physical Activity/Exercise and Diabettes Mellitus. Diabetes Care..2003; 26:S73-S77.
- Dolan NC, Liu K, Criqui MH, Greenland P, Guralnik JM, Chan C, Schneider JR, Mandapat AL, Martin G, McDermott MM. Peripheral artery disease, diabetes, and reduced lower extremity functioning. Diabetes Care..2002;25(1):113-20.
- Gardner AW, Katzel LI, Sorkin JD, Killewich LA, Ryan A, Flinn WR, Goldberg AP. Improved functional outcomes following exercise rehabilitation in patients with intermittent claudication. J Gerontol A Biol Sci Med Eci..2000;55(10):M570-7.
- Ambrostti M, Salerno M, Tramarin R, Pedretti RF. Efficacy of a short-course intensive rehabilitation program in patients with moderate-to-severe intermittent claudication. Ital Heart J..2002;3(8):467-72.
- Gartenmann Ch, Kinrchberger I, Herzing M, Baumgartner I, Saner H, Mahler F, Meyer K. Effects of exercise training program on functional capacity and quality of life in patients with peripheral arterial occlusive disease. Evaluation of a pilot project. Vasa..2002;31(1):29-34.
- Tsai JC, Chan P, Wang CH, Jeng C, Hsieh MH, Kao PF, Chen YJ, Liu JC. The effects of exercise training on walking function and perception of health status in elderly patients with peripheral arterial occlusive disease. J Intern Med..2002:252(5):448-55.
- Gardner AW, Katzel LI, Sorkin JD, Bradham DD, Hochberg MC, Flinn WR, Goldberg AP. Exercise rehabilitation improves functional outcomes and peripheral circulation in patients with intermittent claudication: a randomized controlled trial. J Am Geriatr Soc..2001;49(6):755-62.
- Regensteiner JG, Steiner JF, Hiatt WR. Exercise training improves functional status in patients with peripheral arterial disease. J Vasc Surg..1996;23(1):104-15.
- Fowler B, Jamrozik K, Norman P, Allen Y, Wilkinson E. Improving maximum walking distance in early peripheral arterial disease: randomized controlled trial. Aust J Physiother..2002,48(4):269-75.
- Gardner AW, Katzel LI, Sorkin JD, Goldberg AP. Effects of log-term exercise rehabilitation on claudication distances in patients with peripheral arterial disease: a randomized controlled trial. J Cardiopulm Rehabil.. 2002;22(3):199-200.
- Gibellini R, Fanello M, Bardile AF, Salerno M, Aloi T. Exercise training in intermittent claudication. Int Angiol.. 2000;19(1):8-13.
- Carlon R, Morlino T, Maiolino P. Beneficial effects of exercise beyond the pain threshold in intermittent claudication. Ital Heart J..2003;4(2):113-20.
- McDermott MM, Tiukinhoy S, Greenland P, Liu K, Pearce WH, Guralnik JM, Unterreiner S, Gluckman TJ, Criqui MH, Ferrucci L. A pilot exercise intervention to improve lower extremity functioning in peripheral arterial disease unaccompanied by intermittent claudication. J Cardiopulm Rehabil.. 2004;24(3):187-96.
- Womack CJ, Ivey FM, Garner AW, Macko RF. Fibrinolytic response to acute exercise in patients with peripheral arterial disease. Med Sci Sport Exerc..2001;33(2):214-9.
- Gardner AW, Montgomery PS, Killewich LA. Natural history of physical function in older men with intermittent claudication. J Vasc Surg.. 2004;40(1):73-8.
- Donnelly R. Assessment and management of intermittent claudication: importance of secondary prevention. Int J Clin Pract Suppl.. 2001;(119):2-9.
- Pipinos II, Sharov VG, Shepard AD, Anagnostopoulos PV, Katsamouris A, Todor A, Filis KA, Abbah HN. Abnormal mitochondrial respiration in skeletal muscle in patients with peripheral arterial disease. J Vasc Surg.. 2003;38(4):827-32.
- Hou XY, Geen S, Askew CD, Barker G, Geen A, Walker PJ. Skeletal muscle mitochondrial ATP production rate and walking performance in peripheral arterial disease. Clin Physiol Funct Imaging..2002:22(3):226-32.}
- Hiatt WR. Carnitine and peripheral arterial disease. Ann N Y Acad Sci..2004;1033:92-8.
- Comerota AJ, Throm RC, Kelly P, Jaff M. Tissue (muscle) oxygen saturation (StO2): a new measure of symptomatic lower-extremity arterial disease. J Vasc Surg.. 2003;38(4):724-9.
- Komiyama T, Onozuka A, Miyata T, Shigematsu H. Oxygen saturation measurement of calf muscle during exercise in intermittent claudication. Eur J Vasc Endovasc Surg..2002;23(5):388-92.
- Brendle DC, Joseph LJ, Corretti Mc, Gardner Aw, Katzel LI. Effects of exercise rehabilitation on endothelial reactivity in older patients with peripheral arterial disease. Am J Cardiol.. 2001;87(3):324-9.
- McGuigan MR, Bronks R, Newton RU, Sharman MJ, Graham JC, Cody DV, Kraemer WJ. Resistance training in patients with peripheral arterial disease: effects on myosin isoforms, fiber type distribution, and capillary supply to skeletal muscle. Gerontol A Biol Sci Med Sci.. 2001;56(7):B302-10.
- Killewich LA, Macko RF, Montgomery PS, Wiley LA, Gardner AW. Exercise training enhances endogenous fibrinolysis in peripheral arterial disease. J Vasc Surg. 2004;40(4):741-5.
- Thompson, PD, Zimet, R, Forbes WP, Zhang P. Meta-analysis of results from eight randomized, placebo-controlled trial on the effect of cilotazol on patients with intermittent claudication. Am J Cardiol 2002;90:1314-1319.
- Girolami B, Bernardini E, Prins MH et al. Treatment of intermittent claudication with physical training, smoking cessation, pentoxifylline, or nafronyl: a meta-analysis. Arch Intern Med.. 1999;159:3333-345.
- Brevetti G, Perna S, Sabba C, el al. Propionyl-L-carnitine in intermittent claudication. Double-blind, placebo-controlled, dose titration, multicenter study.. J Am Coll Cardiol..1995;26:1411-1416.
- Aronow WS. Management of peripheral arterial disease. Cardiol Rev..2005;13(2):61-8.
- Holler D; Claes C; von der Schulenburg JM. Treatment cost and quality of life of patients with peripheral arterial occlusive disease—the German perspective. Vasa.2004;33(3):145-53.
- Ambrostti M, Salerno M, Boni S, Daniele G, Tramarin R, Pedretti RF. Economic evaluation of a short-course intensive rehabilitation program in patients with intermittent claudication. Int Angiol..2004:23(2);108-13.
- de Vries SO, Visser K, de Vries JA, Wong JB, Donaldson MC, Hunink MG. Intermittent claudication: cost – effectiveness of revascularization versus exercise therapy. Radiology..2002;222(1):25-36.
- Izquierdo-Porrera AM, Gardner AW, Powell CC, Katzel LI. Effects of exercise rehabilitation on cardiovascular risk factors in older patients with peripheral arterial occlusive disease. Vasc Surg.. 2000;31(4):670-7.
- Garner AW, Katzel LI, Sorkin JD, Bradham DD, Hochberg MC, Flinn WR, Goldberg AP. Exercise rehabilitation improves functional outcomes and peripheral circulation in patients with intermittent claudication: a randomized controlled trial. J Am Geriatr Soc. 2001;49(6):755-62.
- Schainfeld RM. Management of peripheral arterial and intermittent claudication. J Am Board Fam Pract.. 2001;14(6):443-50.
|- Especialista en Cardiología, y en Medicina del Deporte.
- Vicepresidente del Comité de Cardiología del Ejercicio, Federación Argentina de Cardiologia, Buenos Aires, Argentina.
- Obtención del título de Especialista en Cardiología, Consejo Médico de la Provincia de Córdoba, Córdoba, Argentina.
- Instructor Docente en la Residencia de Cardiología, Clínica Privada Sucre, Instituto del Corazón S.R.L., Córdoba, Argentina.
- Médico Cardiólogo a Cargo del Departamento de Ergometría y Rehabilitación Cardiovascular del Instituto del Corazón S.R.L., Córdoba, Argentina.
- Médico de Planta Permanente Encargado del Área de Clínica Médica en el Servicio de Urgencias Médico-Quirúrgicas del Hospital San Roque, Córdoba, Argentina.
- Obtención del Título de Especialista en Medicina de Deporte, Universidad Nacional de Córdoba, Córdoba, Argentina.
- Médico Integrante del Servicio de Medicina del Deporte del Hospital de Niños de la Santísima Trinidad de la Ciudad de Córdoba, Córdoba, Argentina.