Question

A 63-year-old man comes to the emergency department due to left leg pain. The patient typically has pain in both legs after walking a couple of blocks, but several hours ago, severe left leg pain suddenly developed while he was resting. He reports numbness in the left leg, and he is also experiencing intermittent palpitations. Medical history includes hypertension and hyperlipidemia. The patient has smoked a pack of cigarettes daily for 45 years. Blood pressure is 130/80 mm Hg, and pulses 116/min and irregular. On examination, hair is sparse on both legs. Distal pulses are absent on the left and diminished on the right. Sensation to light touch is decreased on the dorsum of the left foot and leg, and ankle dorsiflexion is weaker on the left. Which of the following is the best first step in management of this patient?

A. Ankle-brachial index

B. CT angiography of the lower extremities

C. Intravenous heparin infusion

D. Surgical bypass grafting

E. Transthoracic echocardiography

Answer: C. Intravenous heparin infusion

🧠 Intravenous heparin stops thrombus progression and buys time for intervention.

🧠 Triggers in the Scenario

Atrial fibrillation (irregular pulse) → Thrombus formation in left atrium

Smoking, hypertension, hyperlipidemia → Chronic vascular damage

⬇️

Atrial fibrillation → Blood stasis in left atrium → Thrombus formation

⬇️
Thrombus dislodges (embolism) → Travels to lower extremity artery (e.g., femoral artery)

⬇️

Hesitant?

Understandable.

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