DR DALEY: Mrs D is a 52-year-old mother of
2 children who has progressive pain in her right leg while walking. She lives
in Boston and has her health care insurance through Massachusetts Medicaid
and Medicare.
Mrs D has had insulin-dependent diabetes mellitus for 29 years, complicated
by peripheral neuropathy, retinopathy, and nephropathy with nephrotic range
proteinuria. She has had 1 atrophic kidney since childhood and has required
chronic hemodialysis since June 1997. She has had hypertension since age 16
years. The patient has long-standing coronary artery disease with a history
of 2 myocardial infarctions. She had percutaneous transluminal angioplasty
for chronic angina without relief, followed by coronary artery bypass graft
for triple vessel disease, including significant stenosis of the left anterior
descending artery, in June 1997. She had an episode of congestive heart failure
in 1995 with an ejection fraction of 0.25. She has hyperlipidemia and has
tried several lipid-lowering agents, but has been unable to tolerate them
because of adverse effects. Most recently she discontinued treatment with
gemfibrozil because of gastrointestinal side effects. She has an 80 pack-year
history of smoking and stopped smoking in the summer of 1997. Family history
is significant for her father who died of coronary artery disease at age 53
years and for her mother who had diabetes mellitus, coronary artery disease,
and renal failure requiring dialysis.