The most appropriate treatment is the addition of cilostazol. Cilostazol is an oral phosphodiesterase-3 inhibitor that has demonstrated increases in pain-free walking and overall walking distance in patients with claudication in randomized clinical trials. Cilostazol is contraindicated in patients with heart failure or a left ventricular ejection fraction below 40%. This contraindication exists because cilostazol has a similar pharmacologic action to the inotropic drugs milrinone and amrinone, which demonstrated increased mortality rates with long-term use in patients with heart failure. In the absence of heart failure, a therapeutic trial of cilostazol should be considered in all patients with lifestyle-limiting claudication.

Antihypertensive therapy is recommended for reduction of cardiovascular events in patients with peripheral arterial disease (PAD). Although concern has been raised in the past regarding use of β-blockers for treatment of hypertension in patients with PAD because of the possibility of loss of β-receptor–mediated vasodilation causing worsening claudication, this has not been supported by study data. Therefore, β-blockers may be used in patients with PAD for blood pressure control. However, this patient's hypertension is well controlled, and β-blockade is not indicated as therapy for claudication symptoms.

Clopidogrel or another thienopyridine should be added to aspirin therapy in all patients following an acute coronary syndrome and in those undergoing coronary stent placement. However, there is no benefit in adding clopidogrel to aspirin in patients with PAD for treatment of the vascular occlusion or reducing the risk of cardiovascular events.

In the Warfarin Antiplatelet Vascular Evaluation (WAVE) trial among patients with PAD, the combination of an oral anticoagulant and antiplatelet therapy was not more effective than antiplatelet therapy alone in preventing major cardiovascular complications and was associated with an increase in life-threatening bleeding.