If grandpa complains of chest pain we call an ambulance, but if he complains of leg pain while walking to the mailbox, we tell him he’s getting old. Cardiac chest pain, also called angina, typically results from blockage in the coronary vessels that feed the heart muscle. A certain type of leg pain, called claudication, often results from a similar blockage but in the arteries that feed muscles below the knees. The problem is that we are conditioned to act quickly when there are signs of a heart attack but awareness of the same issue in the legs is sorely lacking. Lower extremity peripheral artery disease is a common health occurrence that is too often missed, resulting in avoidable amputations and high costs.

Peripheral artery disease is when the arteries of the legs become blocked with plaque, the result of atherosclerosis. High cholesterol, high blood pressure, diabetes, smoking, obesity and inactivity, especially when combined with inflammation, are risk factors for PAD, heart attack and stroke. PAD is found in 30 percent to 40 percent of diabetic patients over age 50 and in 10 percent to 20 percent of the general population over 50.

Symptoms of significant PAD include:

» Leg pain with exercise.

» Foot or toe wounds that heal poorly.

» Foot or toes with bluish or dusky appearance.

» A difference in temperature between the two feet.

A simple screening test often done in the office of your family doctor called ABI compares blood pressure readings between the arms and ankles. If pressure in the ankles is less than in the arms, it may be an indication for further testing. Between one-quarter and one-half of patients with positive tests are asymptomatic.

About 6.8 percent of the elderly Medicare population receives care for lower extremity PAD, which is about 1 in 3 patients who likely have the disease. Unfortunately, 88 percent of Medicare expenditures for PAD were for inpatient care, according to one study. In contrast, hospital costs across the board were just 31 percent of total health expenditures.

At present, Medicare and Medicaid pay about 75 percent of the treatment bill for PAD. This is especially problematic considering that Medicare and Medicaid expenditures are currently 5.5 percent of gross domestic product and are expected to reach as much as 13 percent of GDP by 2050.

We can do better. Lifestyle prevention including diet, exercise and weight management is the best way to control risk factors and prevent this disease. Early detection through ABI testing in the primary care office is also of paramount importance and lends itself to outpatient treatment rather than inpatient care, including amputation. Early testing for PAD also can identify coronary disease as an estimated 50 percent of patients with PAD have coronary disease. In both cases, the earlier the disease is detected and treated, the better for the patient and all concerned.

Interventional radiologists and some vascular or cardiothoracic surgeons have the ability to shoot dye into the arteries of the legs, identify the exact location of blockages and, where possible, place stents to restore a healthy blood flow to the tissues. This treatment can be done on an outpatient basis.

Instead, primary amputation is the first and only treatment for one-quarter to one-third of all Medicare patients with severe blockage. Sixty percent of these amputations occur without first attempting to clear the blockage with the use of a stent. Forty-five percent to 73 percent of these cases did not even have a dye study to see if the blockage was treatable. It has been calculated that the bill for major amputations in the U.S. exceeds $10 billion per year.

Solving deficiencies in the identification of lower extremity PAD begins with enhanced awareness of the condition and includes focused prevention, early detection and prompt outpatient treatment when blockage is found. Many amputations are avoidable. Let’s save feet and money.

Ira “Kawika” Zunin, M.D., MPH, MBA, is a practicing physician. He is medical director of Manakai O Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.