It is with great honor that I have been asked by the publishers of NSIDE magazine to be the new medical editor. The previous editor, Dr. Max Garoutte, should be applauded for his wonderful and meaningful contributions. Hopefully, I will maintain his standard of excellence.

I am a board certified cardiologist working in north San Antonio. I see patients with a broad spectrum of cardiac issues. This includes patients with chest pain, palpitations and rhythm problems, high blood pressure and cholesterol, and diseases affecting the arteries of the brain, kidneys, and lower extremities.

I specialize in general cardiology and electrophysiology, interventional cardiology and electrophysiology, nuclear cardiology, and endovascular medicine. I am one of the few cardiologists in the country who specializes in all five areas of cardiology noted above. My first article will be dedicated to one of these areas: endovascular medicine.

If you happen to be up between 1 and 4 in the morning and watch TNT, there have been a series of public announcements on peripheral arterial disease or PAD. PAD affects 8-12 million new patients annually and is second only to coronary artery disease in prevalence of atherosclerotic diseases in the United States. Cerebral vascular disease affects 4.8 million and is ranked third.

The prevalence of peripheral artery disease increases with age and can be as high as 19 percent by the age of 70. If you have been diagnosed with peripheral artery disease, you may be at a two-time increased risk for coronary artery disease (a myocardial infarction), or cerebral vascular disease (stroke). The importance of this cannot be over-emphasized.

Risk factors for peripheral artery disease include diabetes, smoking, a history of coronary artery disease, elevated cholesterol or decreased HDL, hypertension, sedentary lifestyle, obesity, male gender, and increased age. Patients with the above risk factors generally should be screened and asked several questions:

1) Do you ever have any discomfort or aching in the muscles of your legs when you walk that is relieved by rest?

2) Do your legs ever feel fatigued or heavy when walking or active?

3) Do you ever need to stop and rest when walking or have difficulty keeping up with others?

4) Do your feet or toes bother you at night?

5) Do you experience any visual or speech disturbances?

6) Do you ever experience numbness, paralysis, dizziness, or loss of consciousness (syncope)?

7) Have you had difficulty controlling your blood pressure?

8) Has your physician noticed that your kidney function has been deteriorating.

The first four questions specifically deal with arterial diseases involving the lower extremities, while questions five and six involve the arteries supplying the brain, the carotid arteries. Questions seven and eight relate to the arteries supplying the kidney, called the renal arteries. There are many medical offices, as well as outpatient imaging services that screen for all of these areas, as well as testing for abdominal aortic aneurysms.

Approximately 30 percent of all patients who present to my office complain of pain with walking relieved with rest; also known as claudication. Significant problems, however, occur with patients who have disease of the lower extremities, but are asymptomatic. They rarely have any complaints or symptoms. This can occur in up to 50 percent of the patients presenting to the office with peripheral arterial disease. This group especially needs to be taken seriously. Therefore, it is important for physicians to keep in mind those risk factors mentioned above and perform screening.

One study called the Partner Study suggested that screening should occur in any patients with the following: 1) exertional leg pain, 2) patients older than 50 years of age or ol der along with a history of diabetes, smoking, or coronary artery disease, and 3) all patients older than 70 years of age or older. The problem is that a good proportion of the patients mentioned above may be asymptomatic and some insurance carriers may not pay for routine screening even with the above aforementioned risk factors.

As there are multiple tests to screen for coronary artery disease, there is also a magnitude of tests to screen for peripheral arterial disease. This includes 1) Arterial Doppler Ultrasound, 2) CAT scans and MRAs, 3) PVR with segmental pressures, and 4) Determination of the ankle/brachial indices (also known as the ABI). The simplest of these tests is the ABI. The ABI can easily be performed in your doctor’s office. It requires measuring the systolic blood pressure in both the arms and taking the higher pressure of the two and taking the systolic pressure in each of the lower extremities.

A ratio is performed. The systolic pressure in the limb is placed in numerator, and the higher systolic pressure in the arms is placed in the denominator. Normal ABIs should be approximately 1.0. An ABI of .7 to .9 is consistent with evidence for mild obstruction, while an ABI of less than 0.5 is considered severe obstruction.

I generally prefer to perform an ABI with and without exercise. Finally, it is important to note the seriousness of this problem. If the diagnosis is not made early, this could result in possible significant functional loss or loss of limb. It is currently estimated that the cost including a leg prosthesis plus rehabilitation after amputation is somewhere in the area of $300,000 to $400,000. Early detection and treatment, on the other hand, can reduce this cost to $15,000 to $20,000.

Previously, in the United States, these vascular procedures were performed by vascular surgeons and involved major surgery. Currently, the procedures are being performed by endovascular specialists, which may include interventional cardiologists or radiologists, as well as vascular surgeons. The technique involves the same techniques that cardiologists have been using to unclog heart arteries for many years, specifically balloons and stents.

There have been a plethora of new devices that have hit the U.S. markets to treat other types of lesions. These include 1) newer specialized balloons called cutting balloons, 2) atherectomy devices, which can shave out material inside the artery, and 3) devices that even pass through a 100 percent occluded arteries. The process of what types of cases are better served with an endovascular approach over a surgical approach remains unclear.

What can you do if you have peripheral artery disease?

1) If you smoke set a quit date and ask for help to succeed,

2) Lower your blood pressure to less than 140/90 mmHg or less than 130/80 mmHg if you have diabetes or chronic kidney disease,

3) Lower your LDL, bad cholesterol, to less than 80 mg/dl,

4) If you have diabetes manage your glucose to an A1C less than 7 percent and practice proper foot care,

5) Use anti-platelet medications such as aspirin or Clopidogrel to reduce your risk for heart attack and stroke,

6) Exercise appropriately; there are supervised PAD rehabilitation programs presently available. Do this at least 35 minutes a day and at least 3 times per week. Gradually increase your time, distance, and endurance.

7) Ask your doctor about Cilostazol, which may reduce symptoms.

Therefore, if you or anyone you know has any of the symptoms or risk factors mentioned above, please consult your physician and consider undergoing screening.