For years I put calf pain in the same mental drawer as a stiff knee: mechanical, local, annoying, nothing to do with the rest of me. You know the ache. It shows up a block into a walk and fades when you stand still, and I’d always read it as age, or being out of shape, or some plumbing issue down in the pipes. I had the geography exactly backwards. So, according to The Lancet, does almost everyone else.
In early October the journal ran an editorial titled Peripheral arterial disease: counting what matters, and it starts by naming the two things most of us assume about peripheral arterial disease (that it is a local disease of the legs, and that it is relatively benign when it causes no symptoms) and calling both of them inaccurate. The American College of Cardiology’s summary of the accompanying series shows why that matters. The epidemiology paper, led by Christian-Alexander Behrendt, reports that advanced PAD carries a five-year mortality of 30 to 50 percent, higher than some cancers and higher than acute heart attack. The condition people wave off as a circulation nuisance kills somewhere between a third and half of its advanced-stage patients within five years.
of patients dead within five years
- Lower bound
- 30
- Upper bound
- 50
It also isn’t rare. Behrendt’s group counts more than 113 million people aged 40 or older worldwide, and the series warns that doctors and policymakers still underestimate how big the problem is, partly because of systemic limits in how the disease gets studied. I was surprised at how much I had underrated it. That surprise explains the editorial’s title: medicine has been counting legs and missing the body.
So wait, why would a narrowed artery behind your knee tell you anything about the vessels feeding your heart? Once I chased that question down, the answer seemed obvious, and it changed how I read the whole series. PAD is atherosclerosis, the same artery-clogging process that fills the coronary and carotid arteries, and it is showing up in the limbs. Plaque sits on artery walls all over the body. When it has narrowed the leg arteries enough to starve the calf of oxygen mid-walk, the ache you feel (doctors call it intermittent claudication) tells you what is happening everywhere your blood travels. The series puts numbers on this: between 46 and 68 percent of PAD patients have polyvascular disease, with plaque already built up in more than one arterial bed. The leg is just where the smoke shows. The fire is in the whole circulatory system.
You can pick up that signal with a blood-pressure cuff. The ankle-brachial index compares systolic pressure at the ankle to pressure in the arm, and a low ankle reading means blood is struggling to get down there. The outcomes paper, led by Jonathan Golledge, reports that a low index, at or below 0.9, doubles the ten-year rates of major coronary events, cardiovascular death, and death from any cause. That’s a few minutes with a cuff, and it can show you that your odds of dying from a heart event are double what they looked like. To be fair, the series says evidence for screening the whole population is still limited, and it points to risk-based screening under the ACC/AHA guideline. I think that’s reasonable. But risk-based screening only helps if someone thinks to check, and “it’s probably just your age” is a very easy thing for a doctor to say.
Treatment is where I got angry, because the most effective option is the one patients can least often get. The management paper, led by Riikka Tulamo, calls supervised exercise therapy, meaning structured and monitored walking programs, one of the most effective treatments for claudication. It is available in only 59 percent of European countries, and just 24 percent of European vascular surgeons say they have access to one. Meanwhile, treatment of the most severe stage, chronic limb-threatening ischemia, varies by up to 86 percent across U.S. centers. A walking program that works is so scarce that most patients will never see one, while what you get at the severe end depends on which center you happen to walk into. Nobody makes money selling a supervised walk. Maybe that’s a coincidence, but if you’ve watched medicine neglect the intervention with no product attached, it’s hard to believe that.
Then there are the patients who never get even the basics. A study from Intermountain Health, presented by Viet T. Le at the American College of Cardiology’s 2025 meeting, followed 7,522 patients diagnosed with symptomatic PAD between 2006 and 2021. Only 29.6 percent of women and 33.5 percent of men received all of the guideline-directed care they qualified for. “Every single person in these groups should have at least received antiplatelet therapy and statin,” Le said. “Instead, only about one in three did.” These are cheap, old, standard drugs, and Le was blunt about the stakes: “We should not be seeing a 50% death rate among these patients.” Golledge’s paper finds the same pattern across sex, race, geography and socioeconomic status: underserved patients are diagnosed later, see specialists less, and are more likely to have advanced disease and amputations.
None of this comes from a fresh randomized trial. It’s reviews, epidemiology, an editorial, and one health system’s conference data. But you don’t need a trial to confirm what these papers describe, because it’s a structural failure, and mainstream vascular medicine is documenting it about itself: a common, systemic and often lethal disease written off as a minor leg complaint, a cheap test that depends on someone remembering to use it, an effective non-drug treatment that most patients can’t get, and basic medications that don’t reach most of the people who need them.
Here’s what I’m doing with it. If I had calf pain that reliably came on with walking and eased with rest, or if I were over 40 with a smoking history or diabetes, I would ask for the ankle-brachial index by name and refuse to let “it’s probably just your age” end the conversation. Whatever the cuff said, I would get evaluated properly and also start walking on purpose, as part of treatment rather than instead of it, because that’s the one piece of PAD care nobody can keep from me.