Nearly 1 in 3 Black adults may develop PAD; disparities in care increase amputation risk

Statement Highlights:

• Nearly 1 in 3 Black adults may develop peripheral artery disease (PAD), compared to about 1 in 5 Hispanic or white adults. If amputation is necessary for treatment, Black, Hispanic and American Indian adults experience lower survival rates and worse quality of life after amputation compared to white adults.
• Multiple social, economic and health variables contribute to disparities by sex, race and ethnicity in the development, diagnosis and treatment of PAD.
• Opportunities to address disparities include greater focus on prevention in health care systems, increasing cultural competency and diversity among the physician workforce and public health efforts to raise awareness in affected communities.
• Implementing routine preventive strategies, such as regular blood glucose testing, ankle blood pressure monitoring and foot exams for high-risk individuals, may decrease the risk of PAD complications and improve outcomes, particularly among people from diverse racial and ethnic groups.

Newswise — DALLAS, June 15, 2023 —Affordable, regular testing could aid in diminishing inequalities and healthcare expenses for individuals with peripheral artery disease (PAD), as per a recent scientific declaration by the American Heart Association, released today in the organization's leading peer-reviewed publication Circulation.

The fresh scientific statement, titled "Disparities in Peripheral Artery Disease," assesses recent research, delineates racial and ethnic discrepancies in PAD diagnosis and treatment, and presents prospective measures to lessen inequalities and enhance health parity among PAD patients. Earlier investigations have revealed that PAD and its ramifications disproportionately affect Black, American Indian, and Hispanic populations. These demographic cohorts encounter elevated rates of PAD and encounter more severe PAD-related consequences, including disability, depression, coronary artery disease, cerebrovascular disease, and/or limb amputation.

PAD is the constriction of arteries that transport blood to the extremities, frequently resulting in reduced blood flow to the legs. It occurs due to the accumulation of fatty plaque in the arteries, causing discomfort, cramping, or weakness in the legs and feet during physical activity. Roughly 1 out of 10 individuals with PAD may develop chronic limb-threatening ischemia, where they experience pain even at rest, elevating the risk of limb amputation and cardiovascular disease-related mortality. Furthermore, individuals with both PAD and Type 2 diabetes have a higher likelihood of complications, including amputation, in comparison to those without Type 2 diabetes. The prevalence of PAD exceeds 12 million individuals in the United States and reaches 200 million people worldwide, with a majority of PAD patients aged 40 and above.

The declaration recommends regular, cost-effective preventive screening and surveillance for individuals with PAD, encompassing hemoglobin A1c testing (a gauge of average blood glucose over three months), ankle-brachial index measurements (a comparative assessment of blood pressure at the ankle versus the arm to monitor blood circulation), and, for individuals with Type 2 diabetes, foot examinations to detect ulcerations and neuropathy.

"This incapacitating condition carries grave consequences, such as significant limb amputation, which often leads to diminished quality of life, heightened disability, and imposes social, economic, and financial burdens on individuals, their families, and the healthcare system," stated Carlos Mena-Hurtado, M.D., a member of the writing group for the statement. Dr. Mena-Hurtado serves as an associate professor of cardiology and the director of vascular medicine at Yale New Haven Hospital and Yale University in New Haven, Connecticut. "High-risk patients should receive regular, low-cost preventive interventions. By averting complications before they arise, we can potentially enhance quality of life and reduce long-term healthcare expenses for individuals with PAD."

Some of the disparities identified in the statement include:

• Nearly 1 in 3 Black adults may develop PAD, compared to about 1 in 5 Hispanic or white adults.
• When seeking medical care, Black adults are more likely to have more advanced PAD and are more likely to undergo leg or foot amputation in comparison to peers who are white adults.
• Compared to white adults, Black, Hispanic and American Indian adults experience lower survival rates and worse quality of life after amputation. People in these demographic groups are also less likely to use a prosthesis to regain the ability to walk and more likely to live in a nursing home.
• People from underrepresented racial and ethnic groups also have an increased risk of death after amputation, with the rate of death within five years ranging from 45%–60%, depending on the location of the amputation.
• Limited access to health care resources may play a role in differences in outcomes for patients with PAD. Underrepresented, rural and low-income adults are at greater risk of being uninsured and are more likely to seek care at a more advanced stage of the disease compared with white, urban and higher-income adults, which increases the risk for amputation.

Mena-Hurtado further emphasized, "Even when accounting for conventional cardiovascular risk factors, we were taken aback to discover the enduringly higher prevalence of PAD among Black adults. However, we now understand that social determinants of health, such as access to nourishing food, neighborhoods conducive to physical activity, and structural disparities, exert a profound influence on an individual's health status."

Disparities in Risk Factors for PAD

The statement highlights smoking as the foremost risk factor for PAD. It reveals that individuals of American Indian and Alaska Native heritage exhibit higher smoking rates compared to other racial and ethnic groups. While smoking rates have decreased across the United States as a whole, the decline has been comparatively slower among Black and American Indian adults.

Additional risk factors for PAD encompass Type 2 diabetes, high blood pressure, high cholesterol, and obesity. It is worth noting that Black and Hispanic individuals in the United States exhibit higher rates of obesity in comparison to white adults. Moreover, among individuals with PAD, Black adults have elevated rates of Type 2 diabetes, high blood pressure, and chronic obstructive pulmonary disease (COPD) when compared to their white counterparts.

Disparities in vascular health may also play a role in the elevated rates of PAD among Black adults. Social determinants of health have been associated with changes in blood vessel function, accelerated vascular aging, and increased stiffness of blood vessels, all of which contribute to an augmented risk of PAD. Numerous studies have indicated that Black adults are more prone to experience accelerated vascular aging, reduced endothelial function, heightened arterial stiffness, and elevated biomarkers of systemic inflammation. These factors are closely linked to an increased susceptibility to cardiovascular disease.

Potential Solutions to Reduce Disparities

The statement suggests opportunities to reduce disparities in PAD care from three perspectives:

• a system-wide approach that integrates PAD screening into routine care;
• improving cultural competence and increasing diversity of clinicians and physicians; and
• improving community education and support programs.

The writing team proposes that the growing progress in telehealth consultations and remote patient surveillance could aid in widening the reach of regular and preventive healthcare. Widespread adoption of telehealth and remote monitoring may contribute to lowering the disproportionately elevated rate of amputations nationwide, particularly among individuals from various racial and ethnic backgrounds.

Community health endeavors targeting the enhancement of public awareness and understanding of PAD could also enhance patient results. For instance, innovative methods to provide healthcare and promote awareness among Black men, like screening and follow-up programs conducted in barbershops, are mentioned as an illustration. Research has indicated that community-centered care and support initiatives effectively reduce blood pressure and increase PAD awareness.

Ceasing smoking, enhancing dietary habits, and engaging in exercise therapy are pivotal in diminishing cardiovascular risk, mortality, and amputation rates among individuals with PAD. Interventions that enhance accessibility to nourishing foods and consider diverse cultural eating habits can aid in curtailing hospital admissions and healthcare expenses. Instances of such interventions encompass collaborating with food banks and establishing community gardens.

In individuals with diagnosed PAD, the administration of medications to control blood pressure, lower cholesterol levels, and inhibit blood clot formation may be contemplated to diminish the likelihood of heart attack, stroke, amputation, and cardiovascular mortality. Certain regions in the United States, particularly among Black, Hispanic, and American Indian communities, have shown a tendency to provide lower rates of surgical revascularization procedures, such as lower extremity arterial bypass, which restore blood flow in obstructed arteries. Enhancing access to these procedures and ensuring adequate post-operative care could aid in reducing disparities.

Mena-Hurtado emphasizes the significance of healthcare professionals comprehending the discrepancies in PAD prevalence and outcomes to deliver suitable, evidence-based care and bridge the treatment gaps within this diverse patient population. Health care systems should strive to optimize cost-effective interventions at every stage to address these disparities effectively.

The PAD National Action Plan, developed collaboratively by the American Heart Association and 25 other organizations, aims to enhance public awareness and comprehension of PAD, prevent complications, overcome health barriers, and enhance the quality of life for individuals living with this condition. This initiative underscores the importance of a comprehensive and coordinated approach to address the challenges posed by PAD and promote better outcomes for those affected.

Scientific statements issued by the American Heart Association play a crucial role in raising awareness regarding cardiovascular diseases and stroke-related matters. These statements serve to provide a comprehensive overview of the existing knowledge on a particular subject while also identifying areas that require further research. Although scientific statements inform the formulation of guidelines, they do not directly offer treatment recommendations. Instead, they contribute to facilitating informed healthcare decisions by presenting the current state of understanding and research in the field.

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