New AHA Scientific Statement Reviews Disparities in Peripheral Artery Disease

Carlos Mena-Hurtado, MD

Credit: Yale Medicine

A new scientific statement released by the American Heart Association (AHA) reviewed the variables that contribute to health disparities among people with peripheral artery disease (PAD), with certain demographic groups experiencing a disproportionately higher prevalence.¹

The statement indicated approximately 1 in 3 Black adults may develop PAD, compared to 1 in 5 Hispanic or White adults. If amputation is required for treatment, adults who are Black, Hispanic, and/or American Indian experience lower survival rates and worse quality of life after amputation, compared with White adults.

Due to these disparities and high healthcare costs for people with PAD, the statement recommended the use of low-cost, routine preventive screening and monitoring for people with PAD, including hemoglobin A1c testing, ankle-brachial index measurements, and for those with type 2 diabetes (T2D), foot exams to check for ulcerations and neuropathy.

“This debilitating condition has devastating outcomes such as major limb amputation, which often leads to lower quality of life and increased disability, and results in social and economic burden for individuals and their families and places an enormous financial burden on the health care system,” Carlos Mena-Hurtado, MD, a statement writing group member and an associate professor of cardiology and director of vascular medicine at Yale University, said in a statement.² “High-risk patients should routinely receive low-cost preventive measures. Preventing problems before they occur may help to improve quality of life and reduce health care costs in the long run for people with PAD.”

The purpose of the scientific statement was to summarize the disparities in PAD across key elements, including epidemiology, medical management, and interventional outcomes, and how social determinants of health intersect with the development of PAD. In doing so, the writing group identified existing gaps in knowledge and further investigational research targets to offer potential structural solutions. The overall prevalence of PAD estimates 7 to 12 million affected individuals in the US and 200 million people worldwide, with most patients aged ≥40 years.

Prior studies have indicated that PAD disproportionately impacts individuals who are Black, American Indian, or Hispanic. People in these demographic groups experience both higher rates of PAD and worse PAD-related outcomes, including disability, depression, coronary artery disease, cerebrovascular disease, and/or limb amputation. The writing group indicated Black adults seeking medical care are more likely to have advanced PAD and are more likely to undergo leg or foot amputation in comparison to peers who are White.

Moreover, Black, Hispanic, and American Indian adults experience lower survival rates and worse quality of life after amputation. Individuals in these demographic groups are less likely to use a prosthesis to regain the ability to walk and are more likely to live in a nursing home.

The statement suggested people from underrepresented racial and ethnic groups have an increased risk of death after amputation, with the rate of death within 5 years ranging from 45% – 60%, dependent on the amputation location. Limited access to healthcare resources may play a role in differences in outcomes for those with PAD. The writing group noted that rural and low-income adults are at greater risk of being uninsured and are more likely to search out care at an advanced disease stage, compared with White, urban, and higher-income adults.

“Even after controlling for traditional cardiovascular risk factors, we were surprised to find that higher PAD prevalence persists among Black adults,” Mena-Hurtado said.² “However, we now know that social determinants of health, such as access to nutritious foods, walkable neighborhoods, and structural inequities, have a profound impact on an individual’s health status.”

The statement suggested smoking is the most important risk factor for PAD; while overall smoking rates have decreased in the US, data has shown a lower decline among Black and American Indian adults.¹ Other risks for PAD include T2D, high blood pressure, high cholesterol, and obesity. Those who are Black, or Hispanic are also shown to have higher rates of obesity compared with White adults, and Black adults with PAD suffer from higher rates of T2D, high blood pressure, and chronic obstructive pulmonary disease (COPD).

The statement offered potential solutions to reduce health disparities in PAD care, from 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.

Emerging advances in telehealth and remote patient monitoring could improve access to care and reduce the disproportionately high number of amputations throughout the US, particularly among diverse racial and ethnic groups. Community-based care and support may be effective at improving patient outcomes through increased public awareness and knowledge around PAD. Smoking cessation, improved diet, and exercise therapy could be critical in reducing cardiovascular risk, mortality, and amputation rates in people with PAD.

The writing group indicated patients with established PAD may need to receive pharmacotherapy to manage blood pressure, lower cholesterol, and reduce blood clotting, to reduce the risk of adverse outcomes. Surgical procedures, such as lower extremity arterial bypass, are less likely in various regions of the country, especially among Black, Hispanic, and American Indian populations. Providing greater access to these procedures and follow-up care may help reduce disparities among people with PAD.

“It is essential that health care professionals understand the disparities in PAD prevalence and outcomes to provide appropriate, evidence-based care and bridge the gaps in the treatment of this diverse patient population,” Mena-Hurtado said.² “Health care systems need to optimize cost-effective interventions at every step.”

References

1. Allison MA, Armstrong DG, Goodney PP, et al. Health Disparities in Peripheral Artery Disease: A Scientific Statement From the American Heart Association [published online ahead of print, 2023 Jun 15]. Circulation. 2023;10.1161/CIR.0000000000001153. doi:10.1161/CIR.0000000000001153
2. Nearly 1 in 3 black adults may develop pad; disparities in care increase amputation risk. American Heart Association. June 15, 2023. Accessed June 20, 2023. https://newsroom.heart.org/news/nearly-1-in-3-black-adults-may-develop-pad-disparities-in-care-increase-amputation-risk.