Health Disparities in Peripheral Artery Disease: Key Points

Allison MA, Armstrong DG, Goodney PP, et al.
Health Disparities in Peripheral Artery Disease: A Scientific Statement From the American Heart Association. Circulation 2023;148:286-296.

The following are key points to remember from an American Heart Association (AHA) Scientific Statement on health disparities in peripheral artery disease (PAD):

  1. PAD is present in >12 million Americans and 200 million people worldwide. However, the prevalence and clinical impact differs across demographic groups, especially in the United States.
  2. Most prevalence estimates of PAD are underestimated, since they rely on patients to have symptomatic disease and present for health care evaluation.
  3. Severe PAD with chronic limb-threatening ischemia that may lead to amputation affects 1.3% of all adults in the United States.
  4. Black American patients are disproportionately affected by PAD. In fact, Black men aged ≥50 years have the highest rate of prevalent PAD: approximately 5% for age 50-59, 13% at age 60-69, about 25% at age 70-79, and 59% at age ≥80 years. Lifetime estimates suggest that 30% of Black men and 27% of Black women will develop PAD during their lifetime. This is higher than for Hispanic men and women (22%) or White men and women (19%).
  5. PAD is also disproportionately prevalent among Hispanic Americans. Among this diverse population, Cuban Americans have the highest risk of PAD (odds ratio, 2.9; 95% confidence interval, 1.9-4.4) as compared to Mexican Americans.
  6. Higher rates of PAD are also seen in Indian American individuals as compared to White Americans.
  7. Some of the racial/ethnic differences in PAD prevalence can be attributed to higher rates of key risk factors, including smoking, diabetes, hypertension, and dyslipidemia. However, patterns of higher PAD prevalence, especially among Black Americans, persist even when accounting for these traditional risk factors.
  8. As a chronic, atherosclerotic process, patients with PAD have a high burden of concomitant coronary artery disease and/or cerebrovascular disease (estimated at 50%). Multivessel arterial disease is also more common in Black and Hispanic Americans as compared to White Americans.
  9. Preventative foot care, especially for patients with diabetes, is critical for reducing the burden of amputation. Social determinants appear to play a central role in the observed outcome disparities for patients with diabetes and PAD. This includes worse access to preventative foot care than for White Americans.
  10. There is strong evidence for the use of antithrombotic therapy, lipid-lowering therapy, and antihypertensive therapy in patients with PAD. However, use of these evidence-based medical therapies is lower among Black and Hispanic patients with PAD as compared to White patients.
  11. Racial disparities in physical activity and health are complicated by several factors: poverty, education, and socioeconomic status. Black Americans who live in more walkable communities have better control of diabetes than their counterparts in less walkable communities.
  12. Evidence supports the use of the Mediterranean, Dietary Approaches to Stop Hypertension (DASH), and high fruit/vegetable diets to reduce the risk of PAD. However, Black and Hispanic Americans are less likely to follow these dietary patterns and to have higher rates of obesity than White Americans.
  13. Smoking is the most important risk factor for PAD. American Indian/Alaska Native American patients have higher rates of smoking than other racial and ethnic groups. The quit rate for smoking is lower among Black and American Indian patients than White Americans.
  14. Significant disparities exist in the use and outcomes of invasive lower extremity arterial procedures. Specifically, Black, Hispanic, and Native Americans with PAD are less likely to undergo revascularization procedures and have 10-30% higher rates of complications as compared to White patients with PAD.
  15. Pathophysiologic drivers of PAD clinical expression differ across sex, race, and ethnicity. For example, Black American patients have increased arterial stiffness and oxidative stress compared to White Americans—a marker of vascular aging. Similarly, Black American women without PAD have lower skeletal mitochondrial function that may reflect increased oxidative injury as compared to White women without PAD.
  16. Social determinants of health are linked to the development of PAD. These include lower income, lower education levels, and less social support—each of which is associated with higher rates of amputation. Furthermore, racial discrimination is associated with elevated biomarkers of systemic inflammation and vasoconstriction in Black Americans men.
  17. System-level interventions are needed to address the disparities in PAD diagnosis, management, and outcomes. For example, patients with PAD should receive low/no-cost preventative measures (e.g., diabetes testing, ankle-brachial index testing, diabetic foot exams) in a location that does not introduce unnecessary burden.
  18. Increasing the diversity of the physician and health care provider workforce is a necessary step to bridge the gaps in the care of diverse patient populations.
  19. Public health efforts aimed at educating the public and communities about PAD may help to improve diagnosis and care. Examples of education and diagnostic efforts targeting community gathering locations for Black men (e.g., Barbershop) have increased both general awareness and diagnosis.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Lipid Metabolism, Heart Failure and Cardiac Biomarkers, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine, Diet, Exercise, Hypertension, Smoking, Stress

Keywords: African Americans, Atherosclerosis, Amputation, Ankle Brachial Index, Anticoagulants, Antihypertensive Agents, Biomarkers, Cerebrovascular Disorders, Coronary Artery Disease, Diabetes Mellitus, Diet, Dyslipidemias, Ethnic Groups, Exercise, Fibrinolytic Agents, Hypertension, Inflammation, Ischemia, Lipids, Minority Health, Myocardial Revascularization, Obesity, Oxidative Stress, Peripheral Arterial Disease, Poverty, Primary Prevention, Racism, Risk Factors, Smoking, Socioeconomic Factors, Vascular Diseases, Vasoconstriction, Workforce

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