Vascular Disease Patient Information Page: Addressing disparities in peripheral artery disease-related amputation

What is peripheral artery disease (PAD) and who is at risk?

Peripheral artery disease (PAD) occurs when plaque builds up inside the arteries of the legs. This plaque build-up causes narrowing and blockages of the blood vessels that carry blood flow from the heart to the legs. Many times, the decrease in blood flow does not cause symptoms. However, in some people, PAD can cause pain with walking or at rest, and it can result in wounds that are difficult to heal or even dead tissue (gangrene) in the toes and feet.

PAD is present in over 8–12 million Americans. ¹ People who are older and people who currently or have ever smoked are at high risk for developing PAD. Diabetes, high blood pressure, high cholesterol, and kidney disease are other common problems that place people at risk for PAD. The risk of cardiovascular disease (heart attack and stroke) is much higher among people with PAD compared to people without PAD. People with very severe arterial disease and symptoms are at risk for amputation of the toes or leg. ² In order to decrease this risk of amputation, providers typically recommend several things:

• - Specific medical therapy that helps to reduce the risk of bad outcomes due to cardiovascular disease, such as aspirin and statin medications;

• - Exercise therapy is particularly useful to improve the type of leg pain that happens only when people walk (i.e., ‘claudication’);

• - People who smoke are provided help to quit smoking;

• - Procedures to improve blood flow are considered on a case-by-case basis based on the symptoms someone has, how severe his or her artery disease is, and how well certain types of procedures would work.

Are some people at higher risk of PAD complications, such as amputation, than other people?

People with PAD and diabetes and/or kidney disease are at highest risk of major amputation (above the ankle or above the knee). Women tend to have more severe disease and worse disability when initially diagnosed with PAD. ³ Estimates also show that nearly one-third of Black Americans will develop PAD in their lifetime. ⁴ Furthermore, among people with PAD, women, people with low socioeconomic status (lower income and/or lower educational level), and Black and Hispanic patients are less likely to be prescribed and take medications that can improve quality of life and limb-related outcomes (e.g., worsening of disease and symptoms and associated risk of future amputation). Research shows that among those with PAD, Black people have the highest risk of leg amputation, the most severe limb-related outcome of PAD. In fact, Black and Hispanic patients have anywhere from two to four times the risk of leg amputation compared to White patients. ⁵

What can be done to improve or eliminate racial disparities in PAD?

Unfortunately, we do not yet fully understand why these health disparities exist for those with PAD who identify as Black and/or Hispanic. Perhaps more troubling, we do not yet know how to eliminate them. Experts who are passionate about reducing racial disparities in various aspects of PAD care (diagnosis, treatment, and outcomes) are working hard to find solutions. Ideally, these researchers will work with people diagnosed with PAD to decide, together, what the best solutions might look like to reduce racial disparities. Patients who are interested in being part of the solution can join initiatives like the PAD Collaborative of the PAD National Action Plan (www.heart.org/PADActionPlan), which is sponsored by the American Heart Association, to offer the necessary input that only a patient can provide. ⁶ Other examples of organizations with patient-engaged initiatives include the Association of Black Cardiologists’ PAD Initiative (abcardio.org/advocacy/abc-pad-initiative), the Amputee Coalition (amputee-coalition.org), the American Diabetes Association’s Amputation Prevention Alliance (https://diabetes.org/get-involved/advocacy/amputation-prevention-alliance-take-action), Black Limbs Matter (blacklimbsmatter.com), and more.

What types of doctors and specialists can help prevent amputation?

Any symptoms or concerns for PAD should prompt a primary care visit. Primary care doctors are usually first to identify PAD and refer patients to specialists when they need additional care. Severe PAD can put people at high risk for major amputation. When a person has both PAD and diabetes, this risk increases significantly. A multidisciplinary team approach has been proven to prevent leg amputations among people at high risk. ⁷

Vascular medicine specialists, cardiologists, and endocrinologists help manage additional medical conditions that patients with PAD often have, such as diabetes, coronary artery disease, heart failure, and more. Podiatric surgeons are a vital part of the care of patients with PAD and diabetes as well. They provide foot care, which involves wound management and diabetic shoes/inserts and socks to prevent wound and callus formation. They also perform routine follow-up to identify foot problems at earlier stages before they progress to the point of requiring amputation. Podiatric surgeons are also often called on to help perform smaller amputations to the toes to try to avoid losing the entire foot. When infection sets in, infectious disease specialists help provide targeted antibiotics to help heal wounds. Vascular proceduralists (vascular surgeons, interventional cardiologists, and interventional radiologists) perform procedures to improve blood flow when needed.

The many facets of PAD care can be complex and sometimes confusing. The multidisciplinary team will try their best to make sure care is coordinated with good communication among all the specialists.

If a procedure is not required right away for PAD, what is the typical follow-up?

Close monitoring is recommended to avoid further complications and worsening of symptoms. Recent studies have shown that patient education improves short-term knowledge and may modestly reduce the risk of foot ulcerations and amputation. The International Working Group on the Diabetic Foot created a way to categorize risk for patients with and without wounds and how they should be monitored. ⁸ The categories range from risk category 0 (very low) to category 3 (high). In general, people with low risk (category 0) follow-up once a year and those with higher risk follow-up more frequently during the year.

Summary

Symptoms such as unexplained leg pain, discoloration of the foot or lower leg, or nonhealing wounds or calluses on the foot should prompt evaluation for PAD. The risk of delayed care for a patient with PAD is potential amputation, and the risk of not managing other medical problems can be a heart attack, stroke, and even an early death. Unfortunately, Black and Hispanic communities as well as people with low socioeconomic status are all at higher risk of poor outcomes (such as amputation and early death) when they have PAD. Understanding, acknowledging, and intervening on the cultural, racial, and socioeconomic differences and challenges will be crucial to reducing these healthcare disparities. There are specialists who are ready and willing to help treat PAD, foot wounds, and other associated medical problems. There are also researchers who are partnering with patients who have PAD to find ways to improve PAD outcomes for everyone. For example, Yale University’s Vascular Medicine Outcomes (VAMOS) program which is a very busy group of researchers who study patient-reported outcomes among patients with PAD. Also, Vascular Cures has a strong history of funding research teams that include patients as investigators.

The ‘Vascular Disease Patient Information Page’ is a regular feature of Vascular Medicine. All articles in the collection are available for free online at http://journals.sagepub.com/vmjpatientpage.

The Vascular Disease Patient Information Page is provided for educational purposes only and is not a substitute for medical advice.