Ethnicity and Peripheral Arterial Disease

doi:10.4065/80.1.48

Mayo Clinic Proceedings

Volume 80, Issue 1, January 2005, Pages 48-54

https://doi.org/10.4065/80.1.48 Get rights and content

OBJECTIVE

To determine whether race/ethnicity is an independent risk factor for peripheral arterial disease (PAD).

PATIENTS AND METHODS

From September 2000 through August 2001, we screened patients (age ≥55 years) for PAD within 4 primary care clinics located in the Houston, Tex, area. Variables that were bivariately associated with PAD (P≤.05) were selected for entry into a multivariate logistic regression model to determine the independent risk factors for PAD.

RESULTS

Among 403 patients (136 white, 136 African American, and 131 Latino patients, 81 of whom were Spanish speaking), the prevalence of PAD was 22.8% among African American patients, 13.7% among Latino patients, and 13.2% among white patients (P=.06). Within the multivariate model, adjusting for age, smoking status (odds ratio [OR], 2.58; 95% confidence interval [CI], 1.27-5.25), diabetes mellitus (OR, 2.98; 95% CI, 1.58-5.63), hypertension (OR, 2.58; 95% CI, 1.12-5.95), and education, African American and Latino patients were not more likely than white patients to have a diagnosis of PAD (OR 1.89, 95% CI 0.89-3.99 and OR 1.54, 95% CI 0.59-4.06, respectively).

CONCLUSION

After adjusting for atherosclerotic risk factors and level of education, ethnicity was not an independent risk factor for PAD. When determining ethnic variation in outcomes among patients with PAD, efforts are needed to better understand the role of the primary care setting to reduce the burden of social inequality on health.

Section snippets

Screening Procedures

The Baylor College of Medicine Institutional Review Board approved this study. We screened patients from the Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC) and 3 primary care clinics in the Harris County (Houston, Tex) Hospital District from September 2000 through August 2001. Of note, the MEDVAMC provides care to a predominantly nonminority population (76% white, 20% African American, and 4% Latino). In the Harris County Hospital District, the Martin Luther King Clinic provides

RESULTS

We approached a total of 457 patients and enrolled 403 (88%). Of the patients enrolled, 151 were recruited from the MEDVAMC, and the remainder were recruited from 3 sites within the Harris County Hospital District. Patient demographics are given in Table 1. Among 403 patients (136 white, 136 African American, and 131 Latino patients, 81 of whom were Spanish speaking), the prevalence of PAD was 16.6%. By ethnicity, the prevalence of PAD was 13.2% for white patients, 22.8% for African American

DISCUSSION

In an ethnically diverse population and after adjusting for education, African American patients and Latino patients compared with white patients were not more likely to have a diagnosis of PAD. Important risk factors for PAD included age, currently smoking, diabetes mellitus, and hypertension.

Variation in the prevalence of PAD by ethnicity has been documented in prior research studies that have focused primarily on white, African American, and English-speaking Latino participants. Although the

CONCLUSION

This study found no association of ethnicity with PAD after adjusting for education. Further research is needed to understand the potential role of primary care to improve the process of care for patients who are at increased risk for the development and progression of PAD.

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Cited by (27)

Disparities in peripheral artery disease care: A review and call for action
2022, Seminars in Vascular Surgery
Citation Excerpt :
This could point to the "race" variable being too ambiguous or a "catch-all" for multiple issues simultaneously. Investigators have found that after adjusting for atherosclerotic risk factors and social determinants of health, such as education level, the impact of race and ethnicity diminishes [60,95]. Although race is often used in the literature as an independent risk factor for disease, it is, in fact, a mediator of structural inequalities resulting from unjust policies and practices [96].
Peripheral artery disease (PAD), the pathophysiologic narrowing of arterial blood vessels of the lower leg due to atherosclerosis, is a highly prevalent disease that affects more than 6 million individuals 40 years and older in the United States, with sharp increases in prevalence with age. Morbidity and mortality rates in patients with PAD range from 30% to 70% during the 5- to 15-year period after diagnosis and PAD is associated with poor health outcomes and reduced functionality and quality of life. Despite advances in medical, endovascular, and open surgical techniques, there is striking variation in care among population subgroups defined by sex, race and ethnicity, and socioeconomic status, with concomitant differences in preoperative medication optimization, amputation risk, and overall health outcomes. We reviewed studies from 1995 to 2021 to provide a comprehensive analysis of the current impact of disparities on the treatment and management of PAD and offer action items that require strategic partnership with primary care providers, researchers, patients, and their communities. With new technologies and collaborative approaches, optimal management across all population subgroups is possible.
Epidemiology of peripheral artery disease
2021, Seminars in Vascular Surgery
Peripheral artery disease (PAD) is the clinical manifestation of atherosclerosis that primarily affects peripheral arteries within the lower extremities. In this brief review, we describe the epidemiology and burden of disease of PAD within the United States, particularly among high-risk populations. Although the prevalence of PAD continues to increase and is typically higher among the elderly as well as men, women in lower socioeconomic strata are affected at rates two times that of men. Among racial/ethnic groups, Black and African-American patients both experience higher rates of disease as well as lower rates of access to preventative care. Moreover, despite an overall decrease in amputation rates among all patients with PAD, high-risk populations remain disproportionally affected. Specifically, patients in rural areas, African-American and Native-American patients, and those of low socioeconomic status carry the highest risk of amputation. Efforts to improve care among PAD patients should target these high-risk populations and offer comprehensive, evidence-based preventative care. Wide adoption and integration of these practices into comprehensive care models may help to mitigate amputation in the highest-risk populations. As our treatment pathways continue to evolve, we must place further emphasis on patient input and quality of life as we work toward continual improvement in the care of patients with PAD.
MicroRNA-125a-3p affects smooth muscle cell function in vascular stenosis
2019, Journal of Molecular and Cellular Cardiology
Citation Excerpt :
Up to 20% of adults over 55 years old have peripheral artery disease (PAD) in their legs [1]. In the medical field, lower extremity arteriosclerosis obliterans is a critical disease that is also currently one of the most significant causes of limb loss [2]. To date, the therapeutic effects of exercise and medicine are not sufficient.
Many studies have indicated that microRNAs are closely related to the process of peripheral arterial disease (PAD). Previously, we found that microRNA-125a-3p (miR-125a-3p) in restenotic arteries after interventional therapy of lower extremity vessels was notably decreased compared with that of normal control arteries. However, its role in the development of vascular stenosis is not yet clearly understood. The purpose of this study was to investigate the expression, regulatory mechanism and function of miR-125a-3p in the process of vascular stenosis.
Quantitative reverse-transcription polymerase chain reaction assays indicated that miR-125a-3p in restenotic arteries after interventional therapy was significantly lower than that in normal control arteries. Immunofluorescence and in situ hybridization co-staining assays in arterial sections demonstrated that miR-125a-3p was mainly expressed in the medial smooth muscle layer. Transfection of miR-125a-3p mimics into cultured vascular smooth muscle cells (VSMCs) effectively inhibited cell proliferation and migration. Then, western blot and luciferase activity assays showed that recombinant human mitogen-activated protein kinase 1 (MAPK1) was a functional target of miR-125a-3p and was involved in miR-125a-3p-mediated cell effects. Finally, the lentiviral infection of miR-125a-3p in balloon-injured rat carotid vascular walls showed that miR-125a-3p overexpression significantly reduced the probability of neointimal membrane production.
miR-125a-3p can effectively inhibit the function of VSMCs and the occurrence of vascular stenosis by targeting MAPK1. This study introduces a new molecular mechanism of PAD. We show that regulation of the miR-125a-3p level has the potential to provide a new treatment for PAD and other proliferative vascular diseases.
The prevalence of peripheral arterial disease (PAD) and PAD risk factors among different ethnic groups in the US Population
2012, Journal of Vascular Nursing
Citation Excerpt :
The keywords peripheral arterial disease, ethnic groups, and race identified 49 articles, all of which were part of the 67 identified from the previous keyword search. The San Diego Population Study,10 the Multi-Ethnic Study of Atherosclerosis (MESA),11,12 and two different studies using the National Health and Nutrition Examination Survey (NHANES),2,13 reported PAD trends, risk factors and complications among different ethnic groups but none reported data on the 5 specific ethnic groups examined in this current study. Those studies, unlike this current study, examined associations between prevalence of diabetes, HTN, dyslipidemia or cigarette smoking and PAD among different ethnic groups.
The National Health and Nutrition Examination Survey (NHANES) 2003-2004 data set was utilized to examine and compare trends and differences in PAD-related risk factor variables among 5 different ethnic/racial groups. The sample included individuals 40 years and older with PAD and of the ethnic/racial groups: Mexican American, Other Hispanic, Non-Hispanic White, Non-Hispanic Black, and Other/Multiracial. Two demographic variables (age and gender) and 4 PAD-risk factors (hypertension [HTN], systolic blood pressure [SBP], and diastolic blood pressure [DBP]), dyslipidemia, high-density lipoprotein [HDL] and low-density lipoprotein [LDL], diabetes, and cigarette smoking) were examined for each group. The study design conducted was descriptive using the NHANES 2003-2004 secondary data set. Raw data were weighted. Descriptive statistics were measured, Chi-squares were compared, and Phi-coefficients were measured for association using SAS version 9.1 and SUDAAN 10.0. The group with the highest prevalence of PAD are females 40–50 years of age, and the ethnic group with PAD who have the highest risk for PAD-related risk factors are Non-Hispanic Black. Through Chi-square significant differences (P = 0.00001–0.03874) between specific ethnic groups for all four PAD-related risk factors (i.e., HTN, dyslipidemia, diabetes and cigarette smoking). All of the associations between the prevalence of HTN, dyslipidemia, diabetes, or cigarette smoking and ethnicity were statistically significant (P = < 0.0001). Overall differences exist among the different ethnic groups.
Assessment of functional status and quality of life in claudication
2011, Journal of Vascular Surgery
Citation Excerpt :
Scoring is on a 0% to 100% scale. The WIQ has been used to establish that limitations in walking speeds and distances as well as in stair climbing are present in patients with IC compared with controls.4,73 The WIQ has also been shown to detect impairment in PAD patients who have mild symptoms or are asymptomatic.74
Treadmill walking is commonly used to evaluate walking impairment and efficacy of treatment for intermittent claudication (IC) in clinical and research settings. Although this is an important measure, it does not provide information about how patients perceive the effects of their treatments on more global measures of health-related quality of life (HRQOL).
PubMed/Medline was searched to find publications about the most commonly used questionnaires to assess functional status and/or general and disease-specific HRQOL in patients with peripheral artery disease (PAD) who experience IC. Inclusion criteria for questionnaires were based on existence of a body of literature in symptomatic PAD.
Six general questionnaires and seven disease-specific questionnaires are included, with details about the number of domains covered and how each tool is scored. The Medical Outcomes Study Short Form 36-item questionnaire and Walking Impairment Questionnaire are currently the most used general and disease-specific questionnaires at baseline and after treatment for IC, respectively.
The use of tools that assess functional status and HRQOL has importance in both the clinical and research areas to assess treatment efficacy from the patient's perspective. Therefore, assessing HRQOL in addition to treadmill-measured walking ability provides insight as to the effects of treatments on patient outcomes and may help guide therapy.
Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: A survival prediction model to facilitate clinical decision making
2010, Journal of Vascular Surgery
Citation Excerpt :
The problem with considering racial, social, economic, and cultural factors in any prediction model is that they are difficult to define for the purposes of scientific reporting and do not travel well across national borders. For example, certain baseline variables, such as race,10 socioeconomic class, and educational attainment,20,21 that may be considered important in parts of the world with different health economies than the UK, are relatively less important per se in the UK (and arguably in other European countries) where the population affected by peripheral arterial disease (SLI) is largely white and where all citizens are granted equal access to high-quality free health care and education at the point of delivery funded through general taxation. The reviewers have asked us to specifically discuss the question of race and how that might affect the epidemiology of SLI, outcomes from lower limb interventions, and the appropriateness of generalizing the BASIL trial results and predictive modelling to other parts of the world.
An intention-to-treat analysis of the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial showed that in patients with severe lower limb ischemia (SLI) due to infrainguinal disease who survived for 2 years after intervention, initial randomization to a bypass surgery (BSX)-first vs balloon angioplasty (BAP)-first revascularization strategy was associated with improvements in subsequent overall survival (OS) and amputation-free survival (AFS) of about 7 and 6 months, respectively. This study explored the value of baseline factors to estimate the likelihood of survival to 2 years for the trial cohort (Cox model) and for individual BASIL trial patients (Weibull model) as an aid to clinical decision making.
Of 452 patients presenting to 27 United Kingdom hospitals, 228 were randomly assigned to a BSX-first and 224 to a BAP-first revascularization strategy. Patients were monitored for at least 3 years. Baseline factors affecting the survival of the entire cohort were examined with a multivariate Cox model. The chances of survival at 1 and 2 years for patients with given baseline characteristics were estimated with a Weibull parametric model.
At the end of follow-up, 172 patients (38%) were alive without major limb amputation of the trial leg, and 202 (45%) were alive. Baseline factors that were significant in the Cox model were BASIL randomization stratification group, below knee Bollinger angiogram score, body mass index, age, diabetes, creatinine level, and smoking status. Using these factors to define five equally sized groups, we identified patients with 2-year survival rates of 50% to 90%. The factors that contributed to the Weibull predictive model were age, presence of tissue loss, serum creatinine, number of ankle pressure measurements detectable, maximum ankle pressure measured, a history of myocardial infarction or angina, a history of stroke or transient ischemia attack, below knee Bollinger angiogram score, body mass index, and smoking status.
Patients in the BASIL trial were at high risk of amputation and death regardless of revascularization strategy. However, baseline factors can be used to stratify those risks. Furthermore, within a parametric Weibull model, certain of these factors can be used to help predict outcomes for individuals. It may thus be possible to define the clinical and anatomic (angiographic) characteristics of SLI patients who are likely—and not likely—to live for >2 years after intervention. Used appropriately in the context of the BASIL trial outcomes, this may aid clinical decision making regarding a BSX- or BAP-first revascularization strategy in SLI patients like those randomized in BASIL.

View all citing articles on Scopus

¹: Dr Collins was a recipient of a Robert Wood Johnson Minority Medical Faculty Development Award at the time this work was completed.

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Original ArticleEthnicity and Peripheral Arterial Disease

OBJECTIVE

PATIENTS AND METHODS

RESULTS

CONCLUSION

Section snippets

Screening Procedures

RESULTS

DISCUSSION

CONCLUSION

J Lab Clin Med

J Clin Epidemiol

Cardiovasc Surg

Atherosclerosis

Diagnosis and treatment of chronic arterial insufficiency of the lower extremities: a critical review [published correction appears in Circulation. 2000;102:1074]

Circulation

Lower extremity nontraumatic amputation among veterans with peripheral arterial disease: is race an independent factor?

Med Care

The influence of race on the use of surgical procedures for treatment of peripheral vascular disease of the lower extremities

Arch Surg

Variation in utilization of procedures for treatment of peripheral arterial disease: a look at patient characteristics

Arch Intern Med

Peripheral arterial disease—epidemiological aspects

Vasc Med

Atherosclerotic risk factors are less intensively treated in patients with peripheral arterial disease than in patients with coronary artery disease

J Gen Intern Med

Clinical significance and functional implications of peripheral arterial disease

The prevalence of peripheral arterial disease in a racially diverse population

Arch Intern Med

Interpretation of Doppler segmental pressures in peripheral vascular occlusive disease

Arch Surg

Peripheral arterial disease detection, awareness, and treatment in primary care

JAMA

Benefit of exercise conditioning for patients with peripheral arterial disease

Circulation

The correlation between symptoms and non-invasive test results in patients referred for peripheral arterial disease testing

Vasc Med

SF-36 Health Survey: Manual and Interpretation Guide

Original Article
Ethnicity and Peripheral Arterial Disease