Connecting Peripheral Artery Disease, Social Determinants of Health Could Lead to Earlier Diagnoses

Exploring and understanding the relationship between peripheral artery disease (PAD) and negative social determinants of health (SDOH) in older Black adults could lead to earlier diagnoses, according to investigators from the Medical College of Georgia at Augusta University.

PAD is a disease characterized by impaired blood flow to the legs, which can make walking painful and lead to amputation in severe cases. Both PAD and negative SDOH, such as poverty and racism, disproportionately impact older Black adults.

“African Americans are more likely to have the disease, they are less likely to have it diagnosed, and, if diagnosed, they are less likely to receive appropriate therapy, which can result in irreversible, life-changing events like leg amputation,” said Monique Bethel, MD, a cardiologist at the Medical College of Georgia and Augusta University Health, in a press release.

PAD is more common in Black patients than any other racial or ethnic group, according to the National Institutes of Health. This is partially because related conditions, such as high blood pressure and diabetes, are also more common in this population. Other known risk factors include smoking, high cholesterol, and blood vessel disease elsewhere in the body.

Poor SDOH can include issues such as food and housing insecurity, low educational attainment, and systemic racism. They have been found to directly increase the burden of other blood vessel diseases, such as heart disease and stroke as well as their risk factors, according to the CDC. PAD also shares risk factors such as high cholesterol and high blood pressure with heart disease and stroke.

Despite these known risk factors, the study authors noted that checking blood pressure at the ankle to look for insufficient blood flow to the legs is not routine during most physician visits. There are also mixed recommendations from national panels about screening for PAD. For example, the US Preventive Services Task Force says there is no direct and limited indirect evidence that screening unselected or asymptomatic individuals is beneficial.

However, the American College of Cardiology (ACC) and the American Heart Association have released joint practice guidelines that suggest screening with the ankle brachial index (ABI), which looks at blood pressure in the ankle as an indicator of blood flow, in patients at increased risk. This includes adults aged 65 years or older, adults aged 50 years or older with risk factors for atherosclerosis or a family history of PAD, and adults younger than 50 years of age with diabetes and 1 other risk factor for atherosclerosis.

Experts have called for more research to better determine when and whether screening can improve outcomes in PAD, and the US Preventive Services Task Force has said that screening may benefit some groups. In their new study, the investigators posited that Black Americans may be one of those groups.

“We know there are clear risk factors for this condition,” Bethel said in the press release. “If we know they have the disease, we can attack their risk factors more aggressively.”

In the study, Bethel and her colleague Vishal Arora, MD, are screening patients who come to the general cardiology clinic or peripheral vascular disease clinic, as well as inpatients admitted to the cardiology service at Augusta University Medical Center. They are looking for individuals who meet similar criteria to the ACC guidelines, including those 65 years of age and older, those aged 50 to 64 years who are smokers or have diabetes, and those younger than 50 who smoke and have diabetes. The study will not include those who have already been diagnosed with PAD or who have clear indications of the disease, such as gangrene or nerve damage in their legs, as well as indicators of blood vessel disease elsewhere in the body.

The methods they are using to check for PAD are painless and will be completed in just 1 visit. This includes checking the blood pressure in the arm and comparing it to pressure at the ankle with the ABI test to make the diagnosis. The top number should be approximately the same in both locations, and if it is lower in the ankle, it means something is obstructing blood flow.

Although the ABI is considered diagnostic for PAD, it does not indicate exactly where the plaque is found. A Doppler ultrasound can help determine that location.

In addition, the investigators are using a brief survey to assess SDOH, which are defined as conditions in which individuals are born, grow, live, work, and age that impact socioeconomic status, education, employment, their neighborhood, social support, and access to health care.

In the press release, Bethel said she wants to assess whether certain SDOH are regularly present in Black patients who screen positive for PAD compared with those who do not. These data are a way to collect objective evidence about whether, together, they paint a picture of a clearly at-risk population who could benefit from screening.

“We already know it’s more prevalent among African Americans, but could we do better, could we catch it earlier?” Bethel said in the press release.

Although PAD is most commonly found in the legs, it can happen throughout the thousands of miles of blood vessels in the body. It can make limbs cool to the touch, muscles atrophy, and slow hair growth on the legs, as well as cause pain and cramping that typically subsides with rest. Importantly, however, PAD can be asymptomatic, at least in the earlier stages, and pain can easily get attributed to other issues such as age.

“It’s a disease that is really underrecognized, understudied, and undertreated, but it has a profound effect on patients,” Bethel said in the press release.

REFERENCE

Connections between peripheral artery disease, negative social determinants of health like poverty may lead to earlier diagnosis, intervention in at-risk Blacks. News release. Augusta University; January 31, 2023. Accessed February 2, 2023. https://jagwire.augusta.edu/connections-between-peripheral-artery-disease-negative-social-determinants-of-health-like-poverty-may-lead-to-earlier-diagnosis-intervention-in-at-risk-blacks/