CHICAGO — Physicians should consider racial and ethnic disparities in care for patients with peripheral artery disease and not overlook opportunities to address these problems, according to a speaker at AMP: The Amputation Prevention Symposium.
Nearly 9 million U.S. adults aged older than 40 years have PAD, with the highest prevalence in those who are older, black and other minorities, Bryan Fisher, MD, chief of vascular surgery at Tristar Centennial Medical Center, said here.
“However, only 10% of these patients actually show classic signs of intermittent claudication,” Fisher said. About 40% of patients do not report any leg pain and about 50% have a variety of leg symptoms different from intermittent claudication. “These patients don’t complain or know what to complain about,” he said.
More risk factors, poor adherence
In terms of risk factors for PAD, overweight or obesity, lack of physical activity and diabetes, for example, are more prevalent among black patients. In contrast, smoking and cholesterol are more common among white patients.
Additionally, the prevalence of hypertension — a major risk factor for PAD — in black patients in the United States is the highest in the world, according to Fisher. Nearly half of black women (43%) and men (40%) have high BP, compared with 30% of white women and men. Black patients also have nearly twice the hypertension mortality as white patients, he noted.
“When looking at ethnic prevalence of PAD in men and women in the United States, some very similar trends emerge when it comes to blacks vs. their counterparts,” Fisher said. “For men, the difference is striking, with a 30% to 40% difference in prevalence in PAD between blacks and other ethnicities. For women, the numbers are not as disparate, but there certainly is a difference when it comes to blacks and other groups.”
Another gap that requires attention is adherence to treatment. Fisher cited a study that evaluated adherence to four different treatment modalities known to significantly decrease mortality and CV events. Results showed that patients not adherent to four guideline-directed therapies — smoking cessation, aspirin, statins and ACE inhibitors — had significantly increased risk for MACE.
“Also, when looking at major adverse events in terms of limb loss, those who are not adherent tend to fare far worse,” Fisher said.
A major barrier to amputation prevention efforts is the wide variation in diagnosis and treatment of PAD and critical limb ischemia, according to Fisher.
“We’re failing our patients,” he said. “At any hospital, when a patient comes in with STEMI, the hospital knows exactly what to do. However, when it comes to amputation prevention, it’s completely random.”
Some patients, for example, will come in without claudication and be told that they require bilateral amputation, according to Fisher, which may also be affected by other factors that may not yet be fully understood.
“We are asking complex questions and there are a lot of complex answers. We have opportunities to reach out to minority populations through more than just generic efforts, such as screenings,” he said, adding that physicians have to figure out the best way to educate these various demographics by learning how they take in their information.
“These are important aspects to understand if we’re going to tackle the problem. It has to be a labor of love, especially when we talk about uninsured and underinsured patients,” Fisher said. “In the underinsured patient, will we take the time to spend 3 to 5 hours to get flow back to the foot? I hope so.”
Partnerships with hospital administration and industry are essential to closing these gaps in care, he noted, as is identifying patients at risk for amputation before they come in for treatment. Even visiting different floors in one’s own hospital can help. Many patients on dialysis, for instance, are told they do not have PAD despite having foot ulcers for months, according to Fisher.
“At what point are other people going to get angry when the patient has the opportunity for limb salvage because no one stepped up?” he said. – by Melissa Foster
Fisher B. Racial Disparities in CLI and Amputation. Presented at: AMP: The Amputation Prevention Symposium; Aug. 8-11, 2018; Chicago.
Fisher reports he is a consultant for Abbott Vascular, Asahi, Bard, Cardiovascular Systems Inc., Medtronic and Philips.