AHA Scientific Statement Addresses Health Disparities in PAD

The American Heart Association (AHA) has released a scientific statement aimed at understanding and overcoming health disparities in PAD, with an emphasis on crafting novel solutions to close care gaps.

“It's very important for providers to know about these disparities and particularly to know that the greatest disparity in care is in the Black American population,” said Khendi T. White Solaru, MD (University Hospitals Cleveland Medical Center Harrington Heart and Vascular Institute, OH), an author of the statement. “Almost a third of all Black patients will develop peripheral artery disease at one point in their lives. This is avoidable and we can do things to both help prevent the development of PAD early on, and then once they have it, to prevent the development of cardiovascular complications, most importantly heart attack, stroke, and limb loss.”

The paper, published last week in Circulation, delves into differences in prevalence and presentation, recommendations for lifestyle and pharmaceutical management, and timely vascular interventions to prevent amputation.

“Blacks specifically, are much more likely to get amputations, which leads to a significantly worse quality of life, as well as increased mortality from there,” White Solaru added.

In the statement, the committee, led by Matthew A. Allison, MD, MPH (University of California, San Diego), say while the situation is challenging, there are numerous untapped opportunities to mitigate PAD disparities.

Diabetic foot care, for example, is one area where social determinants of health, such as limited access to preventative podiatric and interdisciplinary foot care, can mean the difference between saving and losing a limb. On the whole, Black patients are more likely than white patients, the statement notes, to present with advanced CLTI, including gangrene or sepsis.

Remote diabetic foot monitoring with smart phones and computers is one promising option that currently is only being used on a limited basis nationwide, but White Solaru and colleagues say increasing its use in underserved communities should be a priority for health systems and health science programs.

“It's not going to be as accurate as doing it in person, but it's better than not having that access to foot care,” she told TCTMD.

EHRs and Other Opportunities to Improve Care

Another frequently neglected area, the paper notes, is electronic health records (EHRs). These could be leveraged as they have in other health conditions, like heart failure, to improve access to low-cost preventive measures, such as hemoglobin A1c testing and ankle-brachial index (ABI) testing, as well as early medical therapy.

“We have a lot of algorithms for coronary disease. For example, if someone has an MI, we'll know that we need to add aspirin, a P2Y12 inhibitor, a beta-blocker, a statin, etc,” White Solaru said. “Those same pathways should pop up in the electronic medical record for someone with peripheral artery disease, making sure they're referred to supervised exercise therapy [and] to a podiatrist for their foot care, making sure that they're on all the guideline-directed medical therapies that can reduce further cardiovascular events and limb events. There's a lot of potential there for what we can develop within the electronic medical record.”

With regard to the physician workforce, the committee says that given evidence suggesting a correlation between physician-patient racial concordance and healthcare outcomes, a racially, ethnically, and culturally diverse workforce is essential in the field of PAD. This can be accomplished, they say, through early engagement of young adults from racial, ethnic, and low-socioeconomic groups with science-based career opportunities, promotion of evidence-based approaches to address cultural competency, and development of international expertise in PAD management.

Community engagement is another avenue that remains to be fully explored for prevention and treatment pathways that may bridge care gaps and reach at-risk populations where traditional healthcare cannot.

Barbershop-based interventions, for example, have been shown to increase compliance with hypertension treatment and, in White Solaru’s own research, have been used to screen for ABI and to improve PAD knowledge and awareness in Black men.

“Most of them were willing to return for subsequent visits in the barbershop, and a lot of the feedback with that was that they were much more comfortable receiving that care in a place where they feel heard and trusted,” she said. “So if we can adapt as providers and be a little more innovative, we have the opportunity to reach a lot more people.”