November 17, 2016

Poverty, Black Race Are Predictive of PAD-related Amputation Risk

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Peripheral artery disease (PAD) occurs when fat, cholesterol, and other substances accumulate in blood vessels away from the heart, restricting blood flow. In addition to increasing the risk for heart attack and stroke, untreated PAD can cause gangrene, which can lead to amputation. Preliminary research presented at the American Heart Association’s Scientific Sessions 2016 indicates that poverty and black race are independently predictive of greater amputation risk among patients with PAD.

Using data from 208,194 veterans with PAD in the U.S. Department of Veterans Affairs (VA) database from 2003 to 2014, researchers found that blacks had a 43 percent higher risk of amputations when compared to whites in the same socioeconomic status, and poverty was associated with a 37 percent increase in amputation risk, independent of race.

“There may be biological mechanisms still unknown as to why black patients are at a higher risk for amputations in PAD, but access to care is an important independent contributor to the risk,” said study lead author Shipra Arya, MD, SM, assistant professor of surgery at Emory University School of Medicine, and vascular surgeon at the Atlanta VA Medical Center, Decatur, Georgia. “Treatment for PAD is multimodal. It includes optimal medical management of risk factors associated with cardiovascular disease, in addition to supervised exercise, which is not yet covered by insurance.”

Sixteen percent of the study’s participants were black, 83 percent were white, and almost all were male. The researchers compared PAD-related amputations by socioeconomic status across different zip codes nationwide, defining the poorest communities as those with more than 30 percent of inhabitants below the poverty level. During an average follow-up of just over five years, 14,981 major amputations occurred.

Previous evidence indicated that the risk of amputation was greater among blacks than among whites, but whether this difference stemmed from biological factors or access to care and other socioeconomic factors was unclear. Accordingly, investigators examined the risk of PAD amputation by race and socioeconomic status as indicators for access to care.

“Patients living in zip codes with a high poverty burden also have incrementally higher risk of amputation, suggesting a role for access to care in determining outcomes for PAD,” Arya said.

The main risk factors for developing PAD are smoking, diabetes, high blood pressure, and high cholesterol. PAD is usually treatable with lifestyle changes and medication.

The study was observational so could only identify associations, not causes. Researchers also caution that the study included mostly male veterans, so its findings may not apply to other groups.

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