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CLINICAL STATEMENTS AND GUIDELINES

June 11, 2024 Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 e1332

including risk of myocardial infarction and stroke.14,21–29 In addition, polyvascular disease has recently been recognized as a risk factor for MALE, perhaps reflective of increased severity of disease as well as an associated prothrombotic state.21–31 The combination of polyvascular disease and diabetes is synergistic in terms of marked amplification of risk among patients with PAD.12,32–34 Depression has been recognized as a prevalent comorbidity among patients with PAD and has recently been associated with higher rates of MACE and MALE outcomes, as well as outcomes such as length of stay and readmission after revascularization.35–40 Simple tools such as the Geriatric Depression Score (GDS) or the Patient Heath Questionnaire (PHQ)-9 can be used to assess for depression.41,42 Beyond these PAD-related risk amplifiers, certain patient demographics (eg, age, sex, race, ethnicity) and health disparities related to social determinants of health (eg, racism, socioeconomic status) have been associated with greater risk of MACE and MALE among those with PAD. These are discussed further in Section 4.2, “Health Disparities in PAD,” and in a recently published AHA scientific statement.43

Recommendation-Specific Supportive Text

1 Because of the association of PAD-related risk

amplifiers with MACE and MALE, evaluation of patients with PAD should include assessment for the presence of these factors (Table 9) and recognition of the clinical impact of these amplifiers in developing a treatment plan. Implementation of GDMT (see Section 5, “Medical Therapy and Preventive Foot Care for Patients With PAD”) and meticulous longitudinal follow-up (see Section 12, “Longitudinal Follow-Up of PAD”) are particularly important among those with PAD-related risk amplifiers, as well as awareness and patient education regarding risk of progression to CLTI with associated risk of amputation. Patients with PAD and other forms of CVD can experience high levels of depression, stress, and anxiety.39 The GDS can be used to screen for depression in patients with PAD. The presence of depressive symptoms (GDS ≥6) has been associated with an increased mortality rate (MACE and MALE) in patients with PAD.35

4.2 Health Disparities in PAD

Recommendation for Health Disparities in PAD COR LOE Recommendation

1 C-EO 1 Clinicians and health care systems should actively

pursue evidence of health disparities in diagnosis, treatment, and outcomes for patients with PAD and use efforts to limit the impact of these disparities on clinical outcomes.

Synopsis Disparities in the detection, management, and outcomes of PAD have long been present in the United States.1,2 High-risk racial and ethnic groups, along with patients of lower socioeconomic status and patients who reside in rural areas, experience disproportionately higher rates of MALE.3–11 Although some of these patient groups have a greater burden of risk-amplifying comorbidities (ie, diabetes, CKD, and ongoing smoking) (Figure 3), these risk factors alone do not fully explain this association with poorer PAD outcomes.12 Social determinants of health, including disparities in housing, health care access, and education, and inequities in personal income and generational wealth all impact health outcomes. These structural barriers limit the equitable access to social, economic, and power resources. In addition, structural racism perpetuates these health disparities and inequities and has been hypothesized to be associated with chronic stress, which can have an impact on health outcomes (“weathering”).13–15 An intersectionality exists between social determinants of health and PAD disparities across race, ethnicity, and income level. Low-income and disenfranchised communities are more likely to have lower-quality school systems, low-wage employment, limited access to high-quality affordable foods,

Risk Factor Epidemiology Data Supporting Amplified Risk (MACE, MALE, or Both) Depression A diagnosis of depression (ICD-9) was identified in 16% of patients with PAD in a VA population.36

14.1% of patients with PAD are seen at specialty clinics with symptoms of depression (PHQ-8). Self-perceived stress (28.7%) and anxiety (8.3%) are also prevalent.39 A Geriatric Depression Score ≥6 was associated with increased MACE during longitudinal follow-up (mean 2.7 y) in an observational study that included 951 patients with PAD.35

In a VA population, a comorbid diagnosis of depression (ICD codes) among patients with PAD was associated with a 13% higher rate of amputation and a 17% higher mortality at a median of 5.9 y follow-up.36 A comorbid diagnosis of depression is associated with a longer length of stay and higher rate of 30-d readmission among patients undergoing major open vascular surgery or peripheral endovascular procedures for PAD.38

ABI indicates ankle-brachial index; ALI, acute limb ischemia; CAD, coronary artery disease; CKD, chronic kidney disease; CLTI, chronic limb-threatening ischemia; COMPASS, Cardiovascular Outcomes for People Using Anticoagulation Strategies; ESKD, end-stage renal disease; EUCLID, Examining Use of Ticagrelor in Peripheral Artery Disease; HR: hazard ratio; ICD, International Classification of Diseases; MACE, major adverse cardiovascular events; MALE, major adverse limb events; MI, myocardial infarction; OR, odds ratio; PAD, peripheral artery disease; PHQ-8, Patient Health Questionnaire-8; VA, US Department of Veterans Affairs; and VOYAGER PAD, Vascular Outcomes Study of ASA (acetylsalicylic acid) Along with Rivaroxaban in Endovascular or Surgical Limb Revascularization for PAD.

Table 9.  Continued

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