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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 June 11, 2024 e1333

lower rates of uninterrupted health insurance coverage, and poor access to early and consistent maintenance of primary and specialty health care.16 Collectively, in the United States, these factors result in a 4-fold higher rate of major limb amputation, 30% higher rate of CVD mortality, and 45% higher rate of stroke among Black Americans compared with non-Hispanic White Americans.17,18 Beyond amputation, health disparities in MALE among Black patients with PAD also include worsening rates of functional decline and lower rates of revascularization for CLTI.5–8,19 Health disparities in PAD have been addressed in a recently published AHA scientific statement.2 The AHA has also published a policy statement establishing a comprehensive multipronged strategy to reduce nontraumatic limb amputation that includes addressing health care disparities.17

Recommendation-Specific Supportive Text

1 Evidence of health disparities is common for patients

with PAD.2 These disparities may be readily apparent or difficult to discern. Patient-centric efforts to address health disparities include identifying patients from disenfranchised at-risk populations for symptoms and signs of PAD, such as exertional leg symptoms and impairment in walking abilities, and conducting regular thorough physical examinations, including assessment of the legs and feet and assessment of pulses for those at risk (see Section 2.2, “History and Physical Examination to Assess for PAD”). Once PAD is diagnosed, implementing a plan of care, including GDMT and management of PAD-related risk amplifiers and other high-risk comorbidities, is crucial, recognizing the presence of socioeconomic and other factors that may require further interdisciplinary efforts to implement the care plan (see Section 5, “Medical Therapy and Preventive Foot Care for Patients With PAD,” and Section 6, “Exercise Therapy for PAD”). Longitudinal follow-up of all patients with PAD, particularly those from disadvantaged at-risk populations, is important because the risk of MACE and MALE is high (see Section 12, “Longitudinal Follow-Up of PAD”). Beyond efforts in clinical practice and across

health care systems, opportunities exist for the cardiovascular community and the public health infrastructure to address disparities in PAD care and outcomes. In an AHA call to action to reduce lower extremity amputations, policy recommendations and proposed policies included the following: broad adoption of quality measures for PAD care; affordable prevention, diagnosis, and management tools; regulation of tobacco products; clinical decision support for PAD care; professional education; and dedicated funding opportunities to support PAD research.17 Each of these actions is required to improve PAD-related outcomes among underresourced groups and will require multidisciplinary and multistakeholder investment to address the impact of social determinants of health on outcomes in PAD.

4.2.1. Race and Ethnicity Racial and ethnic disparities in the outcome and care among patients with PAD are important public health issues.1,2 In the United States, the prevalence of PAD is higher among Black patients than White patients, and this gap widens with increasing age.3–6 It has been estimated that lifetime risks of PAD are 30% in Black men and ∼28% in Black women but ∼19% in White men and women and ∼22% in Hispanic men and women.3,7 Black patients in the United States have high rates of risk-amplifying comorbidities, including systemic hypertension, diabetes, and CKD, which are closely related to the development of PAD and higher risk of adverse outcomes.1,8 PAD is identified more often at a later stage in the disease process (ie, CLTI) among Black patients compared with White patients, highlighting opportunities for initiatives focused on early disease detection and improving health care access.9 Significant disparities in prescription of GDMT have been reported among Black patients with PAD, including lower rates of prescription of antiplatelet and statin therapy and lower participation in supervised exercise therapy compared with White patients.10–12 In observational studies of individuals with PAD, Black participants have been shown to have worse functional status and more rapid functional decline, including mobility loss, than White participants.13,14 Rates of PAD-related amputation have served as an objective marker of health disparities, and race and ethnicity are closely tied to amputation risk. In the United States, Black populations, American Indian populations, and Hispanic populations have a higher risk of limb amputation compared with White populations.15–17 Black patients have a 2- to 4-fold higher risk of amputation compared with White patients,18–20 and this disparity is amplified in patients of advanced age (eg, Medicare population ≥65 years).21,22 This also mirrors the higher rates of MACE experienced by the Black population.17,20 Potential mediators of the higher rate of amputation among Black patients with PAD include more frequent presentation with CLTI, lower likelihood of revascularization for CLTI in some but not all published analyses, and greater burden of high-risk comorbidities.23,24 In addition, disparities in both medical insurance and access to experienced health care centers providing multispecialty care for PAD and limb salvage procedures may contribute to the increased potential for lower extremity amputation.25 These factors also contribute to lower rates of revascularization procedures among Hispanic populations.8,26,27 Patients of American Indian descent are densely populated in rural, Western states, creating geographic barriers

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