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CLINICAL STATEMENTS AND GUIDELINES

June 11, 2024 Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 e1334

to vascular care access and a higher likelihood of presentation at a more advanced stage of PAD with CLTI.28 Hispanic patients experienced lower prevalence rates of PAD compared with either Black patients or American Indian patients.3,29 Disease prevalence notwithstanding, amputation rates within the Hispanic population are similar to those of the Black population, with lower rates of revascularization compared with White patients.27 This may be explained partly by the finding that Hispanic populations have the highest reported rates of being uninsured among all racial and ethnic groups and may further lack basic access to medical care because of communication (eg, language) barriers.30,31 The disproportionately higher risk of amputation among patients of underrepresented racial and ethnic groups may also reflect systemic bias. For example, previous studies have shown that Black patients with PAD are more likely to undergo amputation without attempts at revascularization and are more frequently treated with proximal amputation than White patients, which may be driven by factors such as fragmented access to care.13,24,26,27,32–34 Implementation of interventions to address the racial disparity gap in amputation and revascularization has been identified as an advocacy priority for PAD (see Section 13.2, “Advocacy Priorities”). In addition, increasing the participation of Black individuals and other underrepresented groups in clinical trials across the clinical spectrum of PAD is important.

4.2.2. Female Sex Based on US Census data, the estimated burden of PAD among women who are >40 years of age is greater than that of men who are >70 years of age.1 Women with PAD present, on average, 10 to 20 years later than men.1 Compared with men with PAD, women with PAD tend to present with more atypical leg symptoms, are older, and have more advanced disease.2 Women with PAD also have poorer functional status and greater ambulatory limitations than men with PAD at similar ABI values.3 Studies have shown mixed effects of sex on MACE among women compared with men with PAD, although event rates are high in both groups.1,4,5 Further studies are needed to understand sex-related differences in PAD risk, presentation, and outcomes in women.1,4 It has been shown that MALE among patients with PAD vary by sex.1,2 Women are at greater risk of undergoing above-knee versus below-knee amputation, which has lasting consequences on mobility and morbidity.6 Women with PAD are more likely to receive endovascular revascularization versus surgical revascularization and have increased periprocedural mortality irrespective of the procedure performed.7 Despite the prevalence of PAD in women and opportunities for improvement in MACE and MALE outcomes, women are underrepresented in contemporary PAD cohorts and RCTs as well as trials of therapies for atherosclerotic CVD in general.8–10

4.2.3. Geography and Socioeconomic Status The geographic location of a patient with PAD has been shown to be associated with MALE. Patients in rural areas are at a greater risk of amputation than patients in urban areas.1 Although this relationship is strongest among those who are also from high-risk racial or ethnic groups, disparities in care also affect White patients living in rural areas.2–4 Rural residents tend to be older, be more economically disadvantaged, have higher burdens of comorbidities, and practice riskier health behaviors (eg, ongoing smoking) than their urban counterparts.4,5 These factors are magnified by greater barriers to health care access because of geographic isolation and clinician shortages.6,7 The impact of geography, socioeconomic status, race, and other social determinants of health on PAD-related outcomes are undoubtedly interrelated and apply to urban as well as rural areas. In an analysis of Medicare data, among beneficiaries living in zip codes of metropolitan (urban) areas, Black race, lower median household income, and higher zip code score of the Distressed Communities Index were factors associated with amputation.8 The Distressed Communities Index is a metric that scores communities based on economic factors associated with social determinants of health, including percentage of individuals with no high school diploma, housing vacancy rate, percentage of adults not working, poverty rate, median income, and change in employment.9

4.3 Considerations in Management of PAD in

Older Patients Recommendation for Management of PAD in Older Patients Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation

2a B-NR 1.	 In older patients (ie, ≥75 years of age) with PAD,

assessment for geriatric syndromes (Table 10), such as frailty, sarcopenia, malnutrition, and mobility impairment, can be useful to identify high-risk patients, including before revascularization, and to provide safe and goal-concordant care.1–15

Synopsis PAD disproportionately affects individuals in the later decades of life, with an estimated prevalence of >15% among those >80 years of age.16 Therefore, the identification of PAD is important in at-risk older patients (previously defined in ACC/AHA guidelines as ≥75 years of age)17 through routine assessment comprising history and physical examination including the assessment of the leg and foot and pulses. This is essential because the concomitant presence of geriatric syndromes (Table 10), such as frailty, sarcopenia, malnutrition,

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