Peripheral artery disease is out of control in many rural, low income communities
There is a peripheral artery disease (PAD) epidemic in the United States leading to more than 400 leg amputations per day. The individuals hit hardest by this trend are the underserved patients in rural and low income areas. To gain any improvements in this area, more public awareness is needed to help get these patients the care they need before amputation is the only viable option.
This prompted the PAD Pulse Alliance to launch a 2024 public and physician awareness campaign. The partners of the group include the Association of Black Cardiologists (ABC), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Interventional Radiology (SIR) and Society of Vascular Surgery (SVS).
Cardiovascular Business spoke to one of physicians involved on the frontline of this epidemic, Kumar Madassery, MD, director of the peripheral vascular intervention and critical limb ischemia (CLI) program at Rush University Medical Center in Chicago.
"My practice here in the city of Chicago is primarily based on limb salvage," he said. "Unfortunately, the patients I tend to see have already gone through the process of having wounds on their foot that will not heal because they do not have enough blood flow, their diabetes is out of control, and unfortunately a large proportion of them ... get a major amputation."
He said many patients he sees have diabetes, hypertension and a history of smoking. Often they start to experience leg pain and need to stop and rest before they can move again and write it off to getting older. But, Madassery said the underlying issue is often advanced PAD. If left untreated, it can advance to CLI, which often results in the amputation of toes, feet and legs if not treated in time to restore blood flow to the tissues.
If a patient has a major amputation above the ankle, this results in a mortality rate of more than 55%. Madassery said this is a higher death rate than most cancers.
"From a national and international stance, we just have not done a good job of educating or raising awareness in how to prevent patients from ever getting to this point. Although I love the fact that I do these complex procedures and work with surgeons to save a leg, we have got to work better together to never have a patient in this disease spectrum of the later stages of this arterial disease," Madassery said.
He said a lot of patients he helps are caught in wound care clinics where they have foot ulcers that do not heal. He works with wound care physicians, diabetes and infection control specialists who refer patients because of suspected PAD.
Symptoms of peripheral artery disease that should be referred
Madassery said primary care and clinic physicians should be able to recognize the signs of PAD and make sure these patients are referred to vascular specialties, which can be interventional cardiologists, interventional radiologists or vascular surgeons. Most PAD and CLI patients will have diabetes, smoking history and hypertension. When they start to have pain in their legs or thighs caused by walking, they need to be evaluated for PAD and possibly see a specialist.
Noninvasive testing can be performed using ankle brachial index (ABI) screenings. These test system take blood pressure from the arms and legs to evaluate how much blood is circulating in there leg or foot compared to what the patient's heart is pumping. These measurements can show if a patient likely had PAD.
After that, a patient can be managed conservatively with medication for hypertension, diabetes and cholesterol. If that is not enough because the disease has already progressed to critical stages, vascular specialists can intervene with catheter-based or surgical approaches to restore blood flow.
Chicago Black and low income areas mirror high leg amputation rates
Rush is located on the edge of both the west and south sides of Chicago, where many patients are Black, Hispanic. These areas also include a lot of low-income patients. Madassery said these populations are all disproportionally impacted by PAD, CLI and amputation rates compared to white and wealthier areas of the Chicago area. He pointed to heat maps from a 2021 American Heart Association (AHA) study that looked at Chicago and several other major cities, where these health inequity trends trends were the same across the country.[1]
"What we see isn Chicago mirrors what we see around the country, in that these healthcare deserts where their is low access to care or detection of disease is only in late stages are the same areas with the highest amputation rates," he explained. He added that these areas often lack healthy food options, which contributes directly to a patient's ability to stay healthy.
When patients do not have convenient access to care or are afraid of the costs of care, they may not even seek help until it is too late, Madassery explained. Black and Hispanic patients sometimes do not trust mainstream healthcare providers, he added, where a majority of doctors and nurses are white. Madassery suggests working with community organizations or churches in the impacted communities to try and reach these populations.
"Everyone needs to do a better job of working together. The biggest thing we see that is detrimental to patients is a lot of physicians working in silos, fragmented care. If we all keep in mind what the ultimate goal is we will have an easier time working together. There are not a lot of physicians who can treat these patients, but we can make a significant impact if we work together."
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com