Amputation rates higher for people with PAD who are poor or Black; other health gaps noted in special issue

Issue Highlights:

• A special issue of the Journal of the American Heart Association focuses on health disparities among people from different races and ethnicities. Topics include limb amputation, maternal health, quality of care and other variations in health care and outcomes.
• One article found poverty and Black race were associated with higher rates of lower leg amputation among people with peripheral artery disease (PAD) who live in metropolitan areas.
• In a separate study, women who had hypertensive disorders before or during pregnancy had a higher risk of heart failure within five years after giving birth. Racial/ethnic differences were observed with heart failure event rates highest among non-Hispanic Black women who experienced hypertensive disorders of pregnancy with and without pre-pregnancy hypertension.

DALLAS, Aug. 25, 2021 — Poverty and Black race were associated with higher rates of lower leg amputation among people with peripheral artery disease who live in metropolitan areas, according to new research published today in a special issue of the Journal of the American Heart Association (JAHA), an open access journal of the American Heart Association.

The analysis on PAD-related amputations is one of 16 new research studies highlighting health disparities among people from diverse population groups and published in the special spotlight issue of JAHA.

JAHA senior associate editor Pamela Peterson, M.D., M.S.P.H., and associate editor Sula Mazimba, M.D., M.P.H, note that while management of cardiovascular disease has reduced death rates over time, there are still “striking disparities” in the U.S. that have widened along racial, ethnic, socio-economic and geographical lines.

“We hope that this issue of JAHA will reinforce the recent America Heart Association’s presidential advisory statement urging all stakeholders to a committed path towards transforming the conditions of historically marginalized communities, improving the quality of housing and neighborhood environments of these populations, advocating for policies that eliminate inequities in access to economic opportunities, quality education and health care, and enhancing allyship among racial and ethnic groups,” they wrote.

The study, Geographic and socioeconomic disparities in major lower extremity amputation rates in metropolitan areas, by Alexander Fanaroff, M.D., M.H.S, et al., is an analysis of national Medicare claims data to determine ZIP code-level variation in rates of amputation among Medicare beneficiaries.

Limb amputation is a serious complication of peripheral artery disease, also known as PAD. PAD is a narrowing of the peripheral arteries that carry blood away from the heart to other parts of the body. The most common type of PAD occurs in the lower extremities of the body, characterized by reduced blood flow to the legs and feet. The most common symptoms of lower-extremity PAD are cramping, fatigue, aching, pain or discomfort in the leg or hip muscles while walking or climbing stairs. This pain usually goes away with rest and returns when you walk again. In some patients with PAD, the disease can progress to cause pain at rest, ulceration or non-healing wounds of the feet, and/or amputation of the foot or limb.

“Limb amputation can be delayed and or prevented by timely and aggressive treatment. However, lack of access to specialized care may delay PAD diagnosis and limit efforts to save the limbs if it has progressed to the advanced disease stage,” explained Fanaroff, an interventional cardiologist and assistant professor of medicine in the cardiovascular medicine division at the University of Pennsylvania in Philadelphia.

Fanaroff and colleagues found that ZIP codes with a higher proportion of Black residents had higher amputation rates than ZIP codes with lower proportions of Black residents. In addition, ZIP codes with lower median household income, more residents eligible for Medicaid and worse scores on the Distressed Communities Index scale (a composite marker of socioeconomic status), had higher amputation rates compared to ZIP codes with higher socioeconomic status, even after adjusting for clinical and demographic characteristics.

“Though amputation rates are generally higher in rural areas, this finding shows that the association between lower socioeconomic status, race and amputation rate extends to major metropolitan areas as well as rural regions,” Fanaroff said. “We found that closer proximity to specialized PAD care within metropolitan areas does not ensure access to high quality care. Strategies targeted to communities with high amputation rates are also needed in urban areas to reduce these disparities.”

A recent American Heart Association scientific statement noted sex and ethnic disparities exist in the diagnosis and treatment of the most severe form of peripheral artery disease, critical limb ischemia.

Another article in the spotlight issue is a retrospective study of more than 425,000 women (ages 12-49; 59% non-Hispanic white women, 31% non-Hispanic Black women and 10% Hispanic women) in South Carolina who gave birth from 2004-2016 and were followed through 2017. The study, Incident Heart Failure within the First and Fifth Year of Delivery among Women with Hypertensive Disorders of Pregnancy and Pre-pregnancy Hypertension in a Diverse Population, by Angela M. Malek, Ph.D., et al., found racial and ethnic differences in heart failure rates among women who experience hypertensive disorders during pregnancy as well as among women who experience hypertensive disorders both before and during pregnancy.

Non-Hispanic Black women who had hypertensive disorders of pregnancy with and without pre-pregnancy hypertension had a higher incident heart failure risk within five years of giving birth compared to non-Hispanic white women without hypertension (before or during pregnancy). Among women who had preeclampsia or other hypertensive disorders during pregnancy, heart failure event rates were substantially higher in non-Hispanic Black women than non-Hispanic white women: 2.28 compared to 0.96 per 1,000 person-years, respectively. In women who had hypertensive disorders of pregnancy with pre-pregnancy hypertension, heart failure event rates were also substantially higher among non-Hispanic Black women than non-Hispanic white women: 4.3 compared to 1.22 per 1,000 person-years, respectively.

“These racial and ethnic differences are important since we already know non-Hispanic Black women experience higher pregnancy-related deaths than non-Hispanic white women,” said Malek. “Clinical and public health prevention efforts are needed to reduce complications and death rates in women who have hypertensive disorders before or during pregnancy as they are at increased risk of heart failure or dying from heart failure within five years.”

Additional research is needed to further examine racial/ethnic differences in maternal incident heart failure after delivery. The clinical and public health implications of this research could inform changes to clinical practice to reduce modifiable cardiovascular risk factors and screening for adverse maternal outcomes in women identified as high risk, according to the study.

Other research featured in the JAHA spotlight issue on health disparities can be accessed in full here and include:

• The Impact of Race on the In-hospital Quality of Care among Young Adults with Acute Myocardial Infarction – Louise Pilote, et al. 

• Racial and Sex Disparities in Anticoagulation after Electrical Cardioversion for Atrial Fibrillation and Flutter – Amgad Mentias, et al.
• Racial disparities in adverse cardiovascular outcomes after a myocardial infarction in young or middle-aged patients – Viola Vaccarino, et al.
• Disease Expression and Outcomes in Blacks and Whites with Hypertrophic Cardiomyopathy – Milla Arabadjian, et al.
• Racial/ethnic and Geographic Disparities in Cardiovascular Health among Women of Childbearing Age in the United States – Hui Hu, et al.
• Lp(a)-associated oxidized phospholipids in healthy African Americans and Caucasians in relation to apo(a) size, age and family structure – Enkhmaa Byambaa, et al.
• An Evaluation of Racial and Ethnic Disparities in Cardiac Transplantation – P. Elliott Miller, et al.
• Trends in pre-pregnancy obesity and association with adverse pregnancy outcomes in the United States, 2013-2018 – Sadiya Khan, et al.
• Recruitment of Black Adults into Cardiovascular Disease Trials – Stephen Juraschek, et al.
• Disease Expression and Outcomes in Blacks and Whites with Hypertrophic Cardiomyopathy – Milla Arabadjian, et al.
• Racial Disparities in Modifiable Risk Factors and Statin Usage in Black Patients with Familial Hypercholesterolemia – Anandita Agarwala, et al.
• Race Differences in Interventions and Survival after out-of-hospital cardiac arrest in North Carolina, 2010-2014 – Sidsel Moeller, et al.
• Cardiovascular Health Disparities in Racial and Other Minorities: Initial Results from the All of Us Research Program – Guido Falcone, et al.
• Brain white matter structure and amyloid deposition in Black and White older adults: The ARIC-PET Study – Keenan Walker, et al.

Additional Resources:

Statements and conclusions of studies published in the American Heart Association’s scientific journals are solely those of the study authors and do not necessarily reflect the Association’s policy or position. The Association makes no representation or guarantee as to their accuracy or reliability. The Association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers and the Association’s overall financial information are available here.

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