Risk of peripheral artery disease according to race and sex: The Atherosclerosis Risk in Communities (ARIC) study
Graphical abstract
Introduction
Women have a lower cumulative lifetime risk of atherosclerotic cardiovascular disease than men [[1], [2], [3]]. However, several epidemiologic studies based on ankle-brachial index (ABI) have demonstrated a similar or higher prevalence of peripheral artery disease (PAD) in women compared to men [[4], [5], [6]]. Although the higher prevalence in women may be partially due to lower ABI in persons with shorter height [7], women also tend to have more advanced disease upon presentation with PAD than men [8]. To our knowledge, there are no prospective studies that have evaluated the association of sex with incident PAD, including its severe form, critical limb ischemia (CLI).
There have also been a number of studies describing racial disparities in PAD. In a recent meta-analysis comparing PAD prevalence in different ethnic groups, Blacks were found to have the highest prevalence of disease, followed by Whites and south Asians, respectively [9]. Black patients have been shown to have a higher likelihood of lower extremity amputation compared to White patients [10,11], suggesting a higher prevalence of CLI in Blacks.
The aim of this study was to quantify the risk of PAD- and CLI-related hospitalizations according to sex and race using data from the Atherosclerosis Risk in Communities (ARIC) Study. We hypothesize that incident PAD- and CLI-related hospitalizations will be similar between men and women, and higher in Black participants compared to White participants.
Section snippets
Study cohort
The ARIC Study is a prospective community-based cohort study that enrolled 15,792 adults between 1987 and 1989 from four U.S. communities, including Washington County, Maryland, suburban Minneapolis, Minnesota, Jackson, Mississippi, and Forsyth County, North Carolina. Participants were between 45 and 64 years of age at baseline, and have been followed with serial in-person assessments and hospitalization surveillance. For this analysis, we excluded participants with races other than Black or
Baseline characteristics
Among the 13,451 ARIC participants analyzed, 45.7% (N = 6143) were male and 24.0% (N = 3221) were Black. Within the White cohort, 48.1% (N = 4920) were male. Within the Black cohort, 38.0% (N = 1223) were male. Participant socioeconomic factors, comorbidities, blood pressure, and plasma cholesterol levels differed across sex-race categories (Table 1). In both the White and Black race groups, females tended to have a higher prevalence of anti-hypertensive use and heart failure but a lower
Discussion
Based on 26 years of follow-up in Black and White participants in the ARIC study, we found that the crude cumulative incidence of PAD-related hospitalization was higher for males than females in Whites but not in Blacks. The crude cumulative incidence of CLI was largely similar for males and females within race groups. After adjusting for covariates, Blacks had the highest risk of incident CLI-related hospitalization regardless of sex. The elevated risk of PAD and CLI in White males compared to
Financial support
The Atherosclerosis Risk in Communities study has been funded in whole or in part with Federal funds from the National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, under Contract No. (HHSN268201700001I, HHSN268201700002I, HHSN268201700003I, HHSN268201700005I, HHSN268201700004I). Dr. Hicks was supported by NIH/NIDDK grant K23DK124515. Dr. Selvin was supported by NIH/NIDDK grants K24DK106414 and R01DK089174. Dr. Matsushita was supported
Author contributions
CWH, ND, LK, and KM designed and conceptualized study and analyzed the data. CWH, ND, LK, SB, CAK, ARF, GH, JC, JHB, ES, and KM interpreted the data. CWH, ND, and KM drafted the manuscript for intellectual content. LK, SB, CAK, ARF, GH, JC, JHB, and ES revised the manuscript for intellectual content.
CRediT authorship contribution statement
Caitlin W. Hicks: Conceptualization, Formal analysis, designed and conceptualized study and analyzed the data, interpreted the data, Writing – original draft, drafted the manuscript for intellectual content. Ning Ding: Conceptualization, Formal analysis, designed and conceptualized study and analyzed the data, interpreted the data, Writing – original draft, drafted the manuscript for intellectual content. Lucia Kwak: Conceptualization, Formal analysis, designed and conceptualized study and
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
The authors thank the staff and participants of the ARIC study for their important contributions.
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2022, European Journal of Vascular and Endovascular SurgeryCitation Excerpt :Such therapies are consistently recommended by all major societies.5–7 However, despite clear guideline recommendations regarding medical treatment of patients, implementation of those guideline recommendations is inadequate and depends on social status and race.8,9 The present authors recently reported underuse of guideline recommended therapy for statutorily insured PAD patients in Germany, highlighting treatment opportunities.10