Peripheral artery disease: epidemiology and global perspectives

Journal name:
Nature Reviews Cardiology
Volume:
14,
Pages:
156–170
Year published:
DOI:
doi:10.1038/nrcardio.2016.179
Published online

Abstract

Global populations are undergoing a major epidemiological transition in which the burden of atherosclerotic cardiovascular diseases is shifting rapidly from high-income to low-income and middle-income countries (LMICs). Peripheral artery disease (PAD) is no exception, so that greater focus is now required on the prevention and management of this disease in less-advantaged countries. In this Review, we examine the epidemiology of PAD and, where feasible, take a global perspective. However, the dearth of publications in LMICs means an unavoidable over-reliance on studies in high-income countries. Research to date suggests that PAD might affect a greater proportion of women than men in LMICs. Although factors such as poverty, industrialization, and infection might conceivably influence the development of PAD in such settings, the ageing of the population and increase in traditional cardiovascular risk factors, such as smoking, diabetes mellitus, and hypertension, are likely to be the main driving forces.

At a glance

Figures

  1. Measurement and calculation of ankle-brachial index (ABI) in diagnosing peripheral artery disease.
    Figure 1: Measurement and calculation of ankle–brachial index (ABI) in diagnosing peripheral artery disease.

    ABI is the ratio of a | the higher systolic blood pressure between the posterior tibial artery and the dorsalis pedis artery to b | the higher systolic blood pressure between both arms. Note that the dorsalis pedis artery is just distal to the anterior tibial artery shown in the figure. Reprinted from Tendera, M. et al. ESC guidelines on the diagnosis of peripheral artery diseases. Eur. Heart J. 32 (22), 2851–2906 (2011), with permission from Oxford University Press and the European Society of Cardiology.

  2. Classification of high-income, middle-income, and low-income countries.
    Figure 2: Classification of high-income, middle-income, and low-income countries.

    The map classifies all World Bank country member economies and all other economies with populations >30,000. Economies are divided among income groups according to 2015 gross national income per capita. OECD, Organisation for Economic Co-operation and Development. Source: The World Bank Group. Reprinted with permission from ChartsBin statistics collector team 2016, Country Income Groups (World Bank Classification), http://chartsbin.com/view/2438.

  3. Number of people with PAD in 2000 and 2010, grouped by age in HICs and LMICs.
    Figure 3: Number of people with PAD in 2000 and 2010, grouped by age in HICs and LMICs24.

    The numbers of patients are estimated by applying age-specific and sex-specific prevalence rates of a low ankle–brachial index (≤0.9) to age groups within the populations. A greater increase in prevalence occurred between 2000 and 2010 in LMICs than in HICs. More than half of the patients in LMICs were aged <55 years and were likely to be asymptomatic. HIC, high-income country; LMIC, low-income or middle-income country; PAD, peripheral artery disease.

  4. Risk factors for peripheral artery disease in HICs and LMICs.
    Figure 4: Risk factors for peripheral artery disease in HICs and LMICs.

    The odds ratios for peripheral artery disease, which are based on multivariate analyses of risk factors, have a similar pattern in HICs and LMICs, except for an increased risk for men compared with women in HICs and vice versa in LMICs. For the traditional risk factors of smoking, diabetes mellitus, and hypertension, the odds ratios were higher in HICs than in LMICs, which might be caused by a shorter duration of exposure in LMICs. HIC, high-income country, LMIC, low-income and middle-income country. Reprinted with permission from Criqui, M. H. & Aboyans, V. Epidemiology of peripheral artery disease. Circ. Res. 116 (9), 1509–1536 (2015).

  5. Possible effects of industrialization and urbanization in low-income and middle-income countries on risk of peripheral artery disease.
    Figure 5: Possible effects of industrialization and urbanization in low-income and middle-income countries on risk of peripheral artery disease.

    Rapid economic development with industrialization and urbanization can lead to an increase in less-studied risk factors for peripheral artery disease. Supposedly beneficial developments such as improved transport links can be counterproductive by increasing the risk of disease. Note that lack of exercise might promote development of peripheral artery disease, but might also lead to a reduced detection of exercise-related symptoms.

  6. Systematic review of all-cause mortality ratios in patients with asymptomatic or symptomatic PAD compared with individuals without PAD.
    Figure 6: Systematic review of all-cause mortality ratios in patients with asymptomatic or symptomatic PAD compared with individuals without PAD.

    The results are fairly consistent between the individual studies, and show an increased mortality for individuals with either symptomatic or asymptomatic PAD. The higher mortality ratios for the 1992 publication reflect stricter diagnostic criteria for PAD in that study. Asymptomatic PAD defined as ankle–brachial index <0.9 without clinical manifestations. Symptomatic PAD defined as diagnosed intermittent claudication or critical limb ischaemia. Reference group with no PAD, defined as no symptoms and ankle–brachial index 0.9–1.4. PAD, peripheral artery disease. Reprinted with permission from Sigvant, B. et al. The risk of disease progression in peripheral arterial disease is higher than expected: a meta-analysis of mortality and disease progression in peripheral arterial disease. Eur. J. Vasc. Endovasc. Surg. 51 (3), 395–403 © (2016), with permission from Elsevier.

  7. DALYs from peripheral artery disease per 100,000 population in world regions in 2010.
    Figure 7: DALYs from peripheral artery disease per 100,000 population in world regions in 2010.

    DALYs are a composite of years of life lost owing to premature death and years lived with disability. Around the world, the DALY rate for peripheral artery disease tends to be higher in more developed regions. DALY, disability-adjusted life year. Modified from Sampson, U. K. et al. Global and regional burden of death and disability from peripheral artery disease: 21 regions, 1990 to 2010. Glob. Heart 9 (1), 145–158.e21 © (2014), with permission from Elsevier.

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Author information

  1. These authors contributed equally to this work.

    • F. Gerry R. Fowkes &
    • Victor Aboyans

Affiliations

  1. Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK.

    • F. Gerry R. Fowkes
  2. Department of Cardiology, Dupuytren University Hospital, 2 Avenue Martin Luther King, 87000 Limoges, France.

    • Victor Aboyans
  3. Centre for Population Health, Burnet Institute, 85 Commercial Road, Melbourne, Victoria 3004, Australia.

    • Freya J. I. Fowkes
  4. Department of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine, 675 North Saint Clair, Chicago, Illinois 60611, USA.

    • Mary M. McDermott
  5. Center for Translational Research and Implementation Science, National Heart, Lung and Blood Institute, National Institutes of Health, 6705 Rockledge Drive, Bethesda, Maryland 20824, USA.

    • Uchechukwu K. A. Sampson
  6. Department of Family Medicine and Public Health, University of California San Diego, 9500 Gilman Drive, La Jolla, California 92093, USA.

    • Michael H. Criqui

Contributions

F.J.I.F. researched data for the article. F.G.R.F., V.A., M.M.M., U.K.A.S., and M.H.C. discussed the content of the article, and F.G.R.F., V.A., and F.J.I.F. wrote the manuscript. All the authors reviewed/edited the article before submission.

Competing interests statement

The authors declare no competing interests.

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Author details

  • F. Gerry R. Fowkes

    F. Gerry R. Fowkes is Emeritus Professor of Epidemiology at the University of Edinburgh, UK. He was director of the Centre for Population Health Sciences and of the Wolfson Unit for the Prevention of Peripheral Vascular Diseases in the Edinburgh Medical School, and was founding editor of the Cochrane Collaboration Vascular Group. He has conducted national and international studies on the epidemiology of peripheral artery disease, chronic venous disease, and aortic aneurysms. These include the Edinburgh Artery Study, Edinburgh Vein Study, Ankle Brachial Index Collaboration, and Aspirin for Asymptomatic Atherosclerosis trial. Recognition of his research has included awards of AHA Distinguished Research Scientist and Thomson Reuters Highly Cited Researcher.

  • Victor Aboyans

    Victor Aboyans is Professor of Cardiology at Limoges University and head of the Department of Cardiology at Dupuytren University Hospital in Limoges, France. He has authored >140 scientific papers, mostly in the field of cardiovascular epidemiology and prevention. He is past president of the Working Group on Thrombosis & Vascular Diseases of the French Society of Cardiology, and current vice-president of the Working Group on Aorta & Peripheral Vascular Diseases of the European Society of Cardiology. He co-chaired the 2011 ESC guidelines on the diagnosis and management of peripheral arterial diseases, the 2014 ESC guidelines on the diagnosis and management of aortic diseases, and the AHA scientific statement on the ankle–brachial index in 2012. He is a fellow of the ESC and international fellow of the AHA.

  • Freya J. I. Fowkes

    Freya J. I. Fowkes is head of Malaria and Infectious Disease Epidemiology and Principal Research Fellow at the Burnet Institute, Australia. She trained in parasitology at the University of Glasgow, UK, and then obtained an MSc in Epidemiology from the London School of Hygiene and Tropical Medicine, UK, before completing her doctorate in Infectious Disease Epidemiology at the University of Oxford, UK. She is honorary Associate Professor in the School of Population and Global Health at the University of Melbourne and adjunct Senior Research Fellow in the Department of Epidemiology and Preventive Medicine, Monash University, Australia.

  • Mary M. McDermott

    Mary M. McDermott is the Jeremiah Stamler Professor of Medicine and Professor of Preventive Medicine at Northwestern University Feinberg School of Medicine, USA. She is a general internist and a clinician investigator whose research focuses on lower extremity peripheral artery disease (PAD). Her research has objectively defined the magnitude of functional impairment, functional decline, and mobility loss in people with PAD including those without exertional leg pain. More recently, her research programme consists of randomized clinical trials designed to identify medical therapies to improve lower extremity functional performance and prevent functional decline in people with PAD. She is also an elected member of the American Society of Clinical Investigation and the American Association of Physicians.

  • Uchechukwu K. A. Sampson

    Uchechukwu K. A. Sampson is the chief of the Translation Research Branch in the Center for Translation Research and Implementation Science, NIH/NHLBI, USA. His career was supported by prestigious awards such as the Harold Amos Medical Faculty Development Award of the Robert Wood Johnson Foundation, the Vanderbilt Clinical and Translational Scholars Award, the American College of Cardiology Foundation/General Electric Career Development Award, and the Future Leaders in Cardiovascular Medical Research Award from Merck/Schering-Plough administered by the Leadership Council for Improving Cardiovascular Care. He served on the expert panel for Peripheral Arterial Disease and Abdominal Aortic Aneurysms in the Global Burden of Disease 2010 Project.

  • Michael H. Criqui

    Michael H. Criqui is Distinguished Professor in the Department of Family Medicine and Public Health and in the Department of Medicine at the University of California, San Diego School of Medicine, USA. He is director of the UCSD T32 training programme in cardiovascular disease epidemiology and prevention. He is an active and productive investigator in cardiovascular epidemiology and preventive cardiology, has made seminal contributions in the fields of peripheral vascular disease, subclinical atherosclerosis, and cardiovascular risk prediction. He has received several national and international awards, including in 2010 being named a Distinguished Scientist of the AHA.

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