Differential burden of peripheral artery disease
Authors: Andre Pascal Kengne, Justin Basile Echouffo-Tcheugui
Journal: The Lancet Global Health (2019)

Coronary heart disease, cerebrovascular disease, and peripheral artery disease are the three leading cardiovascular diseases globally. Although global cardiovascular disease prevention and control has gained momentum in the past few decades, efforts have mostly targeted coronary heart disease and cerebrovascular diseases, the leading cause of deaths worldwide.1GBD 2017 Disease and Injury PrevalenceGlobal, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 1789-1858Summary Full Text Full Text PDF Scopus (4905) Google Scholar Despite the fact that peripheral artery disease has received less 0attention, it appears to be an important contributor to the global burden of deaths and disabilities, with an increasingly higher burden in low-income and middle-income countries (LMICs). According to the Global Burden of Disease of 2017, the worldwide number of prevalent cases of peripheral artery disease in 2017 was 118·1 million and the number of incident cases was 10·8 million, with two thirds of prevalent cases of peripheral artery disease being asymptomatic.1GBD 2017 Disease and Injury PrevalenceGlobal, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 1789-1858Summary Full Text Full Text PDF Scopus (4905) Google Scholar Furthermore, peripheral artery disease caused 515 600 years lived with disability.1GBD 2017 Disease and Injury PrevalenceGlobal, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 1789-1858Summary Full Text Full Text PDF Scopus (4905) Google Scholar In 2017, 70 200 people died from peripheral artery disease, which represents a 55·7% increase compared with 2007, and age-standardised death increased by about 10%. In the absence of ongoing screening programmes, peripheral artery disease remains largely undiagnosed and untreated worldwide, partially because a large proportion of patients have asymptomatic disease. In general, peripheral artery disease has not been prioritised in clinical and public health strategies or in research. Song and colleagues2Song P Rudan D Zhu Y et al.Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: an updated systematic review and analysis.Lancet Glob Health. 2019; 7: e1020-e1030Summary Full Text Full Text PDF PubMed Scopus (281) Google Scholar did a systematic review and analysis to assess the prevalence and risk factors for peripheral artery disease, reported in The Lancet Global Health. They reviewed 118 studies on the prevalence of peripheral artery disease (defined as an ankle–brachial index [ABI] ≤0·90) and the related risk factors, covering the period between Jan 11, 2011, to April 30, 2019, extending their previous systematic review. The investigators used modelling techniques to derive the age-specific and sex-specific prevalence of peripheral artery disease and used random-effects model meta-analyses to derive the pooled odds ratio for the association of risk factors with peripheral artery disease prevalence. Using a risk factor-based model approach, the investigators estimated the number of people with peripheral artery disease for ten regions and 201 countries and territories. In 2015, the global prevalence of peripheral artery disease was 5·56%; the prevalence increased with age, and was higher in high-income countries (HICs) than LMICs overall, but higher in LMICs than HICs among younger men (<55 years) and women (<45 years). In 2015, globally, 236·62 million adults aged 25 years and older had peripheral artery disease, with 72·9% of them being in LMICs. The Western Pacific Region (led by China) had the highest number of adults with peripheral artery disease, and 15 countries accounted for two thirds of the global population with peripheral artery disease. Across HICs and LMICs, the risk factors for peripheral artery disease were consistently ageing, smoking, hypertension, diabetes, and history of other concomitant cardiovascular diseases. To our knowledge, Song and colleagues2Song P Rudan D Zhu Y et al.Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: an updated systematic review and analysis.Lancet Glob Health. 2019; 7: e1020-e1030Summary Full Text Full Text PDF PubMed Scopus (281) Google Scholar have provided the most up-to-date global, regional, and country-level estimates of peripheral artery disease prevalence and description of the related risk factors, on the basis of a comprehensive literature search and rigorous modelling strategies. The burden of peripheral artery disease is increasing faster in LMICs, where the disease is occurring at a much younger age. The major risk factors for peripheral artery disease are shared with other cardiovascular diseases. Estimates of the prevalence of peripheral artery disease were driven by available studies from two countries (China and the USA). It is however difficult to speculate on the probable effect of more data points from diverse settings on the global prevalence estimates of peripheral artery disease. Although the prevalence estimates of peripheral artery disease for Africa were the lowest in the their study,2Song P Rudan D Zhu Y et al.Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: an updated systematic review and analysis.Lancet Glob Health. 2019; 7: e1020-e1030Summary Full Text Full Text PDF PubMed Scopus (281) Google Scholar others have argued that the prevalence of peripheral artery disease in sub-Saharan Africa could be similar to or higher than that of HICs.3Johnston LE Stewart BT Yangni-Angate H et al.Peripheral artery disease in sub-Saharan Africa: a review.JAMA Surg. 2016; 151: 564-572Crossref PubMed Scopus (15) Google Scholar Increases in the population with peripheral artery disease in this study2Song P Rudan D Zhu Y et al.Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: an updated systematic review and analysis.Lancet Glob Health. 2019; 7: e1020-e1030Summary Full Text Full Text PDF PubMed Scopus (281) Google Scholar relative to the 2010 estimates by the same investigators4Fowkes FG Rudan D Rudan I et al.Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis.Lancet. 2013; 382: 1329-1340Summary Full Text Full Text PDF PubMed Scopus (1957) Google Scholar probably reflect the combined effect of time trends and improved precision of estimates afforded by the availability of more data (34 studies in 2010 vs 118 studies in 2015). However, the large differences between Song and colleagues'2Song P Rudan D Zhu Y et al.Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: an updated systematic review and analysis.Lancet Glob Health. 2019; 7: e1020-e1030Summary Full Text Full Text PDF PubMed Scopus (281) Google Scholar estimates and the 2017 estimates from the Global Burden of Disease1GBD 2017 Disease and Injury PrevalenceGlobal, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 1789-1858Summary Full Text Full Text PDF Scopus (4905) Google Scholar deserve considerations beyond differences in modelling and methodological approaches. Regarding the observed age interaction in the prevalence of peripheral artery disease across HICs and LMICs, Song and colleagues2Song P Rudan D Zhu Y et al.Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: an updated systematic review and analysis.Lancet Glob Health. 2019; 7: e1020-e1030Summary Full Text Full Text PDF PubMed Scopus (281) Google Scholar attributed it to the relatively low life expectancy in LMICs. Another explanation could be that the older population in LMICs grew up in a healthier environment, whereas the younger generations have instead developed in a less health-promoting environment, with early exposure to the drivers of cardiovascular disease risk. Peripheral artery disease is often classified into four clinical categories depending on symptoms such as asymptomatic, intermittent claudication, chronic limb ischaemia, or acute limb ischaemia.5Norgren L Hiatt WR Dormandy JA et al.Inter-society consensus for the management of peripheral artery disease (TASC II).Eur J Vasc Endovasc Surg. 2007; 33: S1-S75Summary Full Text Full Text PDF Scopus (2397) Google Scholar Song and colleagues2Song P Rudan D Zhu Y et al.Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: an updated systematic review and analysis.Lancet Glob Health. 2019; 7: e1020-e1030Summary Full Text Full Text PDF PubMed Scopus (281) Google Scholar did not include symptoms in the definition of peripheral artery disease, and therefore do not provide data on the global variations in the subtypes of peripheral artery disease. However, asymptomatic peripheral artery disease accounts for more than 50% of the disease, and typically represents the subgroup of patients who are likely to benefit the most from risk factor modification. Unfortunately, most patients with asymptomatic peripheral artery disease remain undiagnosed and accordingly do not receive treatment. On the basis of ABI values, the severity of peripheral artery disease can be distinguished as mild (ABI 0·7–0·9), moderate (ABI 0·5–0·7), and severe (ABI <0·5).6Aboyans V Criqui MH Abraham P et al.Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart Association.Circulation. 2012; 126: 2890-2909Crossref PubMed Scopus (923) Google Scholar Although ABI is a cost-effective method for screening peripheral artery disease, it can be inaccurate in patients with non-compressible arteries, such as those with diabetes and kidney failure or elderly individuals.7Dachun X Jue L Liling Z et al.Sensitivity and specificity of the ankle-brachial index to diagnose peripheral artery disease: a structured review.Vasc Med. 2010; 15: 361-369Crossref PubMed Scopus (187) Google Scholar Alternatives to ABI for diagnosing peripheral artery disease are invasive or less applicable in community-based studies.8Lau JF Weinberg MD Olin JW Peripheral artery disease. Part 1: clinical evaluation and noninvasive diagnosis.Nat Rev Cardiol. 2011; 8: 405-418Crossref PubMed Scopus (65) Google Scholar The population prevalence of many of the risk factors described by Song and colleagues2Song P Rudan D Zhu Y et al.Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: an updated systematic review and analysis.Lancet Glob Health. 2019; 7: e1020-e1030Summary Full Text Full Text PDF PubMed Scopus (281) Google Scholar are set to increase in the next few decades, and more so in LMICs than HICs.9NCD Risk Factor CollaborationWorldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4·4 million participants.Lancet. 2016; 387: 1513-1530Summary Full Text Full Text PDF PubMed Scopus (2162) Google Scholar Thus, there is a need for more effort into the prevention, detection, and treatment of peripheral artery disease in LMICs. In most settings, preventing the uptake of smoking or promoting cessation,10Peer N Kengne AP Tobacco cessation in low- and middle-income countries: some challenges and opportunities.Addiction. 2018; 113: 1390-1391Crossref Scopus (4) Google Scholar which improves the detection and treatment of major risk factors (eg, hypertension,11Ataklte F Erqou S Kaptoge S Taye B Echouffo-Tcheugui JB Kengne AP Burden of undiagnosed hypertension in sub-Saharan Africa: a systematic review and meta-analysis.Hypertension. 2015; 65: 291-298Crossref PubMed Scopus (311) Google Scholar diabetes, and dyslipidaemia), will substantially reduce the burden of peripheral artery disease. In clinical settings, awareness needs to be increased among health-care providers on the importance of screening for peripheral artery disease, more aggressive risk factor control, and timely initiation of specific therapies. In some settings, these initiatives might require upgrading the health-care system to enable the provision of such treatments. In brief, the burden of peripheral artery disease is potentially higher than that shown by Song and colleagues.2Song P Rudan D Zhu Y et al.Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: an updated systematic review and analysis.Lancet Glob Health. 2019; 7: e1020-e1030Summary Full Text Full Text PDF PubMed Scopus (281) Google Scholar Indeed, the amount of available population-based data on numerous diseases sharply contrasts with the scarcity of data on peripheral artery disease prevalence, yet with little training and equipment, ABI can be easily measured in population-based surveys. Including such a measure in future surveys can substantially improve the understanding of the global burden of peripheral artery disease and inform the refinement of prevention and control strategies. We declare no competing interests. Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: an updated systematic review and analysisPeripheral artery disease continues to become an increasingly serious public health problem, especially in LMICs. With the demographic trend towards ageing and projected rise in important risk factors, a larger burden of peripheral artery disease is to be expected in the foreseeable future. Full-Text PDF Open Access