Association of peripheral artery disease and chronic limb-threatening ischemia with socioeconomic deprivation in people with diabetes: A population data-linkage and geospatial analysis

Lifetime risk of lower extremity peripheral arterial disease: a Danish nationwide longitudinal study

BACKGROUND AND AIMS

Lower extremity peripheral arterial disease (PAD) presents a substantial disease burden, yet lifetime estimates remain scant. This nationwide study quantified the lifetime risk of PAD and its clinical outcomes in Denmark.

METHODS

This cohort study included 4 275 631 individuals in Denmark aged 40-99 years between 1998 and 2018. We estimated the lifetime risk using a modified survival analysis method, considering death as a competing risk event.

RESULTS

Over a median 15.5-year follow-up, 151 846 individuals were diagnosed with PAD (median age at diagnosis 71.5 years, interquartile range 63.1-79.2). The overall lifetime risk of PAD from age 40 was 11.6% (95% confidence interval 11.6%-11.7%), decreasing from 12.9% in 1998-2002 to 10.7% in 2013-18. Males had a higher lifetime risk than females (12.8% vs. 10.5%). Socioeconomic disparities were evident, with higher risks for those with lower educational levels (risk difference 3.4%, 95% confidence interval 3.2%-3.6%) and lower income (risk difference 0.4%, 95% confidence interval 0.2%-0.5%). One year after PAD diagnosis, 21.4% had undergone lower limb revascularization, 8.0% had experienced a major amputation, and 16.2% had died. At 5 years, the corresponding proportions were 26.4%, 10.8%, and 40.8%, respectively. The risk of lower limb revascularization showed little variation by sex and socioeconomic status, whereas there was a strong socioeconomic gradient for major amputation and all-cause death.

CONCLUSIONS

More than one in 10 Danish individuals are diagnosed with symptomatic PAD during their lifetime. Peripheral arterial disease diagnosis is associated with high morbidity and mortality at 1 and 5 years.

Impact of regional differences and neighborhood socioeconomic deprivation on the outcomes of patients with lower extremity wounds evaluated by a limb-preservation service

OBJECTIVE

Management of lower extremity (LE) wounds has evolved with the establishment of specialized limb preservation services. Although clinical factors contribute to limb outcomes, socioeconomic status and community factors also influence the risk for limb loss. The Distressed Community Index (DCI) score is a validated index of social deprivation created to provide an objective measure of economic well-being in United States communities. Few studies have examined the influence of geographic deprivation on outcomes in patients with LE wounds. We examined relationships between socioeconomic deprivation and outcomes of inpatients evaluated by a dedicated limb preservation service (Functional Limb Extremity Service [FLEX]).

METHODS

Inpatients referred to FLEX over a 5-year period were included. Wound, Ischemia, foot Infection (WIfI) staging was collected. DCI scores were determined using seven indices based on ZIP Code. Outcomes included any minor or major amputations, any endovascular or open LE revascularization, or wound care procedures. Disease etiology, demographic, and anthropometric data were collected. Associations between neighborhood deprivation and limb-specific outcomes were evaluated in models for the DCI and each of its components separately.

RESULTS

A total of 677 patients were included. Thirty-eight percent were female, with a mean age of 64 years. Sixty percent had WIfI stage 3 or 4 risk of amputation, and 43% had WIfI stage 3 or 4 risk of revascularization. Mean ankle-brachial index and toe pressure were 0.96 (standard deviation [SD], 0.43) and 80 (SD, 57) mmHg. Thirty-five percent were non-White. Amputation was performed in 31% of patients, whereas 17% underwent revascularization. The mean distress score was 64 (SD, 24). Mean DCI scores did not differ across WIfI scores. Likewise, overall DCI distress score was not related to any of the outcomes in univariable or multivariable linear regression models. In univariable linear regression models for amputation, higher poverty rate (odds ratio for SD increase 1.20; 95% confidence interval, 1.02-1.42; P = .025) was significantly associated with the outcome. In multivariable models, neither DCI distress score nor any of its components remained significantly associated with the outcome.

CONCLUSIONS

Despite known racial disparities in limb-specific outcomes, an aggregate measure of community level distress was not found to be related to outcomes. Although the poverty rate demonstrated a significant relationship with amputation in univariable analysis, this association was not found in multivariable models. Notably, non-White race emerged as a predictor of amputation, underscoring the importance of addressing racial disparities in LE outcomes. Further investigation of potential determinants of LE outcomes is needed, particularly the interaction of such factors with race.

Assessing the influence of rural residence and economic distress on lower extremity risk stratification among diabetic foot ulcer patients utilizing the Wound, Ischemia, and Foot Infection (WIfI) classification system

OBJECTIVE

Diabetic foot ulcers (DFU) are a major sequela of uncontrolled diabetes with a high risk of adverse outcomes. Poor DFU outcomes disproportionately impact patients living in rural and economically distressed communities with lack of access to consistent, quality care. This study aimed to analyze the risk of geographic and economic disparities, including rural status and county economic distress, on the disease burden of DFU at presentation utilizing the SVS WIfI classification system.

METHODS

We conducted a retrospective review of 454 patients diagnosed with a DFU from 2011 to 2020 at a single institution's inpatient and outpatient wound care service. Patients >18 years old, with type II diabetes mellitus, and diabetic foot ulcer were included.

RESULTS

ANCOVA analyses showed rural patients had significantly higher WIfI composite scores (F(1,451) = 9.61, p = .002), grades of wound (F(1,439) = 11.03, p = .001), and ischemia (F(1,380) = 12.574, p = .001) compared to the urban patients. Patients that resided in at-risk economic counties had significantly higher overall WIfI composite scores (F(2,448) = 3.31, p = .037) than patients who lived in transitional economic counties, and higher foot infection grading (F(2,440) = 3.02, p = .05) compared to patients who lived in distressed economic counties. DFU patients who resided in distressed economic counties presented with higher individual grades of ischemia (F(2, 377) = 3.14, p = .04) than patients in transitional economic counties. Chi-Square analyses demonstrated patients who resided in urban counties were significantly more likely to present with grade 1 wounds (χ2(3) = 9.86, p = .02) and grade 0 ischemia (χ2(3) = 16.18, p = .001) compared to patients in rural areas. Economically distressed patients presented with significantly less grade 0 ischemia compared to patients in transitional economic counties (χ2(6) = 17.48, p = .008).

CONCLUSIONS

Our findings are the first to demonstrate the impact of geographic and economic disparities on the disease burden of DFU at presentation utilizing the SVS WIfI classification system. This may indicate need for improved multidisciplinary primary care prevention strategies with vascular specialists in these communities to mitigate worsening DFU and promote early intervention.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

Experiences and impact of a rural Australian high-risk foot service: A multiple-methods study

OBJECTIVE

Most podiatry-led high-risk foot services (HRFS) in Australia are located in metropolitan areas or large regional centres. In rural areas, where there are limited specialist services, individuals with diabetes-related foot ulceration are more likely to undergo amputation. This study aimed to explore clinicians' perceptions of a recently implemented HRFS in rural New South Wales, Australia, and compare trends of amputation and hospitalisation prior to and post-implementation of the service.

SETTING

Rural HRFS in Tamworth, New South Wales, Australia.

PARTICIPANTS

Health professionals working within the HRFS were recruited to participate.

DESIGN

This was a multiple-methods study. For the qualitative arm, semi-structured interviews were conducted, which were analysed using a reflexive thematic approach. The quantitative arm of the study utilised a retrospective analytic design which applied an interrupted time series to compare amputation and hospitalisation trends pre- and post-implementation of the HRFS utilising diagnostic and procedural ICD codes.

RESULTS

The qualitative arm of the study derived three themes: (1) navigating the divide, (2) rural community and rural challenges and (3) professional identity. Results of the interrupted time series indicate that there was a downward trend in major amputations following implementation of the HRFS; however, this was not statistically significant.

CONCLUSION

Clinicians were aware of the inequity in DFD outcomes between rural and metropolitan areas and were committed to improving outcomes, particularly with respect to First Nations peoples. Future research will explore service use and amputation rates in the longer term to further evaluate this specialised multidisciplinary care in a rural community.

End of Life Care for Unplanned Vascular Admissions

BACKGROUND

Unplanned vascular admissions have a high mortality. Previous studies have indicated that end of life care (EoLC) among this group of patients is low but there exist limited data on EoLC in the United Kingdom. The aim of this study was to evaluate the quality and predictors of EoLC for unplanned vascular admissions to a tertiary center in the United Kingdom.

METHODS

This was a retrospective single-center cohort study of unplanned vascular surgery admissions from August 1, 2019 to January 22, 2020. Data on patient demographics, markers of quality of palliative care, mortality, and cause of death of unplanned admission to the vascular surgery department were collected from hospital and general practitioner records and evaluated against EoLC to evaluate predictors and efficacy of EoLC. Quality of palliative care markers included documentation of preferred place of death and care priorities, time spent in hospital and the intensive care unit toward the end of life, and realization of documented care objectives. EoLC input was defined as a dedicated palliative care consultation (PCC) by a palliative care professional, medical doctor, surgeon, or advanced care practitioner. We also conducted a subgroup analysis of patients within this group with chronic limb-threatening ischemia (CLTI), diabetic foot, and ruptured aortic aneurysms, as all patients in this group should be offered EoLC according to international guidelines.

RESULTS

One-hundred and fifty patients were included. Median age at presentation was 70.5 years, and the cohort consisted of mostly men (72%). CLTI (31%) was the most common reason for admission. Surgical intervention was carried out in 60% of patients. Two-year mortality was 36%, and pneumonia (22%) was the most common cause of death. Seven percent of patients received PCC, which occurred a median of 10 days before death. Only a minority of patients had preferred place of care/death (14%), care priorities (37%), and family involvement during advance care planning (17%) documented in their notes; 29% of patients had Recommended Summary Plan for Emergency Care and Treatment forms in place. A diagnosis of left ventricular systolic dysfunction, chronic kidney disease, and increasing age predicted Recommended Summary Plan for Emergency Care and Treatment form completion. Patients with PCC were more likely to have advance care planning, but this did not translate into improvements in the other markers of quality of palliative and, consequently, EoLC.

CONCLUSIONS

EoLC was insufficient and of low quality despite a high mortality in this group. Clinical guidelines and pathways are needed to ensure these patients are considered for EoLC and those with CLTI, diabetic foot sepsis or ruptured abdominal aortic aneurysms are offered it by default. Further research is needed to help identify vascular patients who would benefit from EoLC earlier to improve quality at end of life.

Association Between Mental Health Burden, Clinical Presentation, and Outcomes in Individuals With Symptomatic Peripheral Artery Disease: A Scientific Statement From the American Heart Association

Along with the rising burden of peripheral artery disease (PAD), mental health concerns are increasingly being recognized as a comorbidity to address in the chronic disease management of symptomatic PAD. Apart from a high prevalence of comorbid mental health conditions, the role of pain and changing health behaviors and the broader impacts of illness and adaptation to living with PAD require specialized behavioral health expertise. This scientific statement builds a case that this expertise should be integrated within the multidisciplinary PAD team. Furthermore, areas such as cognitive dysfunction and palliative care are highlighted as needing psychological interventions. Although much of the evidence of the efficacy of psychological and psychotropic interventions has been extrapolated from other cardiovascular populations, evidence for the role of psychological interventions for behavior change, for example, uptake of exercise regimens, is increasingly being accrued within PAD. Areas for behavioral health needs and interactions with PAD treatment are discussed, including the use of opioids, depression management, anxiety and stress reduction interventions, the use of benzodiazepines and antidepressants, smoking cessation, rehabilitation trajectories after amputation, and the role of cognitive decline for PAD treatment and outcomes. A case summary highlights the stigma around mental health and vascular disease and the fragmentation of care. This scientific statement provides remarks for building a road map for integrated behavioral PAD care and potential solutions to overcome these barriers. Instrumental to reaching these changes are interprofessional advocacy efforts and initiatives that help break down the stigma around mental health and promote evidence-based collaborative, nonhierarchical, and multidisciplinary PAD care.

Hospital clinicians' perceptions and experiences of care pathways for chronic limb-threatening ischaemia: a qualitative study

BACKGROUND

Chronic limb-threatening ischaemia (CLTI) is a condition associated with significant risks of lower limb loss and mortality, which increase with delays in management. Guidance recommends urgent referral and assessment, but delays are evident at every stage of the CLTI patient pathway. This study uses qualitative methods to explore hospital clinicians' experiences and perceptions of the existing CLTI pathway.

METHODS

A qualitative interview study was conducted. Semi-structured interviews were undertaken with 13 clinicians involved in the assessment of patients referred to hospital with suspected CLTI, identified via purposive sampling from English vascular surgery units. Clinicians included podiatrists, vascular specialist nurses and doctors. Reflexive thematic analysis was performed on the data from a critical realist position.

RESULTS

The need for speed was the single overarching theme identified. Four linked underlying themes were also identified; 1. Vascular surgery as the poor relation (compared to cancer and other specialties), with a sub-theme of CLTI being a challenging diagnosis. 2. Some patients are more equal than others, with sub-themes of diabetes vs. non-diabetes, hub vs. spoke and frailty vs. non-frail. 3. Life in the National Health Service (NHS) is tough, with sub-themes of lack of resource and we're all under pressure. 4. Non-surgeons can help.

CONCLUSIONS

The underlying themes generated from the rich interview data describe barriers to timely referral, assessment and management of CLTI, as well as the utility of non-surgical roles such as podiatrists and vascular specialist nurses as a potential solution for delays. The overarching theme of the need for speed highlights the meaning given to adverse consequences of delays in management of CLTI by clinicians involved in its assessment. Future improvement projects aimed at the CLTI pathway should take these findings into account.

The importance of socio-economic determinants of health in the care of patients with peripheral artery disease: A narrative review from VAS

Socio-economic determinants of health (SDoH) include various nonmedical factors in the socio-economic sphere with a potentially significant impact on health outcomes. Their effects manifest through several mediators/moderators (behavioral characteristics, physical environment, psychosocial circumstances, access to care, and biological factors). Various critical covariates (age, gender/sex, race/ethnicity, culture/acculturation, and disability status) also interact. Analyzing the effects of these factors is challenging due to their enormous complexity. Although the significance of SDoH for cardiovascular diseases is well documented, research regarding their impact on peripheral artery disease (PAD) occurrence and care is less well documented. This narrative review explores to what extent SDoH are multifaceted in PAD and how they are associated with its occurrence and care. Additionally, methodological issues that may hamper this effort are addressed. Finally, the most important question, whether this association may contribute to reasonable interventions aimed at SDoH, is analyzed. This endeavor requires attention to the social context, a whole systems approach, multilevel-thinking, and a broader alliance that reaches out to more stakeholders outside the medical sphere. More research is needed to justify the power in this concept to improve PAD-related outcomes like lower extremity amputations. At the present time, some evidence, reasonable consideration, and intuitive reasoning support the implementation of various interventions in SDoH in this field.

Deep Venous Arterialization: Background, Patient Selection, Technique, Outcomes and Follow-up, and Future Implementation

Critical limb-threatening ischemia (CLTI) is a severe manifestation of peripheral arterial disease with a highly increased risk for morbidity and mortality that has limited and suboptimal opportunities for treatment, ultimately resulting in major amputation for patients. Deep venous arterialization (DVA) provides a suitable limb salvage option for "no-option" patients facing amputation by introducing an artificial anastomosis between a site of proximal arterial inflow and retrograde venous outflow to deliver tissue perfusion to lower extremity wounds. Because DVAs are employed as a last-resort effort in CLTI patients, it is important to provide updated information on indications for usage, strategies in creating DVA conduits, and discussion of outcomes and expectations for patients undergoing this procedure. Additionally, variations in method, including use of various techniques and devices, are explored. The authors provide an up-to-date review of the literature and discuss pertinent procedural and technical considerations for utilizing DVAs in CLTI patients.

Comparative evaluation of socioeconomic insecurity in peripheral and coronary artery disease patients

BACKGROUND

Cardiovascular disease represents the leading cause of death worldwide. Socioeconomic deprivation is a risk factor for cardiovascular disease. We have previously shown that precariousness was more frequent in symptomatic peripheral artery disease (PAD) patients than in the general population. According to a previous study, coronary artery disease (CAD) patients have a higher level of education than CAD with PAD, but no study directly compared the level of precariousness in PAD and CAD patients.

AIM

To measure and compare the level of socioeconomic insecurity in patients suffering from symptomatic PAD with those suffering from isolated CAD, i.e without symptomatic PAD.

METHODS

We conducted an observational, cohort, prospective, multicenter study. Patients suffering from symptomatic PAD or CAD were recruited through the medical or surgical vascular or cardiology departments, or the vascular rehabilitation center. The EPICES score and the INSEE parameters were used for analysis. The individual is considered precarious when his or her score is greater than or equal to 30. Cardiovascular risk factors and peripheral arterial disease stages were also collected.

RESULTS

In total, 230 patients were included. According to the EPICES score, 47.8% [95%CI, 38.7-56.7] of patients with symptomatic PAD were in a precarious situation compared to 17.4% [95%CI, 10.5-24.3] of patients suffering from isolated CAD (P<0.001). The mean EPICES score was 33.3 (SD 22.5) in the PAD and 16.9 (SD 17.02) in the CAD population, respectively (P<0.001). In the PAD population, the level of education was low, with an under-representation of patients with a baccalaureate or higher education degree: 21.7% [95%CI, 14.2-29.3] vs. 41.7% [95%CI, 32.7-50.7] in the PAD and CAD populations, respectively. There was also an under-representation of executives and intellectual and intermediate professions in the PAD population, 18.3% [95%CI, 11.2-25.3], compared to the CAD population, 31.3% [95%CI, 22.8-39.8].

CONCLUSION

PAD patients are more precarious than patients suffering from CAD. A better detection of socioeconomic deprivation in patients suffering from peripheral arterial disease could allow comprehensive care and thus hope for an improvement in terms of morbidity and mortality.

One year clinical outcomes of Rutherford 6 chronic limb threatening ischemia patients undergoing lower limb endovascular revascularisation from Singapore

BACKGROUND

Percutaneous transluminal angioplasty (PTA) is widely used as a first-line revascularisation option in patients with chronic limb threatening ischemia (CLTI). This study aimed to evaluate the short-term endovascular revascularisation treatment outcomes of a cohort of Rutherford 6 (R6) CLTI patients, from a multi-ethnic Asian population in Singapore. Patients with R6 CLTI who underwent endovascular revascularisation from June 2019 to February 2020 at Singapore General Hospital, a tertiary vascular centre in Singapore, were included and followed up for one year. Primary outcome measures included number and type of reinterventions required, 3-, 6- and 12-month mortality, 6- and 12-month amputation free survival (AFS), wound healing success and changes in Rutherford staging after 3, 6 and 12 months.

RESULTS

Two hundred fifty-five procedures were performed on 86 patients, of whom 78 (90.7%) were diabetics, 54 (62.8%) had coronary artery disease (CAD) and 54 (62.8%) had chronic kidney disease (CKD). 42 patients (48.8%) required reintervention within 6 months. Multivariate analysis revealed that the presence of CAD was a significant independent predictor for reintervention. Mortality was 15.1%, 20.9% and 33.7% at 3, 6 and 12 months respectively. AFS was 64.0% and 49.4% at 6 and 12 months. Inability to ambulate, congestive heart failure (CHF), dysrhythmia and CKD were significant independent predictors of lower 12-month AFS.

CONCLUSIONS

PTA for R6 CLTI patients was associated with relatively high mortality and reintervention rates at one year. CAD was an independent predictor of reintervention. More research is required to help risk stratify which CLTI patients would benefit from an endovascular-first approach versus conservative treatment or an immediate major lower extremity amputation policy.

The Nevada Peripheral Artery Disease Screening Effort in a Medicare Advantage Population and Subsequent Mortality and Major Adverse Cardiovascular Event Risk

INTRODUCTION

There is a lack of contemporary estimates of undetected asymptomatic lower-extremity peripheral artery disease (PAD) in the community and its association with adverse outcomes in the population. We aimed to study the long-term association between previously undetected PAD and subsequent all-cause mortality and major adverse cardiovascular events (MACE) in Medicare advantage beneficiaries 65 years and older in a large metropolitan area characterized by concentrations of atherosclerotic risk factors along with a more vulnerable socio-economic risk profile.

METHODS

Data was derived from electronic medical records and linked with claims outcomes data for 13,971 Medicare advantage beneficiaries 65 years and older who underwent PAD screening in 2016 as part of patients' routine annual health assessment in the greater Las Vegas, Nevada metropolitan area. PAD screenings were performed with their primary care provider using volume plethysmography system (VPS) methods. The association between PAD screen status and one-year and 3-year all-cause mortality and MACE rates was documented.

RESULTS

The cohort had a mean age of 75.3±6.6 years and 57.7% of them were female. A total of 4,351 out of 13,768 (31.6%) had a positive PAD screening result. Almost 60% had a lower socio-economic income level, with 15.1% living under the poverty level. The risk estimates associated with a positive vs. a negative PAD screening for both all-cause mortality and MACE was (unadjusted HR mortality=2.17, 95% Confidence Interval, 95%CI 1.79-2.63; unadjusted HR MACE=2.00, 95%CI 1.15-3.49) at 1 year, and (unadjusted HR mortality=2.04, 95%CI 1.84-2.26; unadjusted HR MACE=1.67, 95%CI 1.37-2.02) at 3 year, respectively. Following multivariable adjustment, all associations persisted (P-values <.001) ranging from 1.41-1.69, except for 1-year MACE (similar risk estimate, but P=0.09).

CONCLUSION

A positive screening result of previously undetected lower extremity PAD was independently associated with short-term and long-term increased risks for mortality and MACE in individuals aged 65 years and older living in a large, metropolitan area.

Socioeconomic factors and the onset of peripheral artery disease in older adults

Background: As evidence concerning the impact of socioeconomic factors on the risk of peripheral artery disease (PAD) is sparse, we assessed the association of education and area-level factors (population density, type of municipality and local unemployment rate) on the onset of PAD in older adults. Patients and methods: The analysis used data of the getABI study, a prospective cohort study with seven years of follow-up. Onset of PAD was determined by ankle brachial index (<0.9) or PAD symptoms. Cox regression analysis was employed. Results: Out of 5,444 primary care attendees without PAD at baseline, there were 1,381 participants with PAD onset (cumulative observation time 31,739 years), yielding an event rate of 43.5 (0.95 confidence interval [0.95 CI] 41.2-45.8) per 1,000 person-years. Multivariable Cox regression analysis showed an association of PAD onset with low education (hazard ratio 1.29; 0.95 CI 1.14-1.46; P<0.001), high population density (0.93; 0.89-0.98; P=0.002), small cities (compared to large cities) (0.71; 0.53-0.96; P=0.027) and high local unemployment rate (1.04; 1.00-1.07; P=0.032). The impact of low education on PAD onset was higher for men (2.11; 1.64-2.72) than for women (1.22; 1.07-1.40) (interaction term P=0.013). Conclusions: Socioeconomic factors, education as well as area-level socioeconomic indicators, make independent contributions to PAD onset in older adults.