Prevalence and risk factors of lower extremity disease in high risk groups in Malawi: a stratified cross-sectional study

Abstract

ObjectiveLow/middle-income countries face a disproportionate burden of cardiovascular diseases. However, among cardiovascular diseases, burden of and associations with lower extremity disease (LED) (peripheral arterial disease and/or neuropathy) is neglected. We investigated the prevalence and factors associated with LED among individuals known to have cardiovascular disease risk factors (CVDRFs) in Malawi, a low-income country with a significant prevalence of CVDRFs.DesignThis was a stratified cross-sectional study.SettingThis study was conducted in urban Lilongwe Area 25, and the rural Karonga Health and Demographic Surveillance Site.ParticipantsParticipants were at least 18 years old and had been identified to have two or more known CVDRFs.Main outcome measuresLED—determined by the presence of one of the following: neuropathy (as assessed by a 10 g monofilament), arterial disease (absent peripheral pulses, claudication as assessed by the Edinburgh claudication questionnaire or Ankle Brachial Pulse Index (ABPI) <0.9), previous amputation or ulceration of the lower limbs.ResultsThere were 806 individuals enrolled into the study. Mean age was 52.5 years; 53.5% of participants were men (n=431) and 56.7% (n=457) were from the rural site. Nearly a quarter (24.1%; 95% CI: 21.2 to 27.2) of the participants had at least one symptom or sign of LED. 12.8% had neuropathy, 6.7% had absent pulses, 10.0% had claudication, 1.9% had ABPI <0.9, 0.9% had an amputation and 1.1% had lower limb ulcers. LED had statistically significant association with increasing age, urban residence and use of indoor fires.ConclusionsThis study demonstrated that a quarter of individuals with two or more CVDRFs have evidence of LED and 2.4% have an amputation or signs of limb threatening ulceration or amputation. Further epidemiological and health systems research is warranted to prevent LED and limb loss.

Prevalence of and risk factors for peripheral artery disease in rural South Africa: A cross-sectional analysis of the HAALSI cohort

“…Finally, associations have been observed between long-term exposure to air pollutants, including carbon monoxide and particulate matter, and PAD 42 . While outdoor air pollution is not substantial in Agincourt, HAALSI participants may have been exposed to high levels of indoor air pollutants from indoor cooking with fire as observed in similar settings elsewhere 28 . These risk factors warrant future exploration in the HAALSI cohort.…”

“…In contrast, our prevalence measures were higher than prior estimates from LMIC settings performed in similar age groups. Studies from the Philippines, Malawi, and China estimated a prevalence of PAD ranging from 2% to 5% for comparable age groups [28][29][30][31] . Similarly, a previous global analysis concluded that LMICs have higher PAD prevalence at younger ages compared to high-income countries 7 .…”

Prevalence of and Risk Factors for Peripheral Artery Disease in Rural South Africa: A Cross‐Sectional Analysis of the HAALSI Cohort

“…Studies from the Philippines, Malawi, and China estimated a prevalence of PAD ranging from 2% to 5% for comparable age groups. 27 , 28 , 29 , 30 Similarly, a previous global analysis concluded that LMICs have higher PAD prevalence at younger ages compared with high‐income countries. 8 We estimated the prevalence of clinical PAD in HAALSI participants aged 40 to 49 years as well as aged 50 to 59 years to be over 2 times higher than estimates from the United States.…”

“… 43 While the linkage between indoor air pollution and PAD is limited, prior research in Malawi found an association between indoor fire exposure and lower extremity disease while other work in sub‐Saharan Africa has found an increased risk of cardiovascular disease associated with indoor biomass cooking. 27 , 44 , 45 , 46 These risk factors warrant future exploration in the HAALSI cohort.…”

Prevalence and predictors of lower extremity atherosclerotic disease amongst high-risk patients using ankle brachial index

“…The LMICs are particularly vulnerable to the devastating effects of LEAD given the lack of awareness, limited availability of diagnostic tools and poor health care infrastructure. The prevalence of LEAD and its complications are expected to rise exponentially in these parts of the world with attended significant impact on overall morbidity and mortality 1 , 2 , 6 , 7 , 14 .…”