Clinical Review & Education

Review

Peripheral Arterial Disease in Sub-Saharan Africa

A Review
Lily E. Johnston, MD, MPH; Barclay T. Stewart, MD, MscPH; Herve Yangni-Angate, MD, FWACS;
Martin Veller, MBBCh, FCS, MMe; Gilbert R. Upchurch Jr, MD; Adam Gyedu, MD, MPH; Adam L. Kushner, MD, MPH

Supplemental content at
IMPORTANCE Peripheral arterial disease (PAD) causes significant morbidity and is an jamasurgery.com
important risk factor for cardiovascular disease–related mortality. However, the burden of
PAD in sub-Saharan Africa is poorly understood.

OBJECTIVE To assess epidemiological and clinical reports regarding PAD from sub-Saharan
Africa such that the regional epidemiology and management of PAD could be described and
recommendations offered.

EVIDENCE REVIEW A systematic search in PubMed, Medline, Embase, the Cumulative Index
to Nursing and Allied Health Literature, and Google Scholar for reports pertaining to the
epidemiology and/or management of PAD in sub-Saharan Africa was performed. Reports that
met inclusion criteria were sorted into 3 categories: population epidemiology, clinical
epidemiology, and surgical case series. Findings were extracted and described.

FINDINGS The search returned 724 records; of these, 16 reports met inclusion criteria.
Peripheral arterial disease epidemiology and/or management was reported from 10 of the 48
sub-Saharan African countries. Peripheral arterial disease prevalence ranged from 3.1% to
24% of adults aged 50 years and older and 39% to 52% of individuals with known risk factors
(eg, diabetes). Medical management was only described by 2 reports; both documented
significant undertreatment of PAD as a cardiovascular disease risk factor. Five surgical case
series reported that trauma and diabetes-related complications were the most common
indications for vascular surgery.

CONCLUSIONS AND RELEVANCE The prevalence of PAD in sub-Saharan Africa may be equal to
or higher than that in high-income countries, exceeding 50% in some high-risk populations. Author Affiliations: Author
In addition to population-based studies that better define the PAD burden in sub-Saharan affiliations are listed at the end of this
Africa, health systems should consider studies and action regarding risk factor mitigation, article.
targeted screening, medical management of PAD, and defining essential vascular care. Corresponding Author: Lily E.
Johnston, MD, MPH, Department of
Surgery, University of Virginia
JAMA Surg. doi:10.1001/jamasurg.2016.0446 Medical Center, PO Box 800681,
Published online April 6, 2016. Charlottesville, VA 22908-0681 (lj6p
@virginia.edu).

T
he epidemiological transition from predominately infec-
tious to noncommunicable diseases in sub-Saharan Africa
has made cardiovascular disease (CVD) a public health
priority.1-3 Cardiovascular disease will be the leading cause of death
in low- and middle-income countries (LMICs), including those in sub-
Saharan Africa, as early as 2030.4 This increase is attributed to both
longer life expectancy and greater exposure to chronic disease risk
factors (eg, sedentary lifestyle, poor dietary habits, and smoking).4-6
In addition to ischemic heart and cerebrovascular disease, pe-
ripheral arterial disease (PAD) is responsible for an under-
recognized and significant burden of death and disability in LMICs.7,8
Peripheral arterial disease is a coronary artery disease risk equiva-
lent and is often the presenting condition of both CVD and diabe-
tes in sub-Saharan Africa.9 Furthermore, there is evidence that the
burden of PAD is rising more rapidly than other forms of CVD in sub-
Saharan Africa.5,10 Therefore, in addition to building an evidence base
regarding PAD in sub-Saharan Africa, defining the regional PAD bur-
den may improve the understanding of CVD in these countries more
broadly and lead to effective interventions.
A meta-analysis of global PAD prevalence in LMICs and high-
income countries (HICs)6 estimated that 14.2 million people had PAD
in sub-Saharan Africa in 2010. However, this estimate was gener-
ated based on 12 studies from LMICs worldwide and sub-Saharan
Africa risk factor prevalence, rather than country- or region-
specific disease prevalence. Published estimates of PAD preva-
lence in sub-Saharan Africa vary more than 10-fold (1.7%-53%) based
on study population, study design, and how PAD was defined and
diagnosed.11 These widely variable estimates demand a closer evalu-
ation of the evidence regarding PAD prevalence in sub-Saharan
Africa.

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 Clinical Review & Education Review
To better characterize the health burden of PAD in sub-
Saharan Africa, we performed a scoping review of the literature to
describe PAD epidemiology and management in the region. In do-
ing so, we hoped to clarify what is currently known, inform discus-
sion of guidelines and possible interventions, and identify future
research priorities.12
Methods
Scoping Review
A preliminary search using database-specific language to identify re-
ports of PAD from sub-Saharan Africa returned no high-level evi-
dence. Thus, our ability to conduct a formal systematic review with
a narrowly focused research question and report exclusion based
on study design and bias was limited. Instead, we performed a scop-
ing review, which consists of a systematic literature search with
broader record inclusion criteria and a structured qualitative analy-
sis of retrieved reports.13
Search Strategy
A systematic search strategy was designed to identify all records that
described the epidemiology and/or the clinical management of lower
extremity PAD in adults (ⱖ18 years) living in sub-Saharan Africa. Sur-
gical management was incorporated into the review because PAD
is often a surgically managed disease in HICs and the capacity for vas-
cular surgical care in sub-Saharan Africa is poorly characterized.14-16
The search strategy included terms for geography, dates, and
a sensitive combination of keyword and structured index terms (see
eMethods in the Supplement for complete search strategy). The
search was conducted in 5 databases: PubMed, Medline, Embase,
the Cumulative Index to Nursing and Allied Health Literature, and
Google Scholar.
Eligibility
Studies were eligible for inclusion if they reported prevalence or
management of PAD in at least 1 sub-Saharan African country or a
subpopulation therein. Records from January 1, 2000, to April 1,
2015, were included to describe the epidemiology of PAD and its
management. Given the few reports on PAD in sub-Saharan Africa,
we did not exclude studies based on risk of bias or study design. Rec-
ords without full-text availability were excluded. All languages were
included.
The primary outcomes of interest were prevalence of PAD as
defined by the report and any description of the medical or surgical
management of PAD. The PRISMA guidelines for study design and
reporting were used where applicable.17
Record and Report Management
Records were screened for relevance to inclusion criteria and du-
plication of data from previously published reports. The references
of each included report were reviewed for relevant citations. Re-
ports were then separated into population-based studies, clinical co-
horts, and surgical case series. The latter 2 categories were de-
scribed separately, given the significant differences of these
estimates in settings with limited access to care.18,19 In addition, odds
ratios for several risk factors traditionally related to PAD were
extracted.
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Peripheral Arterial Disease in Sub-Saharan Africa
Key Points
Question What is the prevalence and management of peripheral
arterial disease (PAD) in sub-Saharan Africa?
Findings In this scoping review, prevalence of PAD was highly
variable with as few as 3% or as many as 52% of individuals in
sub-Saharan Africa having PAD, depending on the geographic
region and risk factors of the individuals. Medical management
was described in only 2 studies, both of which reported significant
undertreatment of PAD.
Meaning The prevalence of PAD in sub-Saharan Africa may be
equal to or higher than that in high-income countries. Health
systems should consider studies and action regarding risk factor
mitigation, targeted screening, and medical management.
Data Analysis
Odds ratios for PAD risk factors in sub-Saharan Africa were not
pooled owing to heterogeneity between the studies and risk fac-
tor definitions that were ambiguous or not directly comparable
(eg, tobacco use and active smoker). Therefore, we only reported
the odds ratios along with a reference value from Fowkes et al6 in
the form of a forest plot. To our knowledge, the reference value
provides the best estimate of the effect of these risk factors on
PAD in LMICs based on a large meta-analysis.
Results
Our search returned 724 records. Two additional records were
included based on bibliographic review, yielding a total of 726
records (Figure 1). Titles and abstracts were screened for rel-
evance; 627 records were subsequently excluded (86% of
retrieved records). Of the remaining 99 records, 77 were
excluded after abstract review (11% of retrieved records); 5 did
not have full text records; and 1 was a duplicate. The remaining 16
Figure 1. PRISMA Diagram of Report Selection
Identification
724 Records identified through 2 Additional records identified
database searching through other sources
726 Record titles screened
627 Records excluded based on
nonrelevance of title
Screening
99 Record abstracts screened
85 Records excluded, with reasons
79 Relevance
5 No full text
1 Duplicative study data
Included
14 Studies included in
qualitative synthesis
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 Peripheral Arterial Disease in Sub-Saharan Africa Review Clinical Review & Education

Table. Included Reports of PAD Prevalence and/or Management in Sub-Saharan Africa From 2000-2015
Age, Mean Special PAD prevalence
Study Source Design PAD Definition Countries No. (SD) Population by ABI, %
Prevalence of PAD in the elderly Desormais Cross-sectional ABI <0.9 ROC/CAR 1871 73.1 (6.6) >65 y 14.8
population in urban and rural areas of et al, study
Central Africa: the EPIDEMCA Study 201421
Epidemiology of peripheral artery Guerchet Cross-sectional ABI <0.9 CAR, Congo 976 73.6 (6.7) >65 y 24.2 (95% CI,
disease in elder general population of et al, survey 21.5-27.0)
2 cities of Central Africa: Bangui and 201226
Brazzaville
Prevalence of cardiovascular disease Ngoungou Cross-sectional ECQ, pulse Gabon 736 57.0 (11.6) >40 y NA
in Gabon: a population study et al, survey examination
201223
Risk of cardiovascular disease in a Koopman Cross-sectional ABI <0.9 Ghana 610 Median >50 y 3.1
traditional African population with a et al, study (IQR):
high infectious load: a 201227 66 (56-74)
population-based study
Distribution of a subclinical marker of Fowkes Cross-sectional ABI <0.9 South Africa 322 54.6 (13.9) Rural 16.2
cardiovascular risk, the ankle brachial et al, survey
index, in a rural African population: 200629
SASPI Study
Prevalence of lower extremity Okello et al, Prospective ABI <0.9 Uganda 229 Median Patients 24
peripheral artery disease among adult 201420 consecutive (IQR): with
diabetes patients in southwestern cohort 60 (55-66) diabetes
Uganda
Peripheral arterial disease: high Kumar et al, Prospective ABI <0.9 South Africa 542 62.4a Rural 29.3
prevalence in rural black South 200730 cohort
Africans
Peripheral arterial disease among Mwebaze Cross-sectional ABI <0.9 Uganda 146 53.9 (12.4) Patients 39.0
adult diabetic patients attending et al, study with
a large outpatient diabetic clinic 201411 diabetes
at a national referral hospital
in Uganda: a descriptive
cross-sectional study
The prevalence of peripheral arterial Oyelade Cross-sectional ABI <0.9 Nigeria 219 63 (8.8) Patients 52.2
disease in diabetic patients in B.O. et al, study with
southwest Nigeria 201231 diabetes
Peripheral vascular surgical Adeoye Retrospective NA Nigeria 14 24.4 (16.3) Surgical NA
procedures in Ilorin, Nigeria: et al, series patients
indications and outcome 201132
Vascular surgeries in West Africa: Edaigbini Retrospective NA Nigeria 73 43.5a Surgical NA
challenges and prospects et al, series patients
201433
Major limb amputations: a tertiary Chalya et al, Retrospective NA Tanzania 162 42.3 (13.7) Surgical NA
hospital experience in northwestern 201234 series patients
Tanzania
Major limb amputations: an audit of Akiode et al, Retrospective NA Nigeria 69 Range: (10 Surgical NA
indications in a suburban surgical 200535 series mo-80 y) patients
practice.
Lower limb amputations at the Awori et al, Retrospective NA Kenya 74 44.8 (22.5) Surgical NA
Kenyatta National Hospital, Nairobi 200736 series patients
Abbreviations: ABI, ankle brachial index; CAR, Central African Republic; ECQ, Edinburgh Claudication Questionnaire; IQR, interquartile range; NA, not applicable;
PAD, peripheral arterial disease; ROC, Republic of the Congo.
a
Measure of variance not reported.

reports (2.2% of retrieved records) were reviewed in full. Nine
reports collected primary data on the prevalence of PAD in sub-
Saharan Africa, and 5 reports were surgical case series. These
reports are summarized in the Table.
Five reports provided odds ratios for specific risk factors.20-24
These are discussed in the context of the studies below, and pre-
sented in Figure 2 and the eTable in the Supplement.
Community-Based Surveys
Five reports were cross-sectional community-based surveys. Com-
munity-based surveys do not rely on patients who seek and/or have
access to medical and/or surgical care. Therefore, these reports pro-
vided the most accurate and generalizable estimates of PAD in sub-
Saharan Africa.19,25
Two studies were conducted in the neighboring countries of the
Central African Republic and the Republic of the Congo.21,26 Begin-
ning in 2008, Guerchet et al22,26 performed cross-sectional, com-
munity-based surveys in districts of Bangui, Central African Repub-
lic, and Brazzaville, the Republic of the Congo. They exhaustively
sampled adults older than 65 years of age in a single district. In total,
976 individuals were surveyed: 515 in Brazzaville and 461 in Ban-
gui. The combined prevalence of PAD was 24%. However, preva-
lence differed significantly by community: 15% in Bangui and 32%
in Brazzaville.26
Desormais et al21 performed a similar study in the same coun-
tries in 2011 to 2012. However, they included 1 rural area per coun-
try. The study measured ankle brachial indexes (ABIs) on 1871 par-
ticipants aged 65 years or older (939 in Central African Republic; 932

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 Clinical Review & Education Review Peripheral Arterial Disease in Sub-Saharan Africa

Figure 2. Risk Factors Related to Peripheral Arterial Disease in Sub-Saharan Africa

Risk Factors
for Peripheral Adjusted Odds Reports from
Arterial Disease Source Ratio (95% CI) sub-Saharan
Age Africa
(current study)
Desormais,21 1.03 (1.01-1.06) Recent
Kumar,30 0.99 (0.68-1.44) meta-analysis,
Fowkes,6 1.25 (1.20-1.30) Fowkes et al6
Female sex
Desormais,21 1.36 (0.97-1.89)
Okello,20 2.25 (1.06-4.77)
Kumar,30 0.59 (0.37-0.94)
Fowkes,6 2.00 (1.75-2.33)
Hypertension
Desormais,21 1.33 (0.95-1.87)
Guerchet, women, Central African Republic,26 4.14 (1.65-10.42)
Guerchet, women, the Republic of the Congo,26 2.17 (1.16-4.06)
Guerchet, men, Central African Republic,26 1.67 (0.66-4.23)
Guerchet, men, the Republic of the Congo,26 0.56 (0.28-1.13)
Gabon,23 3.69 (2.21-6.16)
Okello,20 2.59 (1.25-5.33)
Kumar,30 0.57 (0.38-0.86)
Fowkes,6 1.36 (1.24-1.50)
Human Immunodeficiency Virus
Okello,20 0.61 (0.17-2.19)
Diabetes
Desormais,21 1.16 (0.72-1.85)
Guerchet, women, Central African Republic,26 0.85 (0.23-3.10)
Guerchet, women, the Republic of the Congo,26 1.09 (0.62-1.93)
Guerchet, men, Central African Republic,26 5.56 (1.02-30.23)
Guerchet, men, the Republic of the Congo,26 1.39 (0.68-2.85)
Kumar,30 1.72 (1.11-2.69)
Fowkes,6 1.47 (1.29-1.68)
Obesity
Desormais,21 1.98 (1.05-3.71)
Gabon,23 0.97 (0.94-1.00)
Guerchet, women, Central African Republic,26 2.67 (0.46-15.60)
Guerchet, women, the Republic of the Congo,26 1.70 (0.89-3.26)
Guerchet, men, the Republic of the Congo,26 1.27 (0.35-4.66)
Okello,20 1.23 (0.59-2.53)
Kumar,30 0.60 (0.40-0.89)
Fowkes,6 0.72 (0.63-0.81)
Dyslipidemia
Desormais,21 1.88 (1.23-2.88)
Okello_XOL,20 0.90 (0.41-1.98)
Okello, high-density lipoprotein,20 1.21 (0.61-2.41)
Okello_LDL,20 1.39 (0.69-2.78)
Fowkes,6 1.14 (1.03-1.25)
Tobacco use
Desormais,21 1.78 (1.22-2.56)
Guerchet, women, Central African Republic,26 1.00 (0.48-2.10)
Guerchet, women, the Republic of the Congo,26 1.18 (0.44-3.20)
Guerchet, men, Central African Republic,26 0.89 (0.30-2.62)
Guerchet, men, the Republic of the Congo,26 2.93 (1.05-8.11)
Okello,20 1.04 (0.56-1.93)
Kumar,30 4.29 (2.68-6.95)
Fowkes,6 1.42 (1.25-1.62)
Alcohol consumption
Desormais,21 0.63 (0.40-0.99)
Guerchet, women, Central African Republic,26 0.50 (0.25-0.98)
The odds ratios and 95% CIs in blue
Guerchet, women, the Republic of the Congo,26 0.73 (0.45-1.17)
represent reports included in this
Guerchet, men, Central African Republic,26 3.02 (0.92-9.87) study, and the odds ratios and 95%
Guerchet, men, the Republic of the Congo,26 0.43 (0.21-0.88) CIs in orange represent a
0.1 1.0 10 30 meta-analysis6 that examined risk
Odds Ratio for Peripheral Arterial Disease factors in low- and middle-income
countries more broadly.

in the Republic of the Congo) and defined PAD as an ABI of less than Republic and 17% in the Republic of the Congo. The prevalence was
0.9. They reported a PAD prevalence of 15%: 12% in Central African higher in urban Brazzaville compared with the rural area of Gam-

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 Peripheral Arterial Disease in Sub-Saharan Africa
boma in the Republic of Congo (21% vs 14%, P = .01). However, there
was no significant urban/rural difference in the Central African Re-
public (12% vs 13%, P > .05).
Ngoungou et al23 also examined rural populations. Adults aged
40 years or older in Ntoum, Gabon, were exhaustively sampled to
determine the prevalence of CVD. The survey used the Edinburgh
Claudication Questionnaire (ECQ) and physical examination to as-
sess for PAD; ABIs were not calculated. Of the 736 participants, none
had definite claudication by the ECQ measure and 19 (2.7%) had pos-
sible claudication. Based on absent distal pulses, 25 participants (3%)
had PAD.
Koopman et al27 found a similarly low prevalence of PAD in a ru-
ral population in Ghana. Their study used a registry established in
2002 for parasite surveillance among persons living in the Garu-
Tempane district.28 The registry included 924 individuals older than
50 years who were sampled for a cross-sectional survey. In gen-
eral, they found that the prevalence of CVD risk factors was low in
this population, including among those who were overweight (0.2%
of men and 1.4% of women), had diabetes (1.0% of men and 1.4%
of women), had dyslipidemia (1.1% of men and 1.7% of women),
and/or had hypertension (16.7% of men and 13.7% of women). The
total prevalence of PAD was 3.1% (2.3% of men [95% CI, 1.3%-
4.1%] and 3.4% of women [95% CI, 2.1%-5.5%]).
Finally, Fowkes et al29 measured ABI in 322 of 526 adults who
were randomly sampled from Agincourt, a community in rural north-
east South Africa. Their sample was predominately female (78%) ow-
ing to labor dynamics in the region. Although mean ABI was normal
in both women and men (1.04 and 1.05, respectively), a significant
trend of decreasing ABI with age was noted. More than 25% of par-
ticipants older than 60 years and almost 40% of participants older
than 70 years had an ABI less than 0.9.
Clinical Cohorts
Okello et al20 sampled 229 patients with diabetes older than 50 years
from the outpatient diabetes clinic at Mbarara Regional Referral
Hospital in Southwestern Uganda. They calculated ABI and
administered the ECQ. Most patients had been diagnosed as hav-
ing diabetes for at least 1 year and had a median hemoglobin A1c
level of 8.1% (interquartile range, 6.7%-10.1%) (to convert to pro-
portion of total hemoglobin, multiply by 0.01). By ABI, the preva-
lence of PAD was 24%. Fifty-six percent of patients with PAD
were asymptomatic as evaluated by the ECQ. Only 11% of patients
with an ABI of less than 0.9 were taking an aspirin and only 1
patient was taking a statin.
In South Africa, Kumar et al30 quasi-randomly selected 542 out-
patients presenting to Mthatha General Hospital. Inclusion criteria
included age older than 50 years and no prior diagnosis of PAD. The
prevalence of undiagnosed PAD was 29%. Risk factors differed by
sex: men were more likely to be smokers and women were more
likely to be obese and/or have diabetes.
At a teaching hospital in Kampala, Uganda, Mwebaze et al11
quasi-randomly enrolled 146 patients from an outpatient diabetes
clinic. Patients were eligible if they were older than 35 years and had
been patients at the clinic for more than 1 year. Based on ABI, 39%
of participants had PAD; this decreased to 23% based on pulse ex-
amination alone. Comparing ABI with results from the ECQ, 48% of
patients with definite claudication by ECQ had a normal ABI. Pe-
ripheral arterial disease was asymptomatic in 41% of participants.
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Review Clinical Review & Education
Only 12% of patients were taking statin therapy, and 22% were tak-
ing antiplatelet agents.
Oyelade et al31 conducted a survey at Baptist Medical Centre, a
referral center in Ogbomoso, Nigeria. Participants were drawn ran-
domly from adult patients with diabetes older than 50 years who
attended the outpatient department between October 2009 and
April 2010; 219 participants were recruited. The prevalence of PAD
based on ABI was 53%. By history of intermittent claudication, preva-
lence was 25%. Prevalence decreased to 11% by absent pedal pulses
on physical examination. As in other studies, PAD prevalence in-
creased with age: 44% of patients between 50 years and 59 years
had PAD whereas 86% of patients older than 80 years had PAD.
Vascular Surgical Case Series
Our search returned 5 reports, all case series, regarding the surgi-
cal management of vascular pathology. Adeoye et al32 described 14
peripheral vascular cases over a 2-year period at the University of
Ilorin Teaching Hospital in Nigeria. Trauma accounted for more than
70% of the cases (11 of 14 cases). Other indications for surgery in-
cluded dialysis access (1 of 14 cases), nontraumatic lower extremity
aneurysm (2 of 14), and neoplasm (1 of 14).
Similarly, Edaigbini et al33 described their experience from 2008
to 2012 at Ahmadu Bello University in Zaria, Nigeria. Over that time,
73 patients ranging in age from 1 to 90 years had vascular pathol-
ogy medically or surgically managed, and 56 operations were per-
formed. The most common indications for surgery were dialysis
access (38 of 54 cases), trauma (10 of 54), and posttraumatic fistu-
lae or pseudoaneurysms (4 of 54). Eleven patients with traditional
atherosclerotic diseases (PAD [n = 5] and abdominal aortic aneu-
rysm, [n = 6]) were treated nonoperatively owing to inadequate
facilities, resources, and/or experience according to the authors.
The remaining 3 series focused on indications for limb ampu-
tation in Tanzania,34 Nigeria,35 and Kenya.36 Chalya et al34 re-
viewed records from 162 patients who underwent major limb am-
putation at Bugando Medical Centre in Tanzania between March
2008 and February 2010. More than 80% of the amputations dur-
ing the study were for either complications of diabetic foot ulcers
(42%) or trauma (38%). Nondiabetic PAD accounted for 8.6% of the
cases (14 of 162 cases). Similar findings were reported by Akiode et
al35 who audited amputations of 71 limbs in 69 patients from 1998
to 2003 in Nigeria. Trauma accounted for 76% of all amputations
(54 of 71 cases). Diabetes-related gangrene was the most common
nontraumatic indication, which accounted for 14% of amputations
(10 of 71 cases). In contrast to these series from Tanzania and Nige-
ria, the most common indication for amputation at Kenyatta Na-
tional Hospital in Nairobi, Kenya,36 was nondiabetic PAD (28 of 74
cases, 38%) followed by trauma (14 of 74 cases, 19%) and diabetic
PAD (13 of 74 cases, 18%).
Discussion
This review aimed to describe reports of PAD prevalence and man-
agement in sub-Saharan Africa. Estimates of PAD prevalence were
reported from 10 countries. Reports documented a high PAD preva-
lence, ranging from 3.1% to 24% of older adults from community-
based surveys and 39% to 52% of those with known risk factors
(eg, diabetes). Few studies reported either medical or surgical man-
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 Clinical Review & Education Review
agement of PAD in sub-Saharan Africa. Together, these findings sug-
gest a significant burden of PAD in sub-Saharan Africa, most of which
remains undiagnosed and untreated owing to insufficient aware-
ness and capacity.
To put these findings into context, the international Reduction
of Atherothrombosis for Continued Health Registry, which en-
rolled patients older than 45 years worldwide, reported an overall
PAD prevalence of 15%, with estimates ranging from 6% in Asia to
24% in Western Europe.37 In a group of high-risk patients in France,
investigators reported PAD prevalence to be 28% (95% CI,
27%-29%).38 The findings from community-based surveys in sub-
Saharan Africa are similar or higher than the Reduction of Athero-
thrombosis for Continued Health Registry estimates. However, the
prevalence among known risk groups was significantly higher. This
could be related, in part, to poor primary and secondary preven-
tion, evidenced by the lack of appropriate medical management and
paucity of surgical reports retrieved.
Multiple investigators studying PAD in HICs have observed an
increased prevalence in both nonwhite39 and non-Hispanic black
populations,39-42 even after controlling for risk factors such as hy-
pertension and diabetes. The higher overall prevalence reported in
high-risk sub-Saharan Africa patients relative to high-risk groups
elsewhere is likely multifactorial in origin, but may also be related
to the racial and ethnic differences observed in HICs. A 2013
meta-analysis also highlighted the differential effect of traditional
cardiovascular risk factors on PAD prevalence in HICs vs LMICs,
noting that the traditional risk factors were stronger predictors of
risk in HICs than in LMICs.6 This raises the possibility that there
may be other undetermined risk or epigenetic factors that may
play a role in the observed discrepancy in PAD prevalence
between regions such as human immunodeficiency virus (HIV)–
associated vasculopathy.6,10 Numerous studies demonstrate a
link between both HIV infection and HIV treatment and increased
PAD risk43-49; however, only a few are specific to sub-Saharan
Africa.10,50-52 Only 1 of the reports in this study incorporated HIV
status.20 Consequently, the association between HIV prevalence
and PAD in sub-Saharan Africa is unclear, but could have signifi-
cant implications for screening and treatment. Therefore, more
robust epidemiological studies are needed to clearly document
the PAD burden and potentially identify these risk factors so that
targeted interventions might be developed.
Few records examined the effect of traditional atherosclerotic
risk factors on the odds of having PAD. Furthermore, these esti-
mates were often underpowered and varied considerably. Some re-
ports were even contradictory. Overall, the trend for several risk fac-
tors was consistent with the largest meta-analysis to our knowledge
examining PAD risk in LMICs (Figure 2).6 Consistent with existing
literature,6,53,54 the findings from the retrieved reports also sug-
gest that age is a predominant risk factor for PAD in sub-Saharan
Africa. Extrapolating to risk at the city or country level, those loca-
tions within sub-Saharan Africa with the longest life expectancy are
likely to have the largest burden of PAD. The PAD burden will
likely increase at a rate proportional to the increases in life expec-
tancy anticipated across the continent.55 Urbanization and eco-
nomic development in sub-Saharan Africa are linked to both age
and chronic disease risk factor exposure. Specifically, more urban
and higher-income populations are likely to have both longer life
expectancy and greater (both in magnitude and duration) expo-
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Peripheral Arterial Disease in Sub-Saharan Africa
sure to risk factors such as obesity and smoking. This extends the
findings of other authors who have explored the role of urbaniza-
tion and changes in CVD risk in Africa56 and other LMICs more
broadly.57 To blunt the effect of the epidemiological transition,
the World Health Organization has set a target to reduce deaths
caused by noncommunicable disease in people younger than 70
years by 25% by 2025 through investing in cost-effective “best-
buy” interventions. These include cigarette tax increases, increas-
ing public awareness of the benefits of healthy diet and exercise,
and providing multidrug therapy to those at high risk for or with
CVD.58 In addition to mitigating the future CVD burden in LMICs,
the cost benefits are estimated to be more than US $375 billion by
2025.59 Furthermore, given that PAD is often the presenting con-
dition for individuals with undiagnosed diabetes or CVD, improv-
ing the recognition of PAD by health workers may strengthen sec-
ondary prevention efforts in sub-Saharan Africa, including
guideline development and dissemination.9,12
Reports repeatedly described significant discrepancies and low
sensitivity of non-ABI measures to diagnose PAD compared with ECQ
and physical examination. Studies that used multiple methods to
evaluate for PAD suggest that any technique other than ABI, includ-
ing history with physical examination, are likely to underdiagnose
PAD owing to the combination of insensitive techniques and a high
frequency of asymptomatic disease. This is consistent with find-
ings described previously in HICs.6,39,60 Therefore, future preva-
lence studies in sub-Saharan Africa should use ABI measurement to
estimate PAD.
No record in our study examined the effect of low ABI on over-
all cardiovascular risk; however, an extensive body of literature
from HICs has robustly demonstrated that many patients without
symptoms but abnormal ABIs have an increased risk of all-cause
cardiac mortality compared with patients with normal ABIs.61-64
With this in mind, it is concerning that no report in our study
described adequate treatment of PAD with aspirin or statin
therapy; the reports by Okello et al20 and Mwebaze and Kilbirige11
found that only 10% to 22% of patients with an ABI of less than 0.9
were receiving antiplatelet therapy and 2% to 12% of patients were
receiving statin therapy. The implications for screening high-risk
populations are clear: clinicians must be supplied with the training
and tools needed to perform reliable ABI measurements if they
provide care to high-risk populations in sub-Saharan Africa. Argu-
ably, the greatest benefit of understanding PAD prevalence has
more to do with primary prevention of all-cause cardiac mortality
than the management of critical limb ischemia or symptomatic
PAD. Therefore, screening and management of PAD is directly in
line with several World Health Organization Noncommunicable Dis-
ease Global Action Plan objectives.3,65 Moreover, there will be con-
siderable opportunities for limb salvage and prevention of dissemi-
nated infection through prompt surgical management of PAD if
health systems are adequately resourced to care for the impending
burden. Surgeons trained in Africa may receive little exposure to
vascular surgery, and much of that exposure is related to traumatic
injury or other emergent indications.14,15,66,67 Additionally, surgical
indications for amputation differ between communities. This high-
lights the importance of understanding locoregional epidemiology
to strategically build capacity where need is greatest. Additional
studies in this area will need to systematically evaluate the epide-
miology of PAD in sub-Saharan Africa; define essential vascular
jamasurgery.com
 Peripheral Arterial Disease in Sub-Saharan Africa Review Clinical Review & Education

care, which should include prevention initiatives; assess the capac-

ity to deliver such care; and demonstrate the effect of essential vas-
cular care on CVD and/or PAD outcomes.
This review had several limitations. First, more than half of
the reports determined PAD prevalence among clinically based
populations; thus, they are not representative of the population
at large. Although these studies cannot be used to estimate popu-
lation prevalence, they do provide valuable information on spe-
cific high-risk groups such as patients with diabetes or known
CVD. Second, the results for the retrieved reports are difficult to
compare given different definitions of PAD and methods by
which PAD was diagnosed. However, this limitation highlights the
importance of using a standard case definition and technique
when reporting estimates of PAD prevalence. Last, a detailed
examination of risk factors and their effect on PAD prevalence
exceeded the scope of this review. However, this is critical to
understanding and forecasting the burden of PAD in sub-Saharan
Africa. Despite these limitations, this review highlights the poten-
tially significant burden of PAD in sub-Saharan Africa and the lack
of epidemiological understanding and the preparedness for its
management.
Conclusions
The prevalence of PAD in sub-Saharan Africa appears to follow the
pattern of CVD risk factor exposure. In those areas still primarily af-
fected by infectious disease and minimal exposure to traditional CVD
risk factors, prevalence may be low; however, in areas with progres-
sive urbanization, longer life expectancy, and more exposure to CVD
risk factors, prevalence is equal to or higher than that seen in HICs. In
high-risk populations, prevalence has been reported to exceed 50%.
To further define the epidemiology of PAD in sub-Saharan Africa, re-
searchteamsshouldconsidercommunity-basedsurveysandABImea-
surement. Use of claudication history with physical examination is in-
adequate. Three major areas of intervention are needed. First, all
primary clinicians should be made aware of the major risk factors for
PAD and provided the necessary training and tools to diagnose PAD
early. Second, the importance of secondary prevention, including
smoking cessation, hypertension control, and aspirin and statin
therapy in patients with PAD or CVD, must be emphasized to all cli-
nicians. Third, efforts to expand vascular care capacity in treating PAD
must begin now to meet the growing demand.

ARTICLE INFORMATION
Accepted for Publication: January 8, 2016.
Published Online: April 6, 2016.
doi:10.1001/jamasurg.2016.0446.
Author Affiliations: Department of Surgery,
University of Virginia, Charlottesville (Johnston);
Johns Hopkins Bloomberg School of Public Health,
Baltimore, Maryland (Johnston); Department of
Surgery, University of Washington, Seattle
(Stewart); Department of Surgery, School of
Medical Sciences, Kwame Nkrumah University of
Science and Technology, Kumasi, Ghana (Stewart,
Gyedu); Komfo Anokye Teaching Hospital, Kumasi,
Ghana (Stewart, Gyedu); Department of
Interdisciplinary Health Sciences, Stellenbosch
University, Cape Town, South Africa (Stewart);
Department of Surgery, University of Bouake,
Bouake, Cote d’Ivoire (Yangni-Angate); Faculty of
Health Sciences, University of the Witwatersrand,
Johannesburg, South Africa (Veller); Division of
Vascular and Endovascular Surgery, Department of
Surgery, University of Virginia, Charlottesville
(Upchurch); Department of International Health,
Johns Hopkins Bloomberg School of Public Health,
Baltimore, Maryland (Kushner); Surgeons
OverSeas, New York, New York (Kushner);
Department of Surgery, Columbia University, New
York, New York (Kushner).
Author Contributions: Drs Johnston and Kushner
had full access to all of the data in the study and
take responsibility for the integrity of the data and
the accuracy of the data analysis.
Study concept and design: Johnston, Stewart,
Upchurch, Gyedu, Kushner.
Acquisition, analysis, or interpretation of data:
Johnston, Stewart, Yangni-Angate, Veller,
Upchurch, Gyedu, Kushner.
Drafting of the manuscript: Johnston, Stewart.
Critical revision of the manuscript for important
intellectual content: Johnston, Stewart,
Yangni-Angate, Veller, Upchurch, Gyedu, Kushner.
Statistical analysis: Johnston.
Obtained funding: Stewart.
Administrative, technical, or material support:
Gyedu, Kushner.
Study supervision: Yangni-Angate, Upchurch.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was funded in part by
grant R25TW009345 from the Fogarty
International Center, US National Institutes of
Health, and by grant UM1 HL088925 from the
Network for Cardiothoracic Surgical Investigations
in Cardiovascular Medicine.
Role of the Funder/Sponsor: The funders had no
role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
Disclaimer: The content is solely the responsibility
of the authors and does not necessarily represent
the official views of the National Institutes of
Health.
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