By Kirstin Rizk

Heart disease is the leading cause of death worldwide[1] and has been the leading cause of death in the US for over a century.[2] Originally, it was largely thought of as a man’s disease, and researchers did not consider if it might affect women differently from men. Ultimately, it was identified that “Women had an increased risk of hospital death, reinfarction, heart failure, stroke, and transfusion,” yet, were less likely to receive lifesaving and preventive treatment.²

Now that the medical community is aware of the differences in the ways that heart disease and heart attacks present in women, progress is being made to ensure that women are aware of their risk and treatment is equal.

In recent years, progressive physicians have been looking at peripheral artery disease (PAD) and wondering if history is repeating itself.

Dr. Paul Rochon, managing physician at Modern Vascular in Denver, stated, “PAD has traditionally been identified as a male-dominant disease; however, recent population trends and studies in PAD suggest that women are affected at least as often as men.”[3]

Dr. Rochon and coauthor Dr. Kristofer Schramm did a review of existing research on this topic to see if they could form some conclusions from the data when looked at all together.

Differences in PAD in Men and Women

1. While the risk of PAD increases with age, this factor seems to have an even greater impact on women. Women over 85 were 12% more likely to have PAD than men over 85.[4]

The Takeaway: Everyone over 55 should be screened annually for PAD, but women should take extra care to get their annual screening.

2. Women are more likely to have PAD without any symptoms.[5]In fact, up to 63% of elderly females with PAD demonstrated no leg symptoms during exercise.[6]^{, [7]}

The Takeaway: Even if you don’t have leg pain during exercise, you may be at a higher risk for heart attack or stroke due to PAD that you can’t feel.

3. Yet, women are twice as likely to have unusual leg symptoms (other than leg pain) when exercising.^{6, [8]}

The Takeaway: Much like with heart attacks, PAD presents differently in men and women. For this reason, it is harder for patients and physicians who don’t specialize in PAD to recognize PAD in women.

Additionally, treatment of PAD and related outcomes differ for women and men:

1. Women are significantly less likely than men to receive a surgical revascularization procedure.[9]

The takeaway: don’t be afraid to advocate for your health.

2. In patients with critical limb ischemia (a severe, limb-threatening form of PAD) who were treated with open surgery/peripheral bypass, women have a higher incidence of wound complications, limb loss, and mortality than men.[10]

The Takeaway: Open surgery is sometimes necessary, but should be avoided if possible to save the limb in other ways.

3. Women showed higher rates of improved circulation in the legs from balloon angioplasty or stenting alone than men did and also had higher rates of preventing amputation after balloon angioplasty. [11],

The takeaway: Because open surgery shows more complications in women than men, and endovascular approach shows better blood flow after intervention in women than in men, an endovascular approach should be the first line of treatment for PAD in women, before more invasive treatment methods.

These findings lead us to the same recommendations that are pillars of PAD Awareness Month:

-Patient and physician education of PAD (and how it affects both men and women) is of the utmost importance.

-Consistent, annual screening is extremely important, especially for groups that are likely to have PAD without any symptoms.

-A minimally invasive approach first is best and safest for all patients, but perhaps especially important for women.

[1] https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death

[2] https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4830a1.htm#:~:text=Heart%20disease%20has%20been% 20the,approximately%2040%25%20of%20all%20deaths.

[3] Schramm K, Rochon PJ. Gender Differences in Peripheral Vascular Disease. Semin Intervent Radiol. 2018 Mar;35(1):9-16. doi: 10.1055/s-0038-1636515. Epub 2018 Apr 5. PMID: 29628610; PMCID: PMC5886764.

[4] Diehm C, Schuster A, Allenberg JR, et al. High prevalence of peripheral arterial disease and co-morbidity in 6880 primary care patients: cross-sectional study. Atherosclerosis 2004;172(01):95–105

[5] Sigvant B, Wiberg-Hedman K, Bergqvist D, et al. A population based study of peripheral arterial disease prevalence with special focus on critical limb ischemia and sex differences. J Vasc Surg 2007;45(06):1185–1191

[6] McDermott MM, Greenland P, Liu K, et al. The ankle brachial index is associated with leg function and physical activity: the Walking and Leg Circulation Study. Ann Intern Med 2002;136(12):873–883

[7] McDermott MM, Fried L, Simonsick E, Ling S, Guralnik JM. Asymptomatic peripheral arterial disease is independently associated with impaired lower extremity functioning: the women’s health and aging study. Circulation 2000;101(09):1007–1012

[8] McDermott MM, Greenland P, Liu K, et al. Sex differences in peripheral arterial disease: leg symptoms and physical functioning. J Am Geriatr Soc 2003;51(02):222–228

[9] Lancaster RT, Conrad MF, Patel VI, Cambria RP, LaMuraglia GM. Predictors of early graft failure after infrainguinal bypass surgery: a risk-adjusted analysis from the NSQIP. Eur J Vasc Endovasc Surg 2012;43(05):549–555

[10] Nguyen LL, Brahmanandam S, Bandyk DF, et al. Female gender and oral anticoagulants are associated with wound complications in lower extremity vein bypass: an analysis of 1404 operations for critical limb ischemia. J Vasc Surg 2007;46(06):1191–1197

[11] Gallagher KA, Meltzer AJ, Ravin RA, et al. Gender differences in outcomes of endovascular treatment of infrainguinal peripheral artery disease. Vasc Endovascular Surg 2011;45(08):703–711