Women are often overlooked when it comes to cardiovascular diseases (CVDs) as such issues are generally regarded to primarily affect men, but nothing could be further from reality. Peripheral arterial disease (PAD) is no exception and women are at greater risk of misdiagnosis or delayed diagnosis. Complications and outcomes associated with that and late treatment are numerous and lead to greater morbidity and mortality.
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More recent studies have indicated that not only is the prevalence of CVDs and PAD similar for both genders, but it is higher in women (5, 6, 7, 8). Some studies put prevalence at 13.4% for men and 15.6% for women. Yet they do not paint the whole picture as prevalence is highly correlated with age and most epidemiological studies focus on older individuals. In individuals below the age of 70 years, prevalence hovers around 17.1% for men and 11.5% for women but rises to 39% in women and just 27% in men in population aged 85 years and older (9). Preventive measures based on ABI (Ankle-Brachial Index) measurement, particularly in those with additional risk factors and relevant comorbidities, is therefore recommended, even in asymptomatic individuals.
Like many other CVDs, PAD is far more commonly asymptomatic than symptomatic; the former accounts for 40% and the latter for only 10% of all cases (10, 11). When it comes to women, studies have indicated that they are more likely to have asymptomatic PAD then men (12, 13, 14, 15, 16). Additionally, women are more likely to present with atypical symptoms that could be attributed to other medical conditions, delaying accurate diagnosis despite possible inclusion in risk groups (17).
The main risk factors identified for PAD (old age, diabetes mellitus, smoking and hypertension) are the same for men and women but do not necessarily impact them equally (18, 19, 20). Female smokers are, for example, at up to 20 times greater risk for the disease than females who have never smoked (21).
There are, however, specifics regarding comorbidity with other CVDs in women. Namely, prior diagnosis of coronary artery disease (CAD), myocardial infarction (MI), stroke or transient ischaemic attacks (TIAs) is indicative of possible PAD (22, 23, 24, 25, 26, 27). Women, on the other hand, are more likely to have only PAD in the absence of other CVDs (5). Compounded with common asymptomatic presentation, this leads to a greater chance of missed diagnosis and delayed treatment. In other words, women often don’t even receive a simple screening, despite the simplicity and low cost of some diagnostic methods.
There are several methods of diagnosing PAD, some more appropriate for use in general practice than others and varying in accuracy and reliability. The most accurate and reliable one is angiography, boasting a very high detection (between 89% and 100%), and specificity (between 92% and 100%) (28, 29), but it is too expensive for general screening and requires specialised equipment.
For convenience and from a financial perspective, the best method is diagnosis based on an ABI assessment. The ABI can be measured/calculated using a Doppler probe and a sphygmomanometer or an automated oscillometric-plethysmographic diagnostic device. Due to its speed and user-error-free operation, the latter approach is more suitable (30, 31, 32). However, examiners should keep in mind that women may have lower ABI by default due to smaller artery size. Some studies have even used a lower cut-off point (0.88 instead of 0.9) for diagnosis (33). Nevertheless, lower ABI scores are associated with greater rates of morbidity and mortality in both genders (34).
Asymptomatic presentation, the frequent absence of comorbidity with other CVDs and under- or non-utilisation of preventive screening put women at greater risk of severe morbidity and mortality. The correct treatment regime can, of course, mitigate many complications and avert the most serious ones, but only if based on timely and accurate diagnosis. In less severe cases, conservative treatment is usually enough and includes smoking cessation and proper management of diabetes, hypertension, and dyslipidaemia (35).
In practice, many patients aren’t receiving proper treatment. Studies have found that patients with only PAD were less likely to receive treatment with either statins, ACE inhibitors, or antiplatelet agents than those with both PAD and CAD (39, 40). In those cases, women were even less likely than men to receive those drugs (40). The situation is no better at the severe disease end of the spectrum since females who undergo lower extremity revascularisation are usually older and have more severe disease compared to men (41, 42).
Women, especially older ones, are at greater risk of PAD-related morbidity and mortality due to the frequently asymptomatic nature of the disease and consequently delayed diagnosis. Possible solutions are increased screening of elderly patients, particularly those in risk groups, and aggressive treatment and risk factor modification in those with a positive diagnosis.