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.

In this blog you will learn:
- Prevalence of PAD in women.
- Comorbidities & risk factors.
- Symptoms.
- Diagnosis.
- Treatment & outcomes.
Is PAD more common in women?
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.
Is asymptomatic PAD more common in women?
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).
Are risk factors the same for men & women?
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.
How is PAD diagnosed in women?
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).
Are women with PAD undertreated?
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.
(1) ACC/AHA 2005 Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic) > https://www.ahajournals.org/doi/abs/10.1161/CIRCULATIONAHA.106.174526
(2) Gender and Peripheral Arterial Disease > https://www.jabfm.org/content/19/2/132.long
(3) Prevalence of peripheral arterial disease – results of the Heinz Nixdorf recall study > https://www.ncbi.nlm.nih.gov/pubmed/16685578
(4) The prevalence of peripheral arterial disease in a defined population > https://www.ahajournals.org/doi/abs/10.1161/01.CIR.71.3.510
(5) Peripheral Arterial Disease Detection, Awareness, and Treatment in Primary Care > https://jamanetwork.com/journals/jama/fullarticle/194205
(6) A population-based study of peripheral arterial disease prevalence with special focus on critical limb ischemia and sex differences > https://www.ncbi.nlm.nih.gov/pubmed/17543683
(7) Prevalence and prediction of previously unrecognized peripheral arterial disease in patients with coronary artery disease: The peripheral arterial disease in Interventional Patients Study > https://onlinelibrary.wiley.com/doi/abs/10.1002/ccd.21969
(8) Particularities of peripheral arterial disease managed in vascular surgery in the French West Indies > https://www.ncbi.nlm.nih.gov/pubmed/18391869
(9) High prevalence of peripheral arterial disease and co-morbidity in 6880 primary care patients: cross-sectional study > https://www.atherosclerosis-journal.com/article/S0021-9150(03)00204-1/fulltext
(10) Peripheral Arterial Disease Detection, Awareness, and Treatment in Primary Care > https://jamanetwork.com/journals/jama/fullarticle/194205
(11) Leg Symptoms in Peripheral Arterial Disease > https://jamanetwork.com/journals/jama/fullarticle/194250
(12) Prevalence and correlates of lower extremity arterial disease in elderly women > https://www.ncbi.nlm.nih.gov/pubmed/8465807
(13) Women and peripheral arterial disease: same disease, different issues > https://www.ncbi.nlm.nih.gov/pubmed/18334893
(14) Asymptomatic Peripheral Arterial Disease Is Independently Associated With Impaired Lower Extremity Functioning > https://www.ahajournals.org/doi/full/10.1161/01.cir.101.9.1007
(15) Arterial vascular disease in women > https://www.ncbi.nlm.nih.gov/pubmed/17950570
(16) Peripheral Arterial Disease in the Elderly > https://www.ahajournals.org/doi/full/10.1161/01.atv.18.2.185
(17) Sex differences in peripheral arterial disease: leg symptoms and physical functioning > https://www.ncbi.nlm.nih.gov/pubmed/12558719
(18) A population-based study of peripheral arterial disease prevalence with special focus on critical limb ischemia and sex differences > https://www.ncbi.nlm.nih.gov/pubmed/17543683
(19) Ankle-arm index as a marker of atherosclerosis in the Cardiovascular Health Study. Cardiovascular Heart Study (CHS) Collaborative Research Group > https://www.ahajournals.org/doi/abs/10.1161/01.CIR.88.3.837
(20) Peripheral arterial-vascular disease in women: prevalence, prognosis, and treatment > https://www.ncbi.nlm.nih.gov/pubmed/7553710
(21) Smoking, Smoking Cessation and Risk of Symptomatic Peripheral Artery Disease in Women: A Prospective Study > https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3111942/
(22) The prevalence of peripheral arterial disease in high risk subjects and coronary or cerebrovascular patients > https://www.ncbi.nlm.nih.gov/pubmed/17626985
(23) Lower extremity peripheral arterial disease in hospitalized patients with coronary artery disease > https://www.ncbi.nlm.nih.gov/pubmed/15125482
(24) Peripheral artery disease in patients with coronary artery disease > https://www.ncbi.nlm.nih.gov/pubmed/7658111
(25) Prevalence and risk factors associated with peripheral arterial disease in an adult population from Colombia > https://www.elsevier.es/es-revista-archivos-cardiologia-mexico-293-articulo-prevalence-risk-factors-associated-with-S1405994017300113
(26) Systemic risk score evaluation in ischemic stroke patients (SCALA): a prospective cross sectional study in 85 German stroke units > https://www.ncbi.nlm.nih.gov/pubmed/17668260
(27) Low ankle–brachial index predicts an adverse 1‐year outcome after acute coronary and cerebrovascular events > https://onlinelibrary.wiley.com/doi/full/10.1111/j.1538-7836.2006.02225.x
(28) ACC/AHA 2005 Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic) > https://www.ahajournals.org/doi/abs/10.1161/circulationaha.106.174526
(29) Evaluation of Peripheral Arterial Disease with Nonenhanced Quiescent-Interval Single-Shot MR Angiography > https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3121010/
(30) Reliability of ankle:brachial pressure index measurement by junior doctors > https://www.ncbi.nlm.nih.gov/pubmed/8156330/
(31) Detection of peripheral arterial disease with an improved automated device: comparison of a new oscillometric device and the standard Doppler method > https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4973721/
(32) Comparison Of Ankle-Brachial Index (ABI) Measurement Between A New Oscillometric Device (MESI ABPI Md®) And The Standard Doppler Method In The Diagnosis Of Lower Extremity Arterial Disease (LEAD) > http://www.heraldopenaccess.us/fulltext/Non-Invasive-Vascular-Investigation/Comparison-of-Ankle-Brachial-Index-ABI-Measurement-between-a-New-Oscillometric-Device-MESI-ABPI-Md-and-the-Standard-Doppler-Method.php
(33) Intrinsic contribution of gender and ethnicity to normal ankle-brachial index values: the Multi-Ethnic Study of Atherosclerosis (MESA) > https://www.ncbi.nlm.nih.gov/pubmed/17264011
(34) Decreased Ankle/Brachial Indices in Relation to Morbidity and Mortality in Patients with Peripheral Arterial Disease > https://journals.sagepub.com/doi/abs/10.1177/1358863X9700200302
(35) Prevalence, Clinical Significance, and Management of Peripheral Arterial Disease in Women: Is There a Role for Postmenopausal Hormone Therapy? > https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1993945/
(36) Surgical Technique and Peripheral Artery Disease > https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.111.059048
(37) Atherectomy in Peripheral Artery Disease: A Review > https://www.invasivecardiology.com/articles/atherectomy-peripheral-artery-disease-review
(38) Angioplasty and stenting for peripheral arterial disease of the lower limbs > https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-16/Angioplasty-and-stenting-for-peripheral-arterial-disease-of-the-lower-limbs
(39) Risk factor profile, management and prognosis of patients with peripheral arterial disease with or without coronary artery disease: results of the prospective German REACH registry cohort > https://www.ncbi.nlm.nih.gov/pubmed/19221687
(40) Incidence of peripheral vascular disease in women: is it different from that in men? > https://www.jtcvs.org/article/S0022-5223(03)01814-2/fulltext
(41) Gender-related differences in outcome: an analysis of 5880 infrainguinal arterial reconstructions > https://www.ncbi.nlm.nih.gov/pubmed/12563213
(42) Infrainguinal arterial reconstruction: female gender as risk factor for outcome > https://www.ncbi.nlm.nih.gov/pubmed/12217287