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Guest article by Agata Stanek, Katalin Farkas and Mariella Catalano, from the Executive of VAS- European Independent Foundation in Angiology/Vascular Medicine  

Peripheral artery disease (PAD) represents the third major manifestation of systemic atherosclerosis (the build-up of plaque on artery walls). It is a leading cause of lower limb amputation and has a significant impact on mortality. This disease currently affects over 200 million people globally, and its prevalence is projected to increase by approximately 50% by 2045.

Patients with PAD experience the highest rates of cardiovascular death and major adverse cardiovascular events (MACE) among those with atherosclerotic disease. This risk indicates that diagnosing PAD is crucial in determining overall atherosclerotic burden and cardiovascular health. The risks are clear; after one year of follow-up, individuals with PAD faced a 21% risk of MACE and cardiovascular death, compared to 15% in patients with a history of coronary artery disease (CAD) or stroke. Health inequities impact all patients with vascular diseases, and when it comes to patients with PAD, the impacts are even higher in women. Women with PAD face a higher risk of death and MACE compared to those without PAD. The question is: what causes this, and how should these causes be understood in relation to this gender gap?

First off, women with PAD are typically 10–20 years older than men, which is attributed to the reduced vascular benefits of oestrogen (when vasodilation and loss of its antioxidant effects are reduced). Common risk factors for PAD, such as smoking, high blood pressure, diabetes, and high cholesterol, affect both sexes, but there are differences. In women, for example, smoking becomes a risk factor for PAD after only 10 years, whereas for men, it typically takes 30 years to increase that risk. In addition, women face additional risk factors for PAD such as obesity, osteopenia/osteoporosis (low bone mass), hypothyroidism (underactive thyroid), the use of oral contraceptives, hormone replacement therapy, and pregnancy-related complications such as pre-eclampsia, gestational hypertension, or diabetes, placental abruption, and placental infarction.

Also important is the increased risk posed by diabetes, which can raise the risk of PAD by 2 to 4 times. While diabetes does not seem to be a greater risk factor for PAD in women compared to men, women with diabetes are more likely to exhibit certain issues related to cardiovascular risk factors when compared to men with diabetes.

Second, the prevalence of PAD in women is at least similar to, if not higher than, that in men. This can be seen across populations, including women from low- and middle-income countries and socioeconomically disadvantaged groups. Crucially, these figures may be underestimated, as women often present with no symptoms or symptoms that do not fit the usual pattern when compared to men, making diagnosis more difficult. In women, symptoms may be mistaken for conditions such as arthritis, neuropathy, or spinal stenosis, as opposed to PAD, while research also shows that women have a higher prevalence of asymptomatic PAD compared to men.

The result is inequities in the effects of PAD between men and women. For example, women may experience major functional impairment in their lower extremities, which results in a reduced maximum walking distance and a lower quality of life compared to men. There are also disparities between men and women in access to important treatment methods such as the use of guideline-directed medical therapy or optimal medical treatment. Moreover, women are less likely than men to be prescribed crucial medicines like statins (that lower cholesterol), antiplatelet agents (which reduce blood clotting), and angiotensin-converting enzyme inhibitors (which reduce blood pressure).

Aside from physical health, PAD also has a significant impact on women’s mental health; women with PAD experience higher rates of depression compared to both men with PAD and women without the condition. In fact, 21% of women with PAD were found to suffer from depression, whereas only 13% of men exhibited depressive symptoms. Depression may also make recovery from peripheral artery disease more difficult. This is further complicated by the fact that women with PAD typically have limited knowledge and awareness about these conditions.

Despite increasing research on the disproportionate burden faced by women in risk factors, prevalence, and negative effects of peripheral arterial disease, the absence of robust epidemiological studies or medical trials focused on women results in their diagnosis and treatment being approached in the same way as for men. This poses not only a risk to increased prevalence of PAD but will also risk that gender inequities will remain. VAS, the European Independent Foundation in Angiology/Vascular Medicine, is exhorting and supporting the implementation of policies that can make healthcare more accessible and equitable for vascular patients, with specificity and special urgency for PAD. With such a large number of patients, specific attention must be paid to women to ensure gender and health equity.

Sources:

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