Treatments for peripheral arterial disease (PAD) have been widely developed in men and are less effective in women, according to a review published today European Heart Journal – Quality of care and clinical outcomes, a journal of the European Society of Cardiology (ESC). The article highlights the biological, clinical and societal reasons why the condition may be missed in women, who respond less well to treatment and have poorer clinical outcomes.
There is a need to better understand why we are failing to close the gender gap in health. This review encompasses not only the biological reasons, but also how health services and the role of women in society may play a role. All of these must be considered so that more effective diagnostic and treatment methods can be targeted at women with PAD. »
Mary Kavurma, author, associate professor at the Heart Research Institute, Australia
More than 200 million people worldwide have PAD, where the arteries in the legs become clogged, which restricts blood flow and increases the risk of heart attack and stroke. PAD is the leading cause of lower limb amputation. Evidence suggests that an equal or greater number of women have the disease and their outcomes are worse. This review was conducted to identify the reasons for gender inequalities in ODA. The researchers compiled the best available evidence and used the World Health Organization model to analyze gender-related healthcare needs.
The document begins with a summary of gender inequalities in the diagnosis and treatment of PAD. It then describes the biological, clinical and societal variables responsible for these sex-related disparities. Regarding diagnosis, PAD is classified into three phases: asymptomatic, typical symptoms of pain and cramping in the legs when walking that are relieved at rest (called intermittent claudication) and chronic limb threatening ischemia (CLTI) which is the most severe phase and may include gangrene or ulcers. Women often have no symptoms or atypical symptoms such as minor pain or discomfort when walking or at rest. They are less likely than men to have intermittent claudication and twice as likely to have CLTI. Hormones seem to play a role, as women tend to experience typical symptoms (intermittent claudication) after menopause. The ankle-arm index, which compares blood pressure in the upper and lower limbs, is used for diagnosis but is less accurate in people with no symptoms or smaller calf muscles.
Treatment for PAD includes medication, exercise, and surgery. It aims to manage symptoms and reduce the risk of ulceration, amputation, heart attack and stroke. Women are less likely to receive recommended medications than men and respond less well to supervised exercise therapy. Women have lower surgery rates and are more likely to die after amputation or open surgery than men.
Regarding the reasons for the inequalities mentioned above, biological factors may contribute to gender differences in disease presentation, progression, and response to treatment. For example, women have a higher risk of blood clots (a cause of MAP) and small blood vessels, while oral contraceptives and pregnancy complications have been linked to higher MAP levels.
Clinical factors refer to how patients interact with health services, their relationships with physicians, and the processes in place to diagnose and treat PAD. The paper cites low awareness of the risk of PAD in females among healthcare providers and women themselves. Healthcare workers are less likely to recognize PAD in women than in men, and women are more likely than men to be misdiagnosed with other conditions, including musculoskeletal disorders. Women tend to downplay their symptoms and are less likely to discuss PAD with their clinician. Over the past 10 years, only one-third of participants in PAD treatment clinical trials have been women. One reason may be inclusion criteria requiring the presence of intermittent claudication, which is less common in women.
The review identified a number of societal variables that may contribute to gender inequalities in ABS. Lower socioeconomic status is associated with an increased likelihood of PAD and hospitalization with PAD. In addition, the incidence of PAD is higher in low- and middle-income countries, increasing fastest in women. The authors note that women have a lower socioeconomic status than men in most countries, in part due to lower income and education levels, and family responsibilities. “The higher poverty and socioeconomic disparities experienced by women around the world may contribute to increased rates of PAD among women,” the document states.
The authors highlight the low proportion of female vascular surgeons and their underrepresentation in leadership roles and PAD guideline writing teams. There is also evidence that female patients have better outcomes when treated by female clinicians. Associate Professor co-author Sarah Aitken, Vascular Surgeon and Chief of Surgery at the University of Sydney, commented: “As we work to encourage women to train as vascular surgeons, the current shortage means that patients are unlikely to see a same-sex surgeon, and research, publications, and policy may not fully represent women’s perspectives.”
Associate Professor Kavurma urged women not to ignore the symptoms: “Watch out for pain in your calves when walking or at rest. Ask your GP how likely you are to have PAD. Women tend to carry on and attribute sore legs to having a busy life. They need to stop and listen to their body. »
She concluded, “As a vascular biologist, my main research questions on PAD are: Why are women asymptomatic? Is the disease different between men and women, especially before menopause? And why do women respond less well to treatment? The answers to these questions are essential – how can doctors diagnose and treat patients with PAD without understanding how the disease develops and whether it is different between the sexes? To improve treatments, we also need clinical trials to better include women. »
Since 2008, ESC has been calling for awareness of gender differences in cardiovascular disease with a Women in ESC campaign. Many activities followed, including a focus on women and cardiovascular disease at the 2011 ESC Congress. The ESC hosts the only Registry of Pregnancy and Heart Disease (ROPAC). In 2022, the ESC Gender Equality Policy was launched, setting goals for the inclusion of female cardiologists and cardiovascular scientists in leadership positions and outlining actions to improve gender equality, including promoting mentoring and career advancement.
