Prevalence of Peripheral Arterial Disease in Women
Peripheral artery disease (PAD) is the third most common manifestation of atherosclerosis after coronary artery disease and cerebrovascular disease. Globally, 202 million people were estimated to be living with PAD in 2010—this number has increased by nearly a quarter since 2000.1 In addition, mortality due to PAD has increased for the last 2 decades.1
In 2012, the American Heart Association (AHA) published a “Call to Action: Women and Peripheral Artery Disease.”2 The scientific statement outlined the prevalence, typical symptoms, and treatment of PAD in women. At that time, the prevalence of PAD in women was 13.9 million. As part of the call to action, they recognized that there was a paucity of research conducted with women and PAD, there needed to be a public awareness campaign to showcase women with PAD, and there needed to be better dissemination of management guidelines to providers who were not cardiovascular specialists.
Currently, PAD affects more Americans than coronary artery disease, atrial fibrillation, diabetes, and cancers and affects 200 million people worldwide.3 Peripheral artery disease is still more prevalent in women, with more than 20.6 million women affected.3 Studies have shown a high prevalence of PAD in women, particularly women at the extremes of ages (>80 years and <40 years), who represent a greater estimated population burden of PAD.1 As with the 2012 scientific statement, women continue to be underdiagnosed and undertreated for their disease and less likely to be encouraged in secondary prevention.1,3,4 Peripheral artery disease also disproportionately affects African Americans, Native Americans, and Hispanics.3 Peripheral artery disease remains undetected in both men and women because 60% of patients are asymptomatic while the disease is eroding vessels and impacting vascular endothelial function. The disease is often identified when the patient begins to experience extreme pain from neuropathy, compromised physical activity, and functional impairment or presents with circulatory issues, skin breakdown, and pressure ulcers in the lower extremities.5 Finally, PAD has not been studied in women as extensively as stroke and other cardiovascular conditions. However, 2 studies have suggested that reproductive factors such as age of menarche and parity might be linked to the risk of future cardiovascular disease in women.6,7
Symptoms and Risk Factors of Peripheral Artery Disease
Intermittent claudication has been considered the hallmark feature of PAD, but women may often be asymptomatic8 or present with atypical symptoms.9 Noninvasive ankle-brachial index (ABI) can diagnose lower extremity PAD, and American College of Cardiology/AHA guidelines recommend screening for PAD in all adults older than 65 years. If there is a history of any tobacco use or presence of diabetes, screening should begin earlier at older than 50 years. An ABI less than 0.90 is abnormal and indicates the presence of PAD. An ABI of 0.90 to 1.0 is borderline for PAD and represents an increased risk for CVD.10
The face of PAD in women typically includes being older than 65 years, less educated, and less physically active. Risk factors for PAD include a history of hypertension or diabetes, family history of coronary artery disease and stroke, obesity with elevated body mass index, history of smoking, and, in women, parity of greater than 5 births. Diabetes is now considered a coronary heart disease risk equivalent for PAD.11
The Ankle-Brachial Index as a Screening Instrument
The US Preventative Task Force has determined that there is insufficient evidence to recommend the use of ABI as a reimbursable screening instrument for PAD so it is not a formal recommendation at this time.12 However, the ABI has been shown to be accurate in studies that have used it, with the specificity and accuracy of ABI less than or equal to 0.9 for the diagnosis of PAD as high as 83% to 99% and 72% to 89%, respectively, in a meta-analysis of 8 studies.13,14 The ACC/AHA guidelines recommend its use as a screening instrument. The ABI is based on a ratio of systolic pressures obtained from the bilateral upper and lower extremities with the patient in the supine position. Blood pressure values are obtained using a blood pressure cuff and Doppler on the brachial artery and a blood pressure cuff and Doppler on the dorsalis pedis artery. The systolic numbers from each are entered into a ratio by dividing the ankle mean systolic blood pressure by the brachial mean systolic pressure from the same side to obtain the index score. If the score is less than 0.9, PAD is present; a score of 0.91 to 0.99 suggests that PAD may be present; and a score of 1.0 to 1.40 suggests the presence of arterial stiffness so vessels are not able to be sufficiently compressed to determine PAD, but it is likely that diabetes or chronic kidney disease is present.
A New Risk Assessment Instrument for Women
A study by Mansoor and colleagues15 was conducted using the National Health and Nutrition Examination Survey data set to determine the presence of gender-specific risk factors in women for PAD and to create a more comprehensive risk assessment instrument for women that could be used as part of routine clinical care. The data set included 150.6 million women. A weighted PAD diagnosis was reported in 20.6 million subjects (13.7%). In this study, women who had PAD were older, less educated, and less physically active. Those with PAD also had a higher prevalence of traditional cardiovascular risk factors such as diabetes and hypertension, as well as a higher prevalence of history of coronary artery disease and stroke as compared with women without PAD. Because previous studies linked reproductive risk factors to cardiovascular events and stroke, the study examined the relationship between the reproductive factors of age of menarche, use of oral contraceptives, and parity to the risk of prevalent PAD. Among these reproductive risk factors, parity and nonoral contraceptive use were found to be associated with prevalent PAD, whereas age of menarche was not. Finally, both parity and a higher body mass index were independently associated with PAD. The study concluded that these female-specific risk factors should be assessed in all women.
Detecting and Preventing Progressing of PAD
Early screening and modification of risk factors is key to reducing the prevalence of PAD and to prevent progression to ischemic limb disease. The first action is to identify who would be at a high risk for PAD by identifying those who smoke and have diabetes, hypertension, and renal disease; as mentioned earlier, assess women for parity and use of oral contraceptives; and address obesity. The ACC/AHA guidelines recommend screening of asymptomatic individuals older than 65 years and in 50- to 64-year-old patients with diabetes and smoking history.16 All patients should be strongly counseled to quit smoking. The lipid profile should be monitored, and statin therapy should be prescribed as needed. Other cardiovascular risk factors including physical activity should be assessed, and physical function and quality of life should be discussed. When performing a history and physical examination, a detailed vascular history should be obtained to find any atypical symptoms such as leg pain, walking impairment, and poor healing wounds. Patients are more likely to present with these atypical symptoms than claudication, which only presents in 10% of patients. The patient should be assessed for presence of pulses, bruits, presence of foot deformities, and monofilament tested for neuropathy. If neuropathy is present, noninvasive venous Doppler testing should be performed and a referral to a vascular specialist should be made. If there are foot deformities, the patient should be referred to a podiatrist. The patient should be taught to perform self-foot examinations daily.
Treatment of PAD
Treatment of PAD should first begin with aggressive risk factor modification to reduce progression of ischemic vascular events and improve quality of life and physical functioning. Using the guidelines for treatment of PAD, guideline-based medical therapy should include the following: exercise program, smoking cessation, lipid lowering with statin therapy, blood pressure control with angiotensin receptor inhibitors, and aggressive diabetes management.16 In patients with symptomatic PAD, antithrombotic therapy is recommended.17 In the presence of an abnormal ABI and symptomatic PAD, referral to a vascular specialist is recommended. Revascularization is recommended for patients with functionally limiting claudication. As identified in the 2012 call to action, women had lower rates of revascularization than men and higher in-hospital mortality.2 This continues to be true today.18
Advocacy and Legislation
Congressmen Payne (New Jersey) and Paulson (Minnesota), members of the Congressional Black Caucus, submitted a letter to Health and Human Services and held a briefing in Washington in 2018 to address the issue of PAD. The letter asked for the development of an intergovernmental task force to (1) develop a model of care, (2) develop an awareness campaign for the public, and (3) develop an awareness campaign for general practitioners, obstetrics and gynecology providers, and internal medicine providers to increase screening and detection of PAD. This work has been ongoing with several meetings with key stakeholders and national organizations. There is an awareness campaign being developed as a result of this work. This will hopefully bring to fruition the call to action from the 2012 scientific statement.
Peripheral artery disease is much like hypertension and should be dubbed a “silent killer.” It continues to be underdiagnosed, undermanaged, and undertreated in women and people of ethnic backgrounds. These disparities require action and diligent detective work by all healthcare providers to raise awareness and improve screening and detection of this disease to improve the mortality and quality of life of women and to ensure aggressive treatment is provided.
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