Mehran: Underdiagnosis of peripheral artery disease in women ‘daunting and unacceptable’
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Key takeaways:
- Data show the global prevalence of peripheral artery disease is higher in women than in men.
- Providers must screen for PAD using easy, noninvasive tools to increase diagnoses and referrals.
DANA POINT, Calif. — Peripheral artery disease remains underdiagnosed and undertreated among women worldwide and efforts are needed to increase awareness, improve diagnoses and ensure patient referrals, according to a speaker.
PAD, or atherosclerosis of the lower extremities, is a common, morbid and potentially deadly disease that data suggest may disproportionately affect women compared with men, yet women are consistently less likely to be treated in a timely manner, Roxana Mehran, MD, FACC, FACP, FCCP, FESC, FAHA, FSCAI, professor of medicine and director of interventional cardiovascular research and clinical trials at the Zena and Michael A. Weiner Cardiovascular Institute at the Icahn School of Medicine at Mount Sinai, said during a presentation at the Cardiometabolic Health Congress (CMHC) Women’s Cardiometabolic Health and Wellness Masterclass. Data from The Lancet Global Burden of Disease report in 2019 show PAD prevalence to be 1,735 cases per 100,000 women globally.
“This is likely an underestimation of what the true numbers are because women tend to have atypical symptoms and do not get the evaluation that they deserve for the diagnosis,” Mehran said during the presentation.
Clinical, biological and societal factors all likely contribute to the sex-based differences in PAD, which then lead to poorer treatment outcomes, increased mortality and worse quality of life for women vs. men, Mehran said. Poor outcomes also include an increased risk for below- and above-the-knee amputations.
“If you look at the ratio between below-the-knee and above-the-knee amputations, women are having higher rates of above-the-knee amputations,” Mehran said. “This is devastating if you can imagine what this does to the quality of life. When you look at the predictors of a transfemoral vs. a transtibial amputation, female sex rises to the top, as well as being non-white or Black. Why is this happening?”
Data also show sex-based differences in postoperative complications for PAD, with higher rates of infections, bleeding and mortality for women compared with men, Mehran said.
“Is it because of sex? Or is it because by the time [women] come to us, they have so much more disease and many more comorbidities?” Mehran said. “It is difficult to tease that out.”
Different symptoms, different exam
Because symptoms for women differ from men, the examination is different, Mehran said. Women are more likely to have no symptoms or “atypical” symptoms, which can include leg cramping at rest and critical limb ischemia vs. the more “typical” numbness or tingling, exertional leg cramping, weakness and cold limbs. Women also demonstrate greater functional decline, reduced walking parameters and worse quality of life than men, and are more likely to present with multivessel disease, Mehran said.
“With leg cramping at rest, we should be evaluating [ankle-brachial index] in these patients,” Mehran said.
PAD presentation also differs, according to Mehran. Data show women were more likely than men to be admitted emergently and had a higher frequency of CLI per PAD-related hospitalization, suggesting PAD diagnosis in women at a more advanced stage.
“They waited too long, they show up with CLI and, of course, then have much higher morbidity and mortality and a much more advanced stage at the time of first diagnosis,” Mehran said.
Mehran said allied health care providers need to be involved in screening for PAD using “easy, quick and noninvasive tools,” such as ankle-brachial index (ABI) measurements and thoroughly checking feet during an exam, to increase the probability of establishing a diagnosis and ensure patient referral.
“We believe that allied health professionals, not just physicians, but our wonderful nurse practitioners and physicians’ assistants have to help us,” Mehran said. “We have 30 minutes at most with a new patient. These [visits] require a lot of history taking; understanding what is going on, beyond what is in the chest and extending to the periphery. Having them help us in screening with very quick, easy and noninvasive tools like ABI, which is underused, will help us understand better how we could see these patients, get to them and start the medical management and secondary prevention.”
Lack of data on PAD in women
Mehran said more research is “urgently needed” to tease out the true prevalence of PAD, reasons behind any sex-based differences in PAD, the role of sex-specific and underrecognized risk factors and optimal treatments.
“In certain ZIP codes in the United States, the underdiagnosis of both women and underrepresented minorities [with PAD] is daunting and unacceptable,” Mehran said. “Further efforts are needed to increase awareness about high prevalence of PAD in women, but we absolutely need to get our arms around the true prevalence, which could be a lot higher than what we already imagine it to be.”
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Mehran R. Cardiovascular, renal and type 2 diabetes. Presented at: CMHC Women’s Cardiometabolic Health and Wellness Masterclass; Aug. 17-20, 2023; Dana Point, California.
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