A new scientific statement from the American Heart Association comprehensively examined sex-related differences in peripheral vascular disease, highlighting significant disparities in epidemiology, risk factors, diagnosis, treatment, and outcomes for female patients.
"There are significant sex-based differences and disparities in ... peripheral vascular disease (PVD)," the statement authors reported in the study published in Circulation. "Particularly noteworthy are the delayed presentation and higher mortality of [female patients] from acute aortic syndromes, worse outcomes after aortic repair, and higher likelihood of being offered medical treatment for type A aortic dissection," they continued.
In aortic pathologies, female patients typically present at significantly older ages with more advanced disease. Despite having a lower overall incidence of aortopathies compared with male patients, female patients face a markedly higher risk of rupture at smaller aortic diameters.
The statement noted that "[female patients] have a lower incidence of aortopathies in general but a higher risk of rupture [compated with male patients] for all pathologies." For abdominal aortic aneurysms, female patients experience rupture at smaller sizes, with "up to 30% occur at diameters of < 5.5 cm compared with 8% in [male patients] at the same size threshold," they detailed.
This disparity may reflect anatomical differences, as normal aortic size is 2 to 6 mm smaller in female patients, suggesting that sex-specific treatment thresholds may be warranted.
Female patients with acute aortic syndromes have significantly higher mortality rates (30.1%) compared with male patients (21.0%). They also experience poorer postoperative outcomes, including higher mortality rates following thoracic endovascular aortic aneurysm repair at both 30 days (5.4% vs 3.3%) and 1 year (9.8% vs 6.3%).
For peripheral artery disease (PAD), the statement revealed significant differences in symptoms and treatment access. Female patients with PAD are more likely to be asymptomatic or present with atypical symptoms, potentially contributing to underdiagnosis. "[Among] [patients] with PAD, rates of atypical leg symptoms and asymptomatic PAD are higher in [female patients compared with male patients]," the statement authors revealed.
Despite evidence that supervised exercise therapy benefits both sexes equally, "among patients with symptomatic PAD and Medicare insurance, [female patients] were significantly less likely than [male patients] to be enrolled in supervised exercise," the statement authors indicated.
Some studies also indicate disparities in guideline-directed medical therapy, with multiple studies reporting that "[female patients] with PAD were less likely than [male patients] with PAD to receive statin medications, antiplatelet drugs, and angiotensin-converting enzyme inhibitors or angiotensin II receptor blocker medications," they continued.
The statement also addressed significant sex differences in arteriopathies like fibromuscular dysplasia (FMD), which predominantly affects female patients (5:1–9:1 female-to-male ratio), and chronic mesenteric ischemia, which affects female patients at three times the rate of male patients.
In inflammatory vascular conditions, giant cell arteritis and Takayasu arteritis both demonstrate strong female predominance, while Behçet's disease shows equal prevalence between sexes but with more aggressive presentations in young male patients.
The scientific statement highlighted that female patients have a greater relative degree of calcification compared with intraplaque hemorrhage and lipid-rich necrotic core in carotid artery plaques, which affects stroke risk differently compared with in male patients.
The statement authors emphasized several key research priorities to address these disparities, including:
- Further understanding sex-specific natural history of aortic disease
- Developing sex-specific screening protocols
- Creating endovascular stent grafts with smaller delivery systems to accommodate female patients' smaller arteries
- Improving female representation in clinical trials
- Identifying methods to help female patients with PAD gain access to exercise therapy.
"These numerous disparities provide opportunities to pursue health equity for [female patients] with PVD, and it is imperative that future research, including basic and translational research, incorporates sex-based variables in their design and reporting," the statement authors concluded.
The statement was developed by the American Heart Association's Council on Peripheral Vascular Disease in collaboration with several other AHA councils.
Disclosures can be found in the statement.