Gender differences in health status and adverse outcomes among patients with peripheral arterial disease

Addressing Psychosocial Care Needs in Women with Peripheral Artery Disease

PURPOSE OF REVIEW

Peripheral artery disease (PAD) is a growing global epidemic. Women with PAD are at elevated risk of experiencing psychosocial stressors that influence the diagnosis, management, and course of their illness due to unique sex- and gender-based factors.

RECENT FINDINGS

We review existing evidence for increased psychosocial risk in women with PAD with a focus on mood disorders, chronic stress, pain experiences, substance use disorders, health behaviors and illness perceptions, and healthcare access. We discuss how these factors exacerbate PAD symptomatology and lead to adverse outcomes. Existing gaps in women's vascular care are reviewed and potential solutions to bridge these gaps through psychosocial care integration are proposed. Current care paradigms for women's vascular care do not adequately screen for and address psychosocial comorbidities. Clinician education, integration of evidence-based psychological care strategies, implementation of workflows for the management of individuals with PAD and mental health comorbidities, reform to reimbursement structures, and further advocacy are needed in this space. This review provides a construct for integrated behavioral health care for women with PAD and advocates for further integration of care.

Association of mental health with walking capacity in patients with claudication: a cross-sectional study

OBJECTIVES

The purpose of this investigation was to verify the association between mental health (MH) indicators with walking capacity in patients with PAD.

METHODS

Two hundred and forty-six patients with PAD and claudication symptoms participated in this study. Physical function was assessed objectively with the 6-min walk test (6MWT) and subjectively using the Walking Impairment Questionnaire (WIQ). MH was assessed by the World Health Organization Quality of Life-Bref (WHOQOL-Bref) (six questions were selected - 1, 2, 10, 16, 19, and 26). Patients were divided into tertile groups according to their composite z-score for mental health (Low MH, Middle MH, and High MH).

RESULTS

The High MH group presented higher scores (p < 0.05) for the WIQ (distance = 26.8 ± 25.6, speed = 25.4 ± 17.3, and stairs = 33.6 ± 27.5), claudication onset distance (161.6 ± 83.6 m), and total walking distance (352.9 ± 79.6 m) compared to Low MH (WIQ distance = 14.8 ± 16.2, 17.7 ± 13.0, and stairs = 22.7 ± 20.7). Additionally, the High MH group presented a longer claudication onset distance (115.5 ± 70.5 m), and total walking distance in 6MWT (306.6 ± 83.2 m), and higher scores in the total walking distance compared to Middle MH (309.5 ± 93.6 m) (p < 0.05).

CONCLUSION

In patients with PAD, MH was positively associated with walking capacity. Based on these results, treatments that can improve mental health, through different mechanisms, can also positively influence the ability of these patients to walk.

The Pink Tax: Sex and Gender Disparities in Peripheral Artery Disease

Peripheral artery disease (PAD) is an atherosclerotic disease associated with significant functional impairment, morbidity, and mortality. Among women, PAD remains poorly recognized and undermanaged. Compared with men, women with PAD tend to be underdiagnosed or misdiagnosed, have poorer quality of life, and experience higher rates of PAD-related morbidity and cardiovascular mortality. In this review, we describe the sex- and gender-related differences in the epidemiology, presentation, diagnosis, and management of PAD. We provide specific recommendations to overcome these factors, including greater awareness and an increased emphasis on tailored and more aggressive interventions for women with PAD. Such changes are warranted and necessary to achieve more equitable outcomes in women with PAD, including improved limb outcomes, enhanced lifestyle, and cardiovascular risk reduction.

Dietary antioxidant intake increases ankle brachial pressure index in men but not in women: a cross-sectional study

Objective

Atherosclerosis is a significant cause of cardiovascular and cerebrovascular diseases, with a greater impact on men than women. Dietary antioxidant intake is inversely related to the risk of atherosclerosis development. We aimed to investigate the association between dietary composite antioxidant intake and the ankle brachial pressure index (ABPI). The ABPI is not only used for assessing the progression of arterial lesions but also for stratifying the risk of atherosclerotic disease.

Methods

We conducted a cross-sectional analysis involving 1,049 participants from the National Health and Nutrition Examination Survey (NHANES). We examined six antioxidants (zinc, selenium, carotenoids, and vitamins A, C, and E) and a composite dietary antioxidant index (CDAI) derived from these antioxidants as exposure variables. The primary outcomes encompassed cardio-metabolic parameters, including body mass index (BMI), body fat mass (BFM), systolic and diastolic blood pressure, triglycerides, HDL and LDL cholesterol, C-reactive protein, and the Ankle-Brachial Pressure Index (ABPI). Associations and interactions between variables were assessed using linear regression analyses. Moreover, mediation and moderation analysis is employed.

Results

Hierarchical multiple regression analysis revealed that among men, dietary intake of zinc, selenium, and vitamin A remained positively associated with a higher ABPI even after adjusting for covariates. Conversely, in the stratified regression analysis based on CDAI quartiles, a U-shaped association between CDAI and ABPI was suggested. Notably, no significant association between dietary antioxidant intake and ABPI was observed among women. CDAI, intake of Vitamin A, Vitamin C, and Vitamin E do not influence all-cause death through mediation by abpi, but rather have a direct effect on all-cause death. Moreover, there is a significant interaction between the intake of Vitamin A and gender, where a daily intake of Vitamin A more than 776 ug is especially beneficial for women.

Conclusion

The combined intake of nutrients with antioxidant properties may prevent the initiation and progression of atherosclerosis and influence the outcome in a sex-specific manner.

Association Between Mental Health Burden, Clinical Presentation, and Outcomes in Individuals With Symptomatic Peripheral Artery Disease: A Scientific Statement From the American Heart Association

Along with the rising burden of peripheral artery disease (PAD), mental health concerns are increasingly being recognized as a comorbidity to address in the chronic disease management of symptomatic PAD. Apart from a high prevalence of comorbid mental health conditions, the role of pain and changing health behaviors and the broader impacts of illness and adaptation to living with PAD require specialized behavioral health expertise. This scientific statement builds a case that this expertise should be integrated within the multidisciplinary PAD team. Furthermore, areas such as cognitive dysfunction and palliative care are highlighted as needing psychological interventions. Although much of the evidence of the efficacy of psychological and psychotropic interventions has been extrapolated from other cardiovascular populations, evidence for the role of psychological interventions for behavior change, for example, uptake of exercise regimens, is increasingly being accrued within PAD. Areas for behavioral health needs and interactions with PAD treatment are discussed, including the use of opioids, depression management, anxiety and stress reduction interventions, the use of benzodiazepines and antidepressants, smoking cessation, rehabilitation trajectories after amputation, and the role of cognitive decline for PAD treatment and outcomes. A case summary highlights the stigma around mental health and vascular disease and the fragmentation of care. This scientific statement provides remarks for building a road map for integrated behavioral PAD care and potential solutions to overcome these barriers. Instrumental to reaching these changes are interprofessional advocacy efforts and initiatives that help break down the stigma around mental health and promote evidence-based collaborative, nonhierarchical, and multidisciplinary PAD care.

Women, lipids, and atherosclerotic cardiovascular disease: a call to action from the European Atherosclerosis Society

Cardiovascular disease is the leading cause of death in women and men globally, with most due to atherosclerotic cardiovascular disease (ASCVD). Despite progress during the last 30 years, ASCVD mortality is now increasing, with the fastest relative increase in middle-aged women. Missed or delayed diagnosis and undertreatment do not fully explain this burden of disease. Sex-specific factors, such as hypertensive disorders of pregnancy, premature menopause (especially primary ovarian insufficiency), and polycystic ovary syndrome are also relevant, with good evidence that these are associated with greater cardiovascular risk. This position statement from the European Atherosclerosis Society focuses on these factors, as well as sex-specific effects on lipids, including lipoprotein(a), over the life course in women which impact ASCVD risk. Women are also disproportionately impacted (in relative terms) by diabetes, chronic kidney disease, and auto-immune inflammatory disease. All these effects are compounded by sociocultural components related to gender. This panel stresses the need to identify and treat modifiable cardiovascular risk factors earlier in women, especially for those at risk due to sex-specific conditions, to reduce the unacceptably high burden of ASCVD in women.

Sex-Based Differences in Clinical Characteristics and Outcomes among Patients with Peripheral Artery Disease: A Retrospective Analysis

Peripheral arterial disease (PAD) is a prevalent medical condition associated with high mortality and morbidity rates. Despite the high clinical burden, sex-based differences among PAD patients are not well defined yet, in contrast to other atherosclerotic diseases. This study aimed to describe sex-based differences in clinical characteristics and outcomes among hospitalized patients affected by PAD. This was a retrospective study evaluating all patients with a diagnosis of PAD admitted to the Emergency Department from 1 December 2013 to 31 December 2021. The primary endpoint of the study was the difference between male and female PAD patients in cumulative occurrence of Major Adverse Cardiovascular Events (MACEs) and Major Adverse Limb Events. A total of 1640 patients were enrolled. Among them, 1103 (67.3%) were males while females were significantly older (median age of 75 years vs. 71 years; p =< 0.001). Females underwent more angioplasty treatments for revascularization than men (29.8% vs. 25.6%; p = 0.04); males were treated with more amputations (19.9% vs. 15.3%; p = 0.012). A trend toward more MALEs and MACEs reported in the male group did not reach statistical significance (OR 1.27 [0.99-1.64]; p = 0.059) (OR 0.75 [0.50-1.11]; p = 0.153). However, despite lower extremity PAD severity seeming similar between the two sexes, among these patients males had a higher probability of undergoing lower limb amputations, of cardiovascular death and of myocardial infarction. Among hospitalized patients affected by PAD, even if there was not a sex-based significant difference in the incidence of MALEs and MACEs, adverse clinical outcomes were more common in males.

The association of depression with mortality and major adverse limb event outcomes in patients with peripheral artery disease: A systematic review and meta-analysis

BACKGROUND

Peripheral artery disease (PAD) is highly prevalent and associated with poor outcomes. Depression is a risk factor for adverse outcomes in patients with coronary artery disease. Despite evidence showing that depression is common in patients with PAD, less is known about its association with adverse prognostic outcomes. To address this, we conducted a systematic review and meta-analysis to summarize the association between depression and outcomes in patients with PAD.

METHODS

We performed a systematic search of eight databases to January 2022 including studies that reported a risk estimate for the association of depression or depressive symptoms with all-cause mortality or major adverse limb events (MALE) in patients with PAD and pooled results in a meta-analysis. Risk of bias was assessed using ROBINS-I.

RESULTS

Of the 7048 articles screened, 5 observational studies with 119,123 patients were included. A total of 16.2 % had depression or depressive symptoms. Depression was associated with a statistically significant increased risk of all-cause mortality (HR 1.24, confidence interval 1.07-1.25, p = .005). The association between depression and MALE was not significant but trended toward a positive association.

LIMITATIONS

Due to lack of data, results were limited by a single study with a large sample size, overrepresentation of men, and lack of information of depression severity or treatment status.

CONCLUSION

Depression or depressive symptoms are associated with a 24 % increased risk of all-cause mortality in patients with PAD. Future work should explore the mechanisms and directionality of this association and identify depression as an important comorbidity to address for patients with PAD.

REGISTRATION

PROSPERO CRD 42021223694.

Sex Differences in Peripheral Artery Disease

Peripheral artery disease (PAD) is a prevalent condition that confers substantial morbidity and mortality and remains underdiagnosed as well as undertreated in the overall population. Although PAD prevalence is similar or higher in women compared with men, associations of traditional and nontraditional risk factors with PAD and clinical manifestations of PAD differ by sex and may contribute to delayed or lack of diagnosis in women. Such sex-based differences in the manifestation of PAD may arise from sexual dimorphism in the vascular substrate in health as well as sex variation in the responses to vascular stressors. Despite the availability of proven therapies for improving symptoms and reducing risk of ischemic cardiovascular and limb events among patients with diagnosed PAD, important sex differences in treatment and outcomes have been observed. We provide an overview of current knowledge regarding sex differences in the epidemiology, pathophysiology, clinical presentation, and management of PAD.

Sex Differences in Trends and In-Hospital Outcomes Among Patients With Critical Limb Ischemia: A Nationwide Analysis

Background Critical limb ischemia (CLI) represents the most severe form of peripheral artery disease and is associated with significant mortality and morbidity. Contemporary data comparing the sex differences in trends, revascularization strategies, and in-hospital outcomes among patients with CLI are scarce. Methods and Results Using the National Inpatient Sample database years 2002 to 2015, we identified hospitalizations for CLI. Temporal trends for hospitalizations for CLI were evaluated. The differences in demographics, revascularization, and in-hospital outcomes between both sexes were compared. Among 2 400 778 CLI hospitalizations, 43.6% were women. Women were older and had a higher prevalence of obesity, hypertension, heart failure, and prior stroke. Women were also less likely to receive any revascularization (34.7% versus 35.4%, P<0.001), but the trends of revascularization have been increasing among both sexes. Revascularization was associated with lower in-hospital mortality among women (adjusted odds ratio [OR], 0.76; 95% CI, 0.71-0.81) and men (adjusted OR, 0.69; 95% CI, 0.65-0.73). On multivariable analysis adjusting for patient- and hospital-related characteristics as well as revascularization, women had a higher incidence of in-hospital mortality, postoperative hemorrhage, need for blood transfusion, postoperative infection, ischemic stroke, and discharge to facilities compared with men. Conclusions In this nationwide contemporary analysis of CLI hospitalizations, women were older and less likely to undergo revascularization. Women had a higher incidence of in-hospital mortality and bleeding complications compared with men. Sex-specific studies and interventions are needed to minimize these gaps among this high-risk population.

Sex-Based Assessment of Patient Presentation, Lesion Characteristics, and Treatment Modalities in Patients Undergoing Peripheral Vascular Intervention

BACKGROUND

Limited evidence suggests that women and men might be treated differently for peripheral arterial disease. This analysis evaluated sex-based differences in disease presentation and its effect on treatment modality among patients who underwent endovascular treatment for peripheral arterial disease.

METHODS AND RESULTS

Using national registry data from the Vascular Quality Initiative between 2010 and 2013, we examined patient, limb, and artery characteristics by sex through descriptive statistics. We studied 26 750 procedures performed in 23 820 patients to treat 30 545 limbs and 44 804 arteries. Women presented at an older age (69 versus 67 years; P<0.001) and were less often current or former smokers (72% versus 85%; P<0.001). Transatlantic Inter-Society Consensus classification was similar among men and women (Transatlantic Inter-Society Consensus C or D: 37% in men versus 37% in women; P=0.81), as was mean occlusion length (4.5 cm in men versus 4.6 cm in women; P=0.04), even after accounting for lesion location. Women more frequently underwent treatment for rest pain (11% in men versus 16% in women; P<0.001) versus claudication (59% in men versus 53% in women; P<0.001) or tissue loss (28% in men versus 27% in women; P=0.75). Treatment modality did not differ by sex but was associated with disease severity (P for trend <0.001) and lesion location (P for trend <0.001).

CONCLUSIONS

Women undergo peripheral endovascular intervention for peripheral arterial disease at an older age with critical limb ischemia. Treatment modalities do not vary by sex but are determined by disease severity and site. Although there exist sex differences in presentation, these differences do not lead to differential treatment for women with peripheral arterial disease.

Gender variation in symptomatic peripheral arterial occlusive disease among type-2 diabetic patients

Purpose:

Little is known about the existence of potential gender disparities in peripheral arterial occlusive disease. To our knowledge, this is the first study to analyze differences attributed to gender in type-2 diabetic patients with symptomatic peripheral arterial occlusive disease, with regard to clinical presentations, risk factors and anatomical distributions of atherosclerosis.

Patients and methods:

This study was conducted at King Abdullah University Hospital, Jordan. Medical records of all diabetic (type-2) patients who presented with symptomatic peripheral arterial occlusive disease in the period from January 2012 and November 2017 were reviewed, data were collected retrospectively. In all, 364 patients (282 males and 82 females) were involved. Criteria for diagnosis include the following Ankle-Brachial Index ⩽ 0.9 and intermittent claudication or critical limb ischemia. Risk factors for atherosclerosis (age, smoking and hypertension) and computed tomography-angiogram findings were analyzed using Statistical Package for the Social Sciences. p < 0.05 was considered statistically significant.

Results:

The mean age was higher in females than males (67.61 vs 62.61 years; p = 0.001). Females had greater prevalence of uncontrolled diabetes compared to males (HbA1c 9.07 in females vs 8.51 in males; p = 0.03). High density lipoprotein was higher in females than males (1.02 vs 0.935; p = 0.009). Females presented more with critical limb ischemia than intermittent claudication in comparison with males (p = 0.017). Involvement of superficial femoral artery, deep femoral artery and peroneal artery in hemodynamic relevant atherosclerotic lesion was significantly higher in females than males (p < 0.05). However, involvement of common iliac artery with hemodynamic relevant atherosclerotic lesion was significantly higher in males than females (p = 0.003).

Conclusions:

Clinical presentation, risk factors and anatomical distributions of atherosclerosis among type-2 diabetic patients with symptomatic peripheral arterial occlusive disease are different between males and females. When compared to males, female patients presented more with critical limb ischemia than intermittent claudication. Females showed higher age at presentation, poor control of diabetes mellitus and higher level of high density lipoprotein. Involvement of superficial femoral artery, deep femoral artery and peroneal artery in hemodynamic relevant atherosclerotic lesion were significantly higher in females than males. In contrast, common iliac artery involvement with hemodynamic relevant atherosclerotic lesion was significantly higher in males than females.

Peripheral Arterial Disease in Women: an Overview of Risk Factor Profile, Clinical Features, and Outcomes

Purpose of Review

Peripheral arterial disease (PAD) is the third most common manifestation of cardiovascular disease (CVD), following coronary artery disease (CAD) and stroke. PAD remains underdiagnosed and under-treated in women.

Recent Findings

Women with PAD experience more atypical symptoms and poorer overall health status. The prevalence of PAD in women increases with age, such that more women than men have PAD after the age of 40 years. There is under-representation of PAD patients in clinical trials in general and women in particular. In this article, we address the lack of women participants in PAD trials. We then present a comprehensive overview of the epidemiology/risk factor profile, clinical features, treatment, and outcomes.

Summary

PAD is prevalent in women and its global burden is on the rise despite a decline in global age-standardized death rate from CVD. The importance of this issue has been underlined by the American Heart Association’s (AHA) “Call to Action” scientific statement on PAD in women. Large-scale campaigns are needed to increase awareness among physicians and the general public. Furthermore, effective treatment strategies must be implemented.

Review of biologic and behavioral risk factors linking depression and peripheral artery disease

The incidence of depression has been rising rapidly, and depression has been recognized as one of the world’s leading causes of disability. More recently, depression has been associated with an increased risk of symptomatic atherosclerotic disease as well as worse perioperative outcomes in patients with cardiovascular disease. Additionally, recent studies have demonstrated an association between depression and peripheral artery disease (PAD), which has been estimated to affect more than 200 million people worldwide. These studies have identified that depression is associated with poor functional and surgical outcomes in patients with PAD. Although the directionality and specific mechanisms underlying this association have yet to be clearly defined, several biologic and behavioral risk factors have been identified to play a role in this relationship. These factors include tobacco use, physical inactivity, medical non-adherence, endothelial and coagulation dysfunction, and dysregulation of the hypothalamic-pituitary-adrenal axis, autonomic system, and immune system. In this article, we review these potential mechanisms and the current evidence linking depression and PAD, as well as future directions for research and interventional strategies. Understanding and elucidating this relationship may assist in preventing the development of PAD and may improve the care that patients with PAD and comorbid depression receive.

Advances in our understanding of the influence of gender on patient outcomes with peripheral arterial disease co-occurring with diabetes

Peripheral arterial disease is an important predictor of cardiovascular morbidity and mortality. Patients with peripheral arterial disease are at a higher risk of myocardial infarction and stroke. The well-known coronary artery disease risk factors such as diabetes, hypertension, smoking and dyslipidemia are also risk factors for peripheral arterial disease. Hyperglycemia is an important mediator in the pathogenesis of this disease in diabetics, more so in women. The morbidity and poor outcomes associated with peripheral arterial disease in women are emerging. Women are more likely to present at an older age are often asymptomatic and have poorer outcomes with revascularization. Women experience specific sex-related challenges in the various diagnostic methods which could lead to a delay in diagnosis. This is a group which needs close attention and aggressive risk factor modification.

Food Insecurity and Peripheral Arterial Disease in Older Adult Populations

OBJECTIVES

Food insecurity, defined as the limited or uncertain availability of nutritious and safe foods, is a complex phenomenon and is linked to poor nutrition and diet-sensitive chronic diseases. Dietary patterns that include saturated fats and meat products are potential risk factors for the progression of peripheral arterial disease (PAD). This study explored whether there is a relationship between food insecurity and PAD among a national sample of older adults.

DESIGN

We conducted a cross-sectional data analysis using data from the 1999-2004 National Health and Nutrition Examination Survey (NHANES). Food security was assessed using the US Household Food Security Survey Module. Bivariate analyses were conducted using the Rao-Scott Chi-square test to examine associations between PAD and sociodemographic variables. Multivariable generalized logistic regression was employed to assess the effect of food security on the presence of PAD, with adjustment for respondent's socio demographic characteristics.

PARTICIPANTS

A total of 2,027 adults with PAD were included (Ankle Brachial Index (ABI) score ≤ 0.90).We excluded participants less than 60 years of age.

RESULTS

Compared to older adults who are food secure, those who are food insecure have an increased risk for PAD. Food insecurity is associated with peripheral arterial disease among older adults (adults adjusted odds ratio, 1.50 [95% CI 1.11-2.03).

CONCLUSION

Older adults with peripheral arterial disease are experiencing food insecurity. While nutrition and PAD are not well-defined, previous literature indicates there is a connection between food insecurity and diet-sensitive chronic diseases (diabetes and hypertension) which are risk factors for PAD. Food insecurity should be taken into consideration when treating older adults with PAD to help decrease poor health outcomes that are linked to an insufficient amount of nutritious foods.

Trends in Procedure Type, Morbidity and In-Hospital Outcomes of Patients with Peripheral Artery Disease: Data from the Brazilian Public Health System

BACKGROUND

The prevalence of peripheral artery disease (PAD) is rising worldwide, with considerable impact on health care systems.

METHODS

We aimed to characterize the trends in therapeutic procedures and outcomes of PAD in the Brazilian Public Health System Database (DataSUS) between 2008 and 2012.

RESULTS

The number of hospitalizations remained stable from 2008 to 2012, although there was a significant change in the proportions of treatment modalities. In 2008, surgical revascularization (SR) = 8,001 (29%), endovascular revascularization (EVR) = 3,207 (11%), and clinical treatment (CT) = 16,887 (60%); and in 2012, SR = 7,882 (28%), EVR = 5,044 (18%), and CT = 15,225 (54%); P < 0.001, a 57% increase in EVR, and 9.8% decrease in CT. Total costs raised 37% (US $18.2-24.9 million, P < 0.001), with a marked 92% increase in EVR costs (US $5.1-9.8 million), compared with SR (11%) and CT (30%). Mortality decreased for EVR (2.0-1.4%, P = 0.048), increased for CT (5.1-5.8%, P = 0.002) and remained stable for SR. A nonsignificant increase was observed in total mortality (5.7-5.9%, P = NS).

CONCLUSIONS

Our analysis depicts the high-PAD mortality in Brazil emphasizing the need of preventing and controlling cardiovascular risk factors. The impact of PAD in costs increased, mainly because of costs related to EVR.