Peripheral artery disease (PAD) may have a lower public profile than coronary heart disease (CHD), but like CHD, PAD afflicts women at high rates. And like CHD, PAD left unmanaged contributes to morbidity, mortality and high healthcare costs, according to a scientific statement published online Feb. 15 in Circulation. “There was a time when people thought PAD was a disease of men,” Alan T. Hirsch, MD, chair of the writing committee that summarized current evidence and challenges of PAD in women, said in an interview. “That myth is busted.”

“A Call to Action: Women and Peripheral Artery Disease” was commissioned by the American Heart Association (AHA) to shed light on the impact of PAD on women and facilitate efforts to better inform clinicians, women, healthcare policy-makers and payors. The statement includes a summary of the epidemiological burden of PAD on women, the associated cardiovascular risk of ischemic events, symptom classes and clinical presentations/treatments. It also highlights the gaps in gender-specific knowledge and lack of awareness among women, and concludes with a list of recommendations.

More women than men in the U.S. who are 40 years old or older have PAD, but neither they nor physicians may be aware of their disease burden, according to the statement. The authors noted that in the past, failure to recognize the impact of coronary disease on women left women uninformed that they were at risk of CHD. Unaware and unmanaged, those women were exposed to potentially preventable sickness and death. Campaigns to educate the healthcare community, women and their families about gender-related aspects of cardiovascular disease and stroke have helped boost research, diagnosis and treatment of women.

“Every cardiovascular practitioner is probably embarrassed in retrospect that we all, men and women alike, are now aware that for decades women were under-informed regarding heart disease risk,” said Hirsch, a professor of medicine, epidemiology and community health at the Lillehei Heart Institute at the University of Minnesota Medical School in Minneapolis. “That gender bias and lack of knowledge regarding heart disease presentations in women occurred in a disease that was in the spotlight—heart attacks. Therefore, it certainly was not surprising to consider that for an equally common but less well known disease—PAD—such gaps would coexist.”

PAD affects approximately eight million Americans and is associated with significant morbidity and mortality. PAD is considered a marker for systemic atherosclerotic disease and while it shares many risk factors with CHD, smoking and diabetes mellitus are stronger risk factors for PAD than CHD (Circulation 2011;123:e18-e209).

Gaps in scientific knowledge continue to vex the healthcare community, including an incomplete evaluation of gender-specific prevalence of PAD. The authors noted the need for PAD research to tease out gender-based differences in disease development, clinical presentation, diagnostic testing and treatments.

Among their recommendations, they called for clinical trials that include women participants at rates that reflect prevalence of PAD in the patient population. The authors noted that many studies were inadequately powered for detecting gender-based differences in outcomes or rates of adverse events.

“There shouldn’t be 20 or 30 percent women in a PAD clinical trial; there should be more than 50 percent,” Hirsch pointed out. “Their sample size should represent the population and be large enough that if a woman had a different preference than a man—hypothetically, for example, a greater focus on exercise than on stenting—then it could be known by asking.”

Other research-related recommendations included:

• Basic research on the impact of gender on the vascular biology of atherosclerotic and aneurysmal disease;
• Prevalence studies with clearly defined methodology and gender-specific analyses; and
• Studies on diagnostic tools with sample sizes to evaluate sensitivity, specificity and accuracy.

Public awareness of PAD is low, impeding prevention and early treatment opportunities. Earlier campaigns rallied women to help amplify messages about the prevalence and risk of heart disease in women, Hirsch said, an approach that may be effective for PAD as well. The AHA’s Go Red for Women is participating in dissemination efforts, he added.

The authors also targeted clinical settings, recommending that:

• Primary care physicians and gynecologists follow current national guidelines on the use of the ankle-brachial index to identify women at risk of PAD;
• Healthcare professionals educate women about PAD risk factors, including cardiovascular risks, and symptoms;
• Heart health initiatives add PAD to their awareness and prevention campaigns; and
• Ensure women at risk of PAD receive appropriate testing.

“Beyond Go Red for Women, will health systems, medical societies, government agencies and payors take the task seriously?” Hirsch asked. “This has yet to be determined. As a hallmark lesson from the work of this writing committee, it should be impressive to women, payors and health systems that currently there are more than one million women seeing clinicians for PAD care—that is equal to stroke—at a time that we know simultaneously that only one fourth of women are aware of PAD’s risk. This burden is high.”

Hirsch added that a societal push to lower exposure to PAD risk factors such as smoking and obesity was feasible.

“A Call to Action: Women and Peripheral Artery Disease” was endorsed by the Vascular Disease Foundation and its Peripheral Artery Disease Coalition. The authors contributed on behalf of numerous cardiovascular councils, including nursing, radiology and intervention, surgery and anesthesia, clinical cardiology and others.