Chapter 2: Gender Differences in the Epidemiology and Management of Vascular Disease

INTRODUCTION

Although gender-related differences in the diagnosis and management of cardiovascular disease have been well established, gender differences in noncoronary vascular disease have gained increasing awareness only in the recent years. Much of the known research has suggested delays in diagnosis, anatomic differences, and clinicians' underestimation of disease magnitude to contribute to gender-driven differences in disease prevalence and outcome.¹

This chapter will review the available literature regarding gender differences in noncoronary vascular disease. Specifically, we will focus on peripheral arterial disease (PAD), cerebrovascular disease, carotid artery disease, renovascular disease, pulmonary vascular disease, mesenteric arterial disease, and the systemic vasculitides. Only with a continued effort into understanding these differences can solutions be offered to help enhance vascular disease recognition and outcomes in women.

PERIPHERAL ARTERIAL DISEASE

PAD is a highly prevalent disease, affecting as much as 12 million people in the United States, and is a major cause of disability, loss of work, and lifestyle changes.^{2,3,4,5,6,7,8,9,10,11} PAD can raise one's risk of death between two- and sixfold over a 10-year period.^11,12 The incidence of PAD dramatically increases with age and, considering the extended longevity in industrialized nations, this number is only expected to increase in the upcoming years.^13,14 More importantly, it is predicted that nearly two-thirds of those affected with PAD over the age of 65 would be females.¹⁵

Although less so recently, traditionally little attention has focused on gender differences in PAD or its epidemiology in women. Many studies cite no gender differences in PAD epidemiology, while others do.¹⁶ It has become widely recognized, however, that the number of PAD cases has been underreported by clinicians especially among women, as symptoms of intermittent claudication on presentation only represent a small fraction of all cases.^3,17,18,19

Epidemiology

Nearly 12% of men and women in the community and up to 16% to 19% of the elderly population are affected with PAD.^20,21,22 Although intermittent claudication is the most common presenting symptom for patients with PAD, it alone is an insufficient diagnostic indicator for PAD in women particularly.¹ In a study of PAD detection, only 7% of female participants reported symptoms of claudication.²³ In a large observational study of more than 3000 patients only one-quarter of those with PAD reporting symptoms of claudication were female.¹⁸

However, ankle–branchial index (ABI) has been found to detect at least four- to fivefold more PAD in women than intermittent claudication by history.²⁴ While only 7% of females reported symptoms of claudication in the above mentioned Chicago-based study of PAD detection including nearly 500 participants with significant PAD, more than 35% of female ...