Young women with PAD are at high risk of cardiovascular complications

Objectives: Prognostic research in patients with peripheral arterial disease (PAD) is scarce and determinants of outcome are mainly studied in males. The current management of PAD in women is based on evidence from, at best, mixed populations. We therefore assessed risk and prognostic factors in 313 men and 169 women from the Dutch Bypass Oral anticoagulants or Aspirin Study of whom long-term follow-up data were available.

Method: The primary composite outcome event was vascular death, myocardial infarction, stroke, or major amputation during 5 years of follow-up. Variables with a p-value <0.2 in the univariate analyses were added to the multivariate Cox proportional hazards model.

Results: Females were older (71 vs. 68 years; p < 0.01), had more advanced PAD (critical limb ischemia (CLI) 52.1 vs. 42.2%; p = 0.04), more often had peripheral bypass surgery as primary intervention (50.5 vs. 32.5%; p < 0.01), and had more often hypertension (48.5 vs. 33.2%; p < 0.01) than males. Males were more often smokers (63.6 vs. 53.3%; p = 0.03) and had more prior myocardial infarctions (18.5 vs. 10.1%; p = 0.02). In total 170 events occurred, 74 (44%) in females and 96 (31%) in males. Overall, independent risk factors for the primary outcome event were age and critical limb ischemia. Independent risk factors in males were: age (HR: 1.06, 95% CI: 1.03-1.09), critical limb ischemia (HR: 1.7, 95% CI: 1.05-2.7), and diabetes mellitus (HR: 1.7, 95% CI: 1.01-2.8) and in females critical limb ischemia (HR: 3.5, 95% CI: 2.0-6.1), ABI≤0.9 (HR: 2.8, 95% CI: 1.2-6.1), and femorocrural bypass (HR: 1.9, 95% CI: 1.1-3.3). Although sex was not an independent risk factor in the overall analysis, women younger than 60 years had an increased risk for cardiovascular events compared to men of that age (HR: 4.9, 95% CI: 1.8-13.6), whereas no difference was seen above 60 years of age.

Conclusions: Risk factors for cardiovascular events in patients with PAD differ between men and women. To our knowledge, this is the first study that shows such a bad outcome in female patients younger than 60 years of age. More awareness leading to early diagnosis and optimal treatment might improve long-term clinical outcome in (young) women with PAD.