PAD: Manifestations and Surgical Outcomes in Men vs Women

Transcript: Deepak L. Bhatt, MD, MPH: Marc, is there anything you can think of in terms of differences between men and women in PAD [peripheral artery disease] that’s worth noting? Are they real or just talking points?

Marc P. Bonaca, MD, MPH: It’s a great question. There are some differences between men and women. It’s always hard to see in the trials because unfortunately, women tend to be underrepresented in randomized trials, but the epidemiology helps inform us. There appear to be differences not only in terms of diagnosis but also in the aggressiveness of care. We see that in coronary disease as well. Women tend to present later. They may have a different set of comorbidities at the time of presentation.

Paradoxically, we see that in patients with diabetes, men seem to be at a higher risk of amputation, although I’m not sure of the biology behind that. We’ve seen that in a couple of different data sets. There are probably sex-based differences that relate to how people manifest symptoms, how they report them to their physician, and their awareness. But there may also be some underlying biological differences.

You were just mentioning public awareness. There may be issues there as well. PAD is a complicated turn for people to understand. Heart attack, everybody gets. But what is PAD and how attuned are you to that? How likely are you to tell your doctor about it? There are some important differences.

Deepak L. Bhatt, MD, MPH: Those are really great points. Matt, as a surgeon, what are your thoughts about outcomes for men versus women after vascular surgery? At least with respect to coronary artery bypass graft surgery, even in the contemporary era, most registries show that women have worse outcomes than men. Some of that, of course, is confounding because of age. But even trying to adjust to that as best one can—most of the time, those adjustments are imperfect—it does seem as though women have worse outcomes after coronary bypass surgery than men do. Though for a coronary stenting, at least in the contemporary era, that no longer appears to be the case. What’s the latest in thinking post vascular surgery?

Matthew T. Menard, MD: They’re similar, Deepak. There are certainly reports in individual series and some trial data that would suggest that women have worse outcomes. Marc is exactly right. They present later and they tend to present with more severe disease, so maybe it’s just a reflection of that. The more recent data would not necessarily point to a big difference. We tend to think of women as having smaller blood vessels, and smaller blood vessels don’t do as well with intravascular therapy or even bypass to smaller distal targets. But most of the big reports would say that surgical outcomes are similar between men and women. You can find data to support either stance, but it’s certainly an important topic.

Transcript Edited for Clarity