A recent AHA Scientific Statement (Hirsch et al, Circulation, 2012) underscores the importance of diagnosing PAD in patients in general, and women in particular. It is thought that 8-12 million people in the US have significant PAD, but only a tiny fraction know it. This is particularly apparent in elderly patients where the prevalence of significant arterial disease may be as high as 15-25%. Despite this, less than 2% of patients in that age group have undergone non-invasive testing. In terms of the population as a whole this discrepancy is even more apparent in women.
Similar to myocardial ischemic syndromes, symptoms of PAD in women are often atypical. Rather than classic claudication type pain, where muscular groups will ache or cramp after exertion, women might have a localizing discomfort in the heel or toes that might not be confined to muscle groups and might not be exertional. Women often only get recognized as having PAD late in the disease course and then they are at risk for worsened outcomes and a greater risk of failure after revascularization. Women with a rest ABI < 0.9 demonstrated trends towards higher event rates. Such patients tend to have more diffuse disease involvement, and that, coupled with smaller caliber vessels might lead to such poor outcomes. The risk of limb loss and amputation consequently are increased.
Much of this is analogous to the situation in coronary disease where atypical presentation and inadequate noninvasive testing result in a poor rate of diagnosis (particularly in high risk groups like diabetics). The problem seems to be compounded in minority populations where diabetes is more prevalent and access to care might be more fragmented.
Would recommended being more proactive in soliciting a history of cold extremities and atypical pain, particularly in high risk groups (smokers, diabetics, those with a history of CAD or cerebrovascular disease) and doing the appropriate testing (screening ABI) when such historical features may be present.
POSTED BY STEVEN C. AJLUNI, MD