Statement Highlights:
- Peripheral vascular disease (PVD)—a condition affecting arteries, veins and the lymphatic systems throughout the body—has significant differences in incidence, risk factors, diagnosis, treatment and outcomes in women vs. men.
- Women with PVD often experience subtle or atypical symptoms, which can lead to underdiagnosis or delay in diagnosis, and they are less likely to receive guideline-recommended treatments.
- Targeted screening, tailored treatment strategies and increased representation of women in clinical trials are critical priorities to addressing these gaps and improving long-term prognosis for people with PVD.
Embargoed until 4:00 a.m. CT / 5:00 a.m. ET Tuesday, March 11, 2025
DALLAS, March 11, 2025 — The disparities between men and women in prevalence, risk factors and symptoms of peripheral vascular disease (PVD) have a profound impact on prevention, diagnosis, treatment and outcomes for women, according to a new American Heart Association scientific statement published today in the Association's flagship, peer-reviewed journal Circulation.
"Peripheral vascular disease is often under-recognized and understudied in women," said Esther S.H. Kim, M.D., M.P.H., FAHA, chair of the writing group for the new scientific statement. Dr. Kim is the Izard Family Distinguished Chair in Cardiovascular Medicine, a professor of medicine at Wake Forest University School of Medicine and director of the Center for Women's Cardiovascular Health at Atrium Health in Charlotte, North Carolina. "While differences in heart disease between men and women are increasingly recognized, equivalent focus on vascular diseases affecting blood vessels outside the heart remains lacking. In order to improve the quality of life and prolong the lives of women with PVD, more research is needed to identify and address these disparities."
The scientific statement, "Sex Differences in Peripheral Vascular Disease," summarizes current knowledge of the differences between men and women with PVD; highlights disparities in risk factors, screening, treatment and outcomes; and outlines key research priorities to mitigate these disparities and promote health equity.
Summary of disparities
The statement highlights numerous disparities in risk factors, symptoms, screening, treatment and outcomes for various types of PVD.
- Peripheral Artery Disease (PAD): PAD, a condition that restricts blood flow to the limbs, is the most common form of PVD, and it affects men and women at similar rates overall. However, women are more likely to experience no symptoms or atypical signs of PAD and greater functional decline compared to men. Women with PAD tend to walk at slower speeds and cover shorter distances, highlighting the functional limitations they often face. Women with PAD may also be less likely to receive guideline-recommended treatment or participate in supervised exercise programs. PAD is also more prevalent in Black women, and they have a higher lifetime risk of PAD (27.6%) compared to white women (19%), yet they are often less likely to receive evidence-based recommended treatments, according to the Association's 2024 Guideline for the Management of Lower Extremity PAD .
- Aortic Disease: Women with aortopathy (conditions affecting the aorta ) tend to be diagnosed at older ages and present with more severe disease compared to men. While women have a lower incidence of some aortic conditions (like aneurysms) due to the protective effect of estrogen hormones, they face a disproportionately higher risk of severe complications, including aneurysm rupture and mortality. In the U.K. Small Aneurysm Trial, women were three times more likely than men to experience aneurysm rupture at the same size of aneurysm. Additionally, 30% of aneurysm ruptures in women occurred with smaller aneurysms, compared to 8% in men. These disparities persist even with treatment. Women undergoing minimally invasive procedures such as thoracic endovascular aortic repair (TEVAR) face higher short- and long-term mortality rates and an increased risk of stroke after surgery. In acute aortic syndromes (which include dissection, intramural hematoma (collection of blood within the aortic wall) and penetrating aortic ulcer), in-hospital mortality for women is 30% compared to 21% for men. Screening guidelines for aortic aneurysms recommend lower repair thresholds for women (5.0 cm) than for men (5.5 cm), however, these thresholds may not fully reflect women's unique risk factors.
- Peripheral Aneurysms and Artery Disorders: These conditions—including fibromuscular dysplasia and vascular Ehlers-Danlos syndrome (vEDS)—vary in their frequency and outcomes between men and women. For example, fibromuscular dysplasia is 5–9 times more common in women than men, while popliteal (behind the knee) artery aneurysms occur about 20 times more often in men.
- Atherosclerotic Extracranial Carotid Artery Disease: Carotid plaque composition in the neck and brain and the impact on stroke risk, along with treatment options and outcomes, are also different for women. Sex-specific risk factors for stroke in women include preeclampsia (high blood pressure during pregnancy), older age at menopause and use of estrogen therapy. While women might have smaller plaque size than men, studies indicate that men experience intraplaque hemorrhages (bleeding with arterial plaque) at higher rates, which can increase stroke risk.
- Atherosclerotic Renal and Mesenteric Artery Disease: Research on differences in kidney and mesenteric arteries (blood vessels that take blood from the aorta to the gastrointestinal tract) disease remains limited. Studies have found women are three times more likely to be affected with chronic mesenteric ischemia (reduced blood flow) than men. Studies also suggest Black adults with renal artery stenosis (narrowing of the blood vessels that supply blood to the kidneys) have higher rates of severe or resistant high blood pressure.
- Vasculitis: The development of vasculitis, an autoimmune disease that causes inflammation in the blood vessels, and clinical features vary strongly by type. Takayasu arteritis occurs five times more often in women, and women are 2–3 times more likely to develop giant cell arteritis. Takayasu is more common in younger women, ages 15–30 years old, while giant cell arteritis incidence is highest among people ages 70- to 80-years-old. In addition, the mortality rate for Takayasu arteritis is two times higher in women, and women with giant cell arteritis who receive prednisone-only treatments are five times more likely to face treatment challenges compared to men.
"PVD leads to significant illness and health complications. However, the disparities between women and men hinder equitable outcomes. Identified disparities in effective prevention, diagnosis, treatment and care underscore the importance of tailored prevention and treatment strategies," said Kim.
Knowledge gaps and future research needs
According to the statement, there is a need to prioritize research to help define differences in PVD between men and women. Future research, from research at the cellular level to clinical trials, should include sex in their design and reporting. Suggestions include:
- Ensure adequate representation of women in clinical trials: Trials should enroll more women to allow for meaningful analysis of sex-specific differences in treatment efficacy, safety and outcomes. Enrollment should mirror the prevalence of the condition in women, ensuring balanced representation.
- Analyze data by sex: Research and clinical trials should include analyses to better understand differences by sex in response to treatments and interventions.
- Establish optimal treatment strategies for women: New research is needed to determine optimal thresholds for intervention in women, considering their unique physiology and differences in disease presentation.
In addition, the statement also includes suggestions that may help improve diagnosis and long-term prognosis for women with PVD:
- Enhance education for clinicians: Health care professionals would benefit from training on recognizing and addressing sex-specific differences in PVD to improve outcomes.
- Improve screening strategies: Current screening methods and guidelines are often inadequate for women and need to be refined to account for sex-specific risk factors, atypical presentations and differences in disease progression.
- Improve access for women to guideline-recommended therapies: Addressing barriers to ensure women have access to guideline-recommended therapies may help to improve outcomes for women.
This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association's Council on Peripheral Vascular Disease; the Council on Cardiovascular and Stroke Nursing; the Council on Clinical Cardiology; the Council on Genomic and Precision Medicine; the Council on Quality of Care and Outcomes Research; and the Stroke Council. American Heart Association scientific statements promote greater awareness about cardiovascular diseases and stroke issues and help facilitate informed health care decisions. Scientific statements outline what is currently known about a topic and what areas need additional research. While scientific statements inform the development of guidelines, they do not make treatment recommendations. American Heart Association guidelines provide the Association's official clinical practice recommendations.
Co-authors are Vice-Chair Shipra Arya, M.D., S.M.; Yolanda Bryce, M.D.; Heather L. Gornik, M.D., M.H.S., FAHA; Chandler A. Long, M.D.; Mary M. McDermott, M.D., FAHA; Amy West Pollak, M.D., M.Sc., FAHA; Vincent Lopez Rowe, M.D.; Alexander E. Sullivan, M.D., M.S.C.I.; and Mary O. Whipple, Ph.D., R.N., P.H.N. Authors' disclosures are listed in the manuscript.
