Background: Sex-related differences relating to therapy and outcome events of cardiovascular diseases are a current matter of debate. Aim of our study is to evaluate a „real-life“ cohort of patients with peripheral artery disease (PAD) for the impact of sex on risk constellation, the usage of invasive and pharmacological treatment, and outcome.

Material and Methods: We analyzed data of 21,261 unselected PAD patients (36.4% female) of the Knappschafts health insurance. All patients were hospitalized at index between 2010-2012 for PAD as main diagnosis, and a follow up period of 7.5 years was included in the analyses.

Results: In our dataset female PAD patients were 7 years older (median age: 79 years) compared to male patients (median age: 72 years). Hypertension as a main cardiovascular risk factor is more often co-prevalent in female patients, whereas ratio of dyslipidemia, smoking and coronary artery disease are significantly higher in male PAD patients.

Furthermore female PAD patients suffer more often of co-morbidities such as chronic heart failure (41.0% vs. 31.7%), chronic kidney disease (38.4% vs. 32.3%) or atrial fibrillation (28.5% vs. 22.3%; all p<0.001) compared to male PAD patients.

The prescription rate of antihypertensive drugs and diuretics is higher in female PAD patients, whereas the use of platelet aggregation inhibitors was higher in male PAD patients. Only around one third of PAD patient received statins, and prescription rates were particularly low in females (32.5% vs. 39.1%; p<0.001).

Despite higher rate of critical limb ischemia (CLI; Rutherford category 4-6) in females (65.2% vs. 52.3%; p<0.001), diagnostic angiography (51.2% vs. 56.7%) and overall revascularization (58.0% vs. 63.8%; all p<0.001) was less frequently performed in female PAD patients.

Female sex is associated with higher incidence of in-hospital complications (ischemic stroke and infections), but no differences were observed for amputation rate (14% vs. 14.0%; p=n.s.) or myocardial infarction (1.1% vs. 1.0%; p=n.s.). In-hospital mortality was higher in female PAD patients (5.2% vs. 3.5%; p<0.001), whereas male sex was associated with a 1.174-fold increased mortality risk (95%CI 1.129-1.220; p<0.001) and a 1.365-fold increased amputation risk (95%CI 1.289-1.446, p<0.001) during long-term follow up.

Conclusions: Female PAD patients are older and at higher clinical PAD stages. In contrast, the rate of guideline recommended medication at index, but also the use of invasive diagnostic and therapeutic interventions is lower in females compared to male PAD patients. In-hospital outcome is significantly impaired in female PAD patients, however male sex is an independent risk factor for amputation and mortality during long-term follow-up. Further analyses with focus on sex-related differences on health-services supply and outcome quality are needed to correspond to the individual needs of male and female PAD patients.

Figure 1: Cox Regression Analysiys on cumulative survival in male and female patients with peripheral artery disease during long-term follow up.