Clin Res Cardiol (2022). https://doi.org/10.1007/s00392-022-02002-5

Impact of sex on lower limb amputation in patients with lower extremity artery disease: a real-world cohort analysis
L. Makowski1, J. Köppe2, C. Engelbertz1, L. Kühnemund1, A. J. Fischer3, S. A. Lange1, P. Dröge4, T. Ruhnke4, C. Günster4, N. Malyar1, J. Gerß2, E. Freisinger1, H. Reinecke1, J. Feld2
1Klinik für Kardiologie I: Koronare Herzkrankheit, Herzinsuffizienz und Angiologie, Universitätsklinikum Münster, Münster; 2Institut für Biometrie und Klinische Forschung, Westfälische Wilhelms-Universität, Münster; 3Klinik für Kardiologie III: Angeborene Herzfehler (EMAH) und Klappenerkrankungen, Universitätsklinikum Münster, Münster; 4Wissenschaftliches Institut der AOK (WIdO), Berlin;

Background: The prevalence of lower extremity artery disease (LEAD) is increasing worldwide and in Europe alone, 40 million people are affected. LEAD patients have a poor prognosis in terms of mortality and lower limb (LL) amputation, rising with higher severity grade. Sex as a risk factor for incidence and progression is a current matter of debate and our aim was to analyze sex-related differences in therapy, diagnostic and outcome in LEAD patients who underwent an amputation of the LL.

Method: The database provided by the AOK (Allgemeine Ortskrankenkasse) included routine data of an unselected "real-world" cohort. All patients with an in-patient treatment for LEAD and amputation of the LL between 01.01.2010 – 31.12.2018 were included in our analysis. We analysed the risk profiles, diagnostic examination and treatment, as well as their impact on death. Beside the index-hospitalization and an up to ten-year follow-up period, we included a two-year prephase in our analysis.

Results: Our dataset consist of 66,424 patients with a primary diagnosis of LEAD and amputation of the LL. Thereof one third were female patients (36.4% women vs. 63.6% men), being eight years older compared to men (median age: 82.4 years vs. 74.5 years). Women were more often diagnosed with hypertension (95% vs. 92%), chronic kidney disease (59% vs. 55%), atrial fibrillation or flutter (41% vs. 39%) and chronic heart failure (59% vs. 53%), while male patients had higher frequencies of diabetes (63% vs. 66%), cerebrovascular diseases (19% vs. 24%) and chronic coronary syndrome (51% vs. 58%; all p<0.001). The performance of any diagnostic angiography (79%) or revascularization (67%) during a two-year period afore amputation of the LL was generally low and even lower in female patients compared to men (diagnostic angiography: 74% vs. 82%, revascularization: 64% vs. 71%, both p<0.001). An analysis of different age groups showed, that the rate of diagnostic angiography and revascularization procedure was equal in both sexes until the age of 80 years. Interestingly both vascular procedures was carried out less frequently in women older than 81 years compared to males. During index-hospitalization, females underwent more frequently major amputation (43% vs. 35%), while the rate of minor amputation was higher in male LEAD patients (62% vs. 72%; both p<0.001). The mortality rate was higher in women and the prognosis was worse if no vascular procedure was done before amputation of the LL (figure 1). After adjustment for age, cardiovascular comorbidities and vascular procedure during the ten-year follow-up period, females had a small, but significantly higher probability of death too (HR 1.036; CI95% 1.035 – 1.037).

Conclusion: Female patients were older and displayed the minority of hospitalized LEAD patients undergoing an amputation of the LL. Diagnostic angiography and revascularization was performed less often in octogenarian women and the mortality rate was higher in women, rising in LEAD patients without any vascular procedure afore amputation. More analyses are urgently needed to correspond to the individual needs of male and female LEAD patients.


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