Arterial vascular disease underdiagnosed, undertreated in older US women

Women's social isolation, lack of female participants in clinical trials largely to blame, study suggests

Though arterial vascular disease is widespread and often deadly among older American women, doctors too often fail to spot and treat it, according to a new report by a team of vascular surgeons from the Columbia University Medical Center and Weill Cornell Medical College campuses of NewYork-Presbyterian Hospital.

“Much of that is due to the fact that for years, cardiovascular research has focused almost exclusively on males, so in many cases we simply don’t understand the true prevalence or level of threat women face from vascular disease,” says the study co-author, Dr. Ageliki G. Vouyouka, assistant professor of surgery in the Department of Vascular Surgery at Weill Cornell Medical College, and a vascular surgeon at NewYork-Presbyterian Hospital. “Obviously, we need more trials focused on the vulnerability of women to these crippling and even lethal conditions.”

She and co-author Dr. K. Craig Kent—the Greenberg-Starr Professor of Surgery at Weill Cornell Medical College, professor of surgery at Columbia University College of Physicians and Surgeons, and chief of vascular surgery at NewYork-Presbyterian Hospital—published their review, titled “Arterial Vascular Disease in Women,” in a recent issue of the Journal of Vascular Surgery.

Arterial vascular disease is an umbrella term for diseases involving the gradual closure of arteries throughout the body, including carotid stenosis (blockage of the arteries that supply blood to the brain), aortic aneurysmal disease (plaque and blockages in the aortic artery leading from the heart to the lower body), and lower-extremity arterial occlusive disease, which involves poor blood flow within the legs.

For decades, these forms of vascular disease were thought primarily as “men’s diseases.”

“That’s because the risk of vascular trouble increases greatly for women after menopause,” Dr. Kent explains. “In years past when lifespans were shorter, women simply didn’t live long enough to develop serious vascular illness. That’s all changed because the average American woman now lives well into her 80s.”

Other factors have conspired to keep women with arterial vascular disease off of doctors’ radar. Women typically outlive their male partners and are then left alone—either isolated at home or placed in nursing homes. They often have fewer financial resources and caregiver support to draw on, as well. “This means they often don’t get the care they deserve,” Dr. Vouyouka says.

In their paper, the two researchers pored over the existing literature on women and arterial vascular disease, breaking the findings down into the three main disease subtypes. Some of their findings:

For carotid stenosis:

• Women’s carotid and vertebral arteries are markedly smaller than those of men, so it takes less plaque buildup to cause severe restrictions in blood flow. However carotid plaque is more stable in women and therefore the risk of stroke becomes significant at higher degree of stenosis as compared to men.

• Plaque composition within the artery appears to differ between the sexes, and certain risk factors—such as high blood levels of C-reactive protein, use of hormone replacement therapy (HRT) and osteoporosis—may be unique to women.

• Women were under-represented in all major trials for carotid endarterectomy (surgery to correct the blockage of the neck arteries-CEA) and therefore the outcome of the procedure on women is not well analyzed. However it appears that carotid endarterectomy (CEA) probably carries a higher rate of complications for women, including stroke and therefore the procedure should be done for higher degree of stenosis in women, compared to men.

For aortic aneurysmal disease (AAA):

• Because of hormonal and other factors, this condition develops much later in life in women, compared to men.

• The U.S. Preventive Service Task Force currently recommends against screening for AAA in women. This may be misguided, the researchers contend, due to the fact that AAA is somewhat less common in women, compared to men. However there are certain groups of women with risk factors such as old age, smoking history and family history that have significantly higher likelihood of developing abdominal aortic aneurysms who deserve screening. Even more so, AAA appears to be more dangerous in women because they are more prone to rupture in smaller sizes and once they rupture are more fatal.

• Women are less likely than men to be offered minimally invasive endovascular techniques to correct AAA, mainly because they have smaller arteries and the current endovascular devices are made to fit the male anatomy. At the same time, female patients are more likely than males to die following traditional “open” aneurysm surgery. However when they undergo endovascular repair, their likelihood of dying is almost as low as that of men; and once the endovascular repair is completed , they actually respond better than men, with more rapid shrinkage of their aneurysm

For lower-extremity arterial occlusive disease:

• The risk for this type of restricted blood flow in the legs rises quickly for women after menopause. In fact, at age 70, males and females share identical odds for acquiring the potentially crippling condition.

• Certain risk factors—including osteoporosis and the probable use of HRT—heighten women’s risk for lower-extremity vascular illness. Women too often delay seeking medical help for the problem, leading to a higher rate of advanced disease at time of diagnosis. Because they seek medical help late, they are more likely than men to require amputation. Rates of wound complications when they undergo bypass surgery are also higher among women. There is not much information available, regarding the outcomes of minimally invasive procedures such as balloon angioplasty or stenting in women. A review of minimal invasive procedures performed by the Division of Vascular Surgery at NewYork-Presbyterian Hospital, a joint program between Columbia University Medical Center and Weill Cornell Medical College, has shown that women, although they come with more advanced disease, do equally well as men.

“Many of these findings remain tenuous, however, because we simply do not have enough women participating in clinical trials to firmly establish their risk factors, disease prevalence, indications for intervention or treatment outcomes,” Dr. Vouyouka says. “For that reason, we urge the creation of more randomized trials focused on women, a closer look at the impact of risk factors such as osteoporosis and HRT on women’s vascular health, and studies examining the role that social isolation plays in older women’s ability to receive care.”

Some of those efforts are already under way—beginning in 2000, the U.S. National Institutes of Health authorized new funding and programs aimed at better understanding cardiovascular disease in women.

Older American women—many of whom have spent their lives caring for others—deserve no less, Dr. Vouyouka says.

NewYork-Presbyterian Hospital

NewYork-Presbyterian Hospital—based in New York City—is the nation’s largest not-for-profit, non-sectarian hospital, with 2,242 beds. It provides state-of-the-art inpatient, ambulatory and preventive care in all areas of medicine at five major centers: NewYork-Presbyterian Hospital/Weill Cornell Medical Center, NewYork-Presbyterian Hospital/Columbia University Medical Center, Morgan Stanley Children’s Hospital of NewYork-Presbyterian, NewYork-Presbyterian Hospital/Allen Pavilion and NewYork-Presbyterian Hospital/Westchester Division. One of the largest and most comprehensive health-care institutions in the world, the Hospital is committed to excellence in patient care, research, education and community service. It ranks sixth in U.S.News & World Report’s guide to “America’s Best Hospitals,” ranks first on New York magazine’s “Best Hospitals” survey, has the greatest number of physicians listed in New York magazine’s “Best Doctors” issue, and is included among Solucient’s top 15 major teaching hospitals. The Hospital is ranked with among the lowest mortality rates for heart attack and heart failure in the country, according to a 2007 U.S. Department of Health and Human Services (HHS) report card. The Hospital has academic affiliations with two of the nation’s leading medical colleges: Weill Cornell Medical College and Columbia University College of Physicians and Surgeons. For more information, visit www.nyp.org.

Weill Cornell Medical College

Weill Cornell Medical College—Cornell University’s Medical School located in New York City—is committed to excellence in research, teaching, patient care and the advancement of the art and science of medicine, locally, nationally and globally. Weill Cornell, which is a principal academic affiliate of NewYork-Presbyterian Hospital, offers an innovative curriculum that integrates the teaching of basic and clinical sciences, problem-based learning, office-based preceptorships, and primary care and doctoring courses. Physicians and scientists of Weill Cornell Medical College are engaged in cutting-edge research in such areas as stem cells, genetics and gene therapy, geriatrics, neuroscience, structural biology, cardiovascular medicine, AIDS, obesity, cancer, psychiatry and public health—and continue to delve ever deeper into the molecular basis of disease in an effort to unlock the mysteries behind the human body and the malfunctions that result in serious medical disorders. The Medical College—in its commitment to global health and education—has a strong presence in such places as Qatar, Tanzania, Haiti, Brazil, Germany and Turkey. With the historic Weill Cornell Medical College in Qatar, the Medical School is the first in the U.S. to offer its M.D. degree overseas. Weill Cornell is the birthplace of many medical advances—from the development of the Pap test for cervical cancer to the synthesis of penicillin, the first successful embryo-biopsy pregnancy and birth in the U.S., the world’s first clinical trial for gene therapy for Parkinson’s disease, and, most recently, the first indication of bone marrow’s critical role in tumor growth. For more information, visit www.med.cornell.edu.

Columbia University Medical Center

Columbia University Medical Center provides international leadership in pre-clinical and clinical research, in medical and health sciences education, and in patient care. The medical center trains future leaders and includes the dedicated work of many physicians, scientists, nurses, dentists, and public health professionals at the College of Physicians and Surgeons, the Mailman School of Public Health, the College of Dental Medicine, the School of Nursing, the biomedical departments of the Graduate School of Arts and Sciences, and allied research centers and institutions. For more information, visit www.cumc.columbia.edu.