Knowledge and awareness of peripheral vascular disease are poor among women at risk for cardiovascular disease.

OBJECTIVE: Peripheral vascular disease (PVD), a manifestation of systemic atherosclerosis, is an independent risk factor for cardiovascular (CV) morbidity and mortality. PVD research has traditionally focused on male patients; thus, there is a lack of current studies focusing specifically on women. In a cross-sectional study, we assessed the prevalence of PVD and associated atherosclerotic risk factors in ambulatory women veterans as well as knowledge and awareness of PVD and its consequences. MATERIALS AND METHODS: We screened 162 ambulatory women veterans aged 40 to 85 who were enrolled for outpatient care at an urban, tertiary care, teaching hospital. Of 207 women who responded to advertisements or mailings about the study, 78.3% met eligibility criteria and gave informed consent to participate. The participants (N = 162, mean age 54.8 +/- 9.3 years) were evaluated via chart review and noninvasive screening procedures (ankle-brachial index [ABI]; carotid artery intimal-medial thickness [IMT]). PVD was defined by having an ABI 1.0 mm, documented PVD, or previous leg revascularization. CV risk levels were determined using a modification of the Framingham risk level score: low risk, +0-1 risk factor; moderate risk, +2 risk factors; and high risk, >or=2 risk factors. Women's knowledge and awareness were assessed with a psychometrically sound survey (average subscale reliability: 0.942) about risk factors, symptoms, and health consequences associated with PVD. RESULTS: Of 162 patients, 66.2% were white and 84.2% had at least some college education. An ABI 1.0 mm was detected in 21.1%, while 1.2% had a prior diagnosis of PVD and 1.9% had previous leg revascularization. Risk factor stratification was as follows: low risk in 32.1%, moderate risk in 20.4%, and high risk in 47.5% of patients. Knowledge and awareness scores (% correct) for PVD were low regardless of CV risk factor group: low-risk average score was 45.7%; moderate risk, 42.1%; and high risk, 46.9% (F = 0.431, P = 0.650). Likewise, low scores for knowledge of CV risk factors and consequences were found in all CV risk factor groups: low-risk average score was 53.6%; moderate risk, 53.8%; and high risk, 54.4% (F = .013, P = 0.987). More than 68% of the women reported they had never discussed PVD or risk reduction with their physician, yet more than 44% believed they were at an increased risk for PVD. CONCLUSIONS: Despite the presence of multiple PVD risk factors, women in this study had low levels of knowledge and awareness about vascular diseases. Future work is needed to develop and disseminate information about PVD in women and its role in women's CV health. Improving education about the significance of PVD will allow women and their physicians to assess risk factors and implement preventive measures.

Quality of life and peripheral arterial disease.

Peripheral arterial disease (PAD) is a common disease entity with the potential to cause considerable impairment in the quality of life (QoL) of millions of Americans. As there is no exact cure for PAD, thus representing a chronic illness, the goal of treatment is disease management including the prevention of cardiovascular events, and improving QoL by helping people with PAD live productive and satisfying lives. Disagreement exists between patients' clinically inferred QoL status and their perceptions of QoL exist concerning PAD. Whereas a clinician may be concerned with a physiological or anatomical abnormality that may ultimately lead to disease and discomfort, a patient may be more concerned with their overall sense of QoL, which is only in part related to their clinical health status. Thus, to truly understand the outcomes of PAD and its treatment, it is necessary to supplement the traditional clinical outcome measures with information from the patient point of view. In this article, we review measurement instruments available to assess patient-reported QoL, and discuss the potential these tools have for providing accurate and meaningful information to complement traditional clinical outcome data.

Propensity score analysis in observational studies: outcomes after abdominal aortic aneurysm repair.

OBJECTIVE: Large databases composed of well-designed prospectively collected cohort data provide an opportunity to examine and compare healthcare treatments in actual clinical practice settings. Because the analysis of these data often leads to a retrospective cohort design, it is essential to adequately adjust for lack of balance in patient characteristics when making treatment comparisons. We used matched propensity scoring in a cohort of patients undergoing elective aneurysm repair as an illustrative example of this important statistical method that adjusts for baseline characteristics and selection bias by matching covariables. METHODS: By using prospectively collected clinical data from the National Surgical Quality Improvement Program of the Department of Veterans Affairs, we studied 30-day mortality, 1-year survival, and postoperative complications in 1904 patients who underwent elective AAA repair (endovascular aneurysm repair [EVAR], n=717 (37.7%); open aneurysm repair, n=1187 [62.3%]) at 123 Veterans Health Administration's hospitals between May 1, 2001, and September 30, 2003. In bivariate analysis, patient characteristics and operative and hospital variables were associated with both type of surgery and outcomes of surgery. Therefore, the predicted probability of receiving EVAR was tabulated for all patients by using multiple logistic regression to control for 32 independent demographic and clinical characteristics and then stratified into 5 groups. Patients were matched within strata based on similar levels of the independent measures (a propensity score technique), creating a pseudo-randomized control design. The proportion of patients with the morbidity and mortality outcomes was then compared between the EVAR and open procedures within strata to control for selection. RESULTS: Patients undergoing EVAR had significantly lower unadjusted 30-day (3.1% versus 5.6%, P=.01) and 1-year mortality (8.7% versus 12.1%, P=.018) than patients undergoing open repair. By using propensity scoring, the proportions of EVAR patients experiencing 30-day mortality were equal or less than patients undergoing open procedures for all levels of probability and decreased as the probability of EVAR increased. Furthermore, propensity scoring also showed that patients having EVAR had lower 1-year mortality and experienced fewer perioperative complications. CONCLUSIONS: We used a propensity score approach to examine outcomes after elective AAA repair to statistically control for many factors affecting both treatment selection and outcome. Patients who underwent elective EVAR had substantially lower perioperative mortality and morbidity rates compared with patients having open repair, which was not explained solely by patient selection in an observational dataset.

Hormone replacement therapy and peripheral vascular disease in women.

Women have been shown to have a lower incidence of vascular disease when compared to men. However, the incidence of vascular disease increases as women progress through menopause and reaches an incidence similar to that of men later in life. Women with peripheral vascular disease often have a delay in diagnosis, a higher incidence of asymptomatic disease, and poorer outcome after interventions. The differences in outcome have been attributed to a number of factors such as anatomic and hormonal differences. It is thought that estrogen deficiency is at least partially responsible for the increased risk of developing vascular disease after menopause, and thus hormone replacement therapy has been considered as a method to prevent progression of vascular disease. Conclusions drawn from a number of recent studies have resulted in a divergent view of hormone replacement therapy (HRT). This article explores the risk of peripheral vascular disease in women and the current state of research on hormone replacement therapy. The aims of this review are to present current perspectives on gender differences in the pathogenesis and outcomes of peripheral arterial disease (PAD). The effect of estrogen on atherogenesis, the role it plays in modulating the vascular endothelium, and the current evidence of the effects of HRT on vascular pathology is discussed. The most recent HRT clinical trials and present evidence for the benefits and risks of postmenopausal hormone replacement therapy are summarized. The effect of these issues on treatment practices is explained and suggestions are made for future directions of HRT and PAD research.