Sex-related differences in treatment and outcome of chronic limb-threatening ischaemia: a real-world cohort

Abstract

Aims The prevalence of chronic limb-threatening ischaemia (CLTI) is increasing and available data often derive from cohorts with various selection criteria. In the present study, we included CLTI patients and studied sex-related differences in their risk profile, vascular procedures, and long-term outcome. Methods and results We analysed 199 953 unselected patients of the largest public health insurance in Germany (AOK: Local healthcare funds), hospitalized between 2010 and 2017 for a main diagnosis of CLTI. A baseline period of 2 years before index hospitalization to assess comorbidities and previous procedures, and a follow-up period until 2018 were included. Female CLTI patients were older (median 81.4 vs. 73.8 years in males; P < 0.001) and more often diagnosed with hypertension, atrial fibrillation, chronic heart failure, and chronic kidney disease. Male patients suffered more frequently from diabetes mellitus, dyslipidaemia, smoking, cerebrovascular disease, and chronic coronary syndrome (all P < 0.001). Within hospitalized CLTI patients, females represent the minority (43% vs. 57%; P < 0.001) and during index hospitalization, women underwent less frequently diagnostic angiographies (67 vs. 70%) and revascularization procedures (61 vs. 65%; both P < 0.001). Moreover, women received less frequently guideline-recommended drugs like statins (35 vs. 43%) and antithrombotic therapy (48 vs. 53%; both P < 0.001) at baseline. Interestingly, after including age and comorbidities in a Cox regression analysis, female sex was associated with increased overall-survival (OS) [hazard ratio (HR) 0.95; 95% confidence interval (CI) 0.94–0.96] and amputation-free survival (AFS) (HR 0.84; 95% CI 0.83–0.85; both P < 0.001). Conclusion Female patients with CLTI were older, underwent less often vascular procedures, and received less frequently guideline-recommended medication. Nevertheless, female sex was independently associated with better OS and AFS during follow-up. Key question Analysis of sex-related differences in patients with chronic limb-threatening ischaemia (CLTI), with a focus on their risk profile, treatment, and long-term outcome. Key finding Female CLTI patients were older, underwent vascular procedures less often, and received less frequently guideline-recommended drugs, but female sex was associated with better outcome. Take-home message Chronic limb-threatening ischaemia should be considered as a multi-organ disease with an ever increasing prevalence and a poor prognosis. Chronic limb-threatening ischaemia patients partly do not receive optimal therapy, and this is more prominent in females.

Sex-Related Differences and Factors Associated with Peri-Procedural and 1-year Mortality in Chronic Limb-Threatening Ischemia Patients from the CLIMATE Italian Registry

“…A recent German study from the cardiologists of the University of Muenster on almost 200000 unselected patients treated for CLTI over an 8-year-period showed that 30-day-mortality is significantly higher in women [3]. Same results were obtained from the US National Inpatient Sample database [7,10].…”

“…Survival of female and male patients that underwent treatment for CLTI have been investigated with discordant results. For instance, some studies from Germany and the USA showed that 30-day mortality was significantly higher in females, while others from Japan and Sweeden respectively identified female sex as a significant positive predictor of 2-year survival, or reported that male sex was significantly associated with an increased risk of death [2][3][4][5][6][7][8][9][10][11].…”

Geschlechtsspezifische Unterschiede in der Versorgung und dem Outcome von pAVK Patienten – Eine Sekundärdatenanalyse-

“…Als Grundlage dieser Aussage wird die Verschreibung eines Medikamentes, jedoch nicht die tatsächliche Einnahme durch den Patienten genutzt. In unserer Kohorte, wie auch in anderen Studien, wurde beschrieben, dass die meisten pAVK Patienten an mindestens einem weiteren kardiovaskulären Risikofaktor und/oder einer Komorbidität leiden [3,[19][20][21]. In unserer Kohorte wurden Männer vor allem häufiger mit weiteren arteriosklerotischen Manifestationen diagnostiziert (wie Koronare Herzerkrankung, Zerebrovaskuläre Erkrankung), was vermuten lässt, dass Männer eher als kardiovaskuläre Risikopatienten eingeschätzt werden.…”

“…Unsere Analysen zeigten, dass Männer häufiger rauchen an zerebrovaskulärer Erkrankung leiden und auch häufiger im Vorfeld einen Herzinfarkt oder Schlaganfall aufwiesen. Ähnliche Ergebnisse konnten wir bei Patienten, die im Stadium der CLTI hospitalisiert wurden, zeigen [23].…”

Sex-Related Differences and Factors Associated with Peri-Procedural and 1 Year Mortality in Chronic Limb-Threatening Ischemia Patients from the CLIMATE Italian Registry

“…The survival of female and male patients who underwent treatment for CLTI has been investigated with discordant results. For instance, some studies from Germany and the USA showed that 30 day mortality was significantly higher in females, while others from Japan and Sweden, respectively, identified female sex as a significant positive predictor of 2 year survival or reported that male sex was significantly associated with an increased risk of death [ 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 ].…”