Sex-related effectiveness of bivalirudin versus abciximab and heparin in non-ST-segment elevation myocardial infarction

Time Trends in Major Adverse Cardiovascular Events After Percutaneous Coronary Intervention: Meta-Analysis on Sex Differences

Background

Percutaneous coronary intervention (PCI) is considered the procedure of choice for patients with acute coronary syndrome (ACS), as it significantly improves cardiovascular outcomes. However, considerable uncertainty persists regarding the potential sex differences in PCI outcomes, due to conflicting results in previous studies.

Objectives

This meta-analysis aims to evaluate potential sex-related differences in cardiovascular adverse outcomes after PCI among ACS patients.

Methods

The primary outcome was major adverse cardiovascular events (MACE) and its components. Outcomes were examined in various time frames including: short-term (within 1 month after PCI), mid-term (within 1 year), and long-term (within >1 year). A random effects model was used to estimate risk ratios (RR) and 95% CIs.

Results

Among 32 trials, at short-term, PCI was associated with a higher risk of MACE (risk ratio [RR]: 1.43; 95% CI: 1.10-1.86), all-cause mortality (RR: 2.51; 95% CI: 1.70-3.71), and myocardial infarction (RR: 1.33; 95% CI: 1.00-1.77) in women compared with men. Over the long-term, women had a higher risk of MACE (RR: 1.11; 95% CI: 1.01-1.22), all-cause mortality (RR: 1.29; 95% CI: 1.17-1.42), and cardiovascular mortality (RR: 1.30; 95% CI: 1.11-1.52), when compared with men. However, the analysis for stroke and repeat revascularization showed no significant difference between the 2 groups in the long- and short-term.

Conclusions

In the meta-analysis of PCI-related trials in ACS, women have a higher risk of adverse cardiovascular outcomes compared with men.

Coronary artery disease and acute coronary syndrome in women

There are important dissimilarities in clinical presentation, aggregation of comorbidities, cardiovascular risk factors and the quality of delivery of medical care among men and women with acute coronary syndrome (ACS). Compared with men, despite the well-known older age and more pronounced frailty, women with ACS present later from symptom onset and are at high bleeding risk after invasive procedures. In addition, autoimmune/inflammatory disease, fibromuscular dysplasia, polycystic ovary, early menopause and history of pre-eclampsia are risk factors preceding ACS among younger women. They more often experience myocardial infarction in the absence of obstructive coronary arteries (MINOCA), which makes diagnosis and treatment of ACS among women more challenging compared with men. Women and men do both benefit from guideline-recommended treatment, although, compared with men, women with ACS have a higher adjusted risk of early death, which equalises between both sexes within the first year. Young women with ACS suffer frequently of depression and present often with MINOCA. Compared with young men, they (young women) have a higher risk of death. Therefore, focusing on young patients with ACS, understanding the particular physiopathology of MINOCA and developing programmes targeting comorbidities and depression-related behavioural risk factors are urgently needed.

Gender-based outcomes of bivalirudin versus heparin in patients undergoing percutaneous coronary interventions: Meta-analysis of randomized controlled trials

OBJECTIVES

We aimed to perform a gender-based meta-analysis of the outcome of bivalirudin versus heparin in patients undergoing percutaneous coronary interventions (PCI).

BACKGROUND

Bivalirudin has been shown to decrease major bleeding when compared to heparin ± glycoprotein IIb/IIIa inhibitors (GPI) in patients undergoing PCI. It is unclear, however, if those differences in outcomes are the same for men and women.

METHODS

We included randomized controlled trials (RCTs) that compared bivalirudin to heparin with or without GPI in patients undergoing PCI and reported outcome data that were stratified by gender. Random effect model was used to pool odds ratio (OR) and 95% confidence intervals (CI).

RESULTS

We included 9 trials with 33,224 patients. Bivalirudin decreased major bleeding when compared to heparin plus routine GPI in both men (OR: 0.51, P < 0.001) and women (OR: 0.55, P < 0.001). However, when GPI were used selectively with heparin, the bleeding lowering effect of bivalirudin was statistically significant in men (OR: 0.69, P = 0.02) but not in women (OR: 0.71, P = 0.21). When compared to heparin ± GPI, there was a nonstatistically significant trend toward lower all-cause mortality with bivalirudin in both men (OR: 0.76, P = 0.055) and women (OR: 0.79, P = 0.21). There were no significant differences in major adverse cardiovascular events between heparin and bivalirudin in both men and women.

CONCLUSION

Bivalirudin decreases major bleeding in both men and women when compared to heparin plus routine GPI. However, when compared to heparin alone, the bleeding lowering benefit of bivalirudin is less evident in women. © 2017 Wiley Periodicals, Inc.

Bivalirudin versus heparin in women undergoing percutaneous coronary intervention: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

The anticoagulant of choice during percutaneous coronary intervention (PCI) in women is not well established.

METHODS

An electronic search was conducted for trials that randomized patients undergoing PCI to bivalirudin versus heparin, and reported outcomes of interest in women. Random effects DerSimonian-Laird risk ratios (RR) were calculated. Main outcome was net adverse clinical events (NACE) at 30-days. Other outcomes included major adverse cardiac events (MACE), all-cause mortality, myocardial infarction (MI), target vessel revascularization (TVR), and major bleeding at 30-days. 1-year all-cause mortality and MACE were also examined.

RESULTS

Nine trials that randomized women undergoing PCI to bivalirudin (n=3960) versus heparin (n=4050) were included. At 30-days, bivalirudin was associated with reduced risk of NACE (RR=0.85; 95% CI 0.73-0.98; p=0.03), mainly driven by reduction in major bleeding (RR=0.59; 95% CI 0.49-0.71; p<0.001) compared with heparin. No difference in MACE (p=0.92), all-cause mortality (p=0.23), MI (p=0.86); or TVR (p=0.53) was demonstrated between both groups. At 1-year, the risk of MACE and all-cause mortality was similar in both groups. On a subgroup analysis, the benefit associated with bivalirudin appeared to be less evident when Glycoprotein IIb/IIIa inhibitors (GPI) was used as bailout therapy with heparin, however without significant interaction. Furthermore, in STEMI population, no difference in NACE, MACE, or major bleeding was observed between both groups.

CONCLUSION

In women undergoing PCI, bivalirudin is associated with reduced risk of major bleeding and NACE compared with heparin especially when GPI is routinely used.

Bivalirudin versus Heparin plus Glycoprotein IIb/IIIa Inhibitors in Women Undergoing Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Controlled Trials

Bivalirudin has been shown to be safe and efficacious compared with heparin plus glycoprotein IIb/IIIa inhibitor (GPI) in patients undergoing percutaneous coronary intervention (PCI). Whether bivalirudin would have the beneficial effects in female patients undergoing PCI remains unknown. We searched the literature for randomized controlled trials that assessed bivalirudin versus heparin plus GPI therapy in female patients undergoing PCI. The primary efficacy end point was major adverse cardiovascular events (MACE) within 30 days. The secondary efficacy end points were 30-day incidence of all-cause mortality, myocardial infarction (MI), urgent/ischemia-driven revascularization of target vessel. The safety end point was major bleeding up to 30 days. A total of 4,501 female patients were included in five randomized trials. No significant difference in MACE emerged between bivalirudin and heparin plus GPI at 30 days (8.15% vs 8.76%, RR 0.94, 95% CI 0.77-1.16, P = .57). There were no significant differences in rates of mortality (1.28% vs 1.91%, RR 0.74, 95% CI 0.45-1.20, P = .22), MI (5.46% vs 5.25%, RR 1.02, 95% CI 0.79-1.32, p = .88), or target vessel revascularization (2.13% vs 1.65%, RR 1.43, 95% CI 0.88-2.30, P = .15). Compared with heparin plus GPI, bivalirudin was associated with a significant reduction in 30-day major bleeding (5.32% vs 9.20%, RR 0.58, 95% CI 0.47-0.72, P < .0001). In conclusion, bivalirudin is associated with a significant reduction in 30-day major bleeding without increased ischemic events compared with heparin plus GPI in female patients undergoing PCI.

The safety and effectiveness of bivalirudin in female patients with acute myocardial infarction undergoing primary angioplasty: A subgroup analysis of the BRIGHT trial

BACKGROUND

Being female is an independent predictor of adverse events during percutaneous coronary interventions (PCI).

OBJECTIVE

To evaluate the safety and efficiency of bivalirudin during emergency PCI in female patients with acute myocardial infarction (AMI).

METHODS

The present study was a subgroup analysis of the randomized Bivalirudin in Acute Myocardial Infarction vs. Heparin and GPI plus Heparin (BRIGHT) trial. A total of 392 female patients enrolled in the BRIGHT trial were assigned to receive bivalirudin with post-procedure dose infusion (n = 127) or heparin with or without tirofiban (n = 265). The primary efficiency endpoint was 30-day net adverse clinical events (NACEs). The secondary efficiency endpoints were 30-day major cardiac and cerebral events (MACCEs) and bleeding events defined according to Bleeding Academic Research Consortium (BARC) definitions.

RESULTS

For female patients, bivalirudin treatment was associated with significantly lower incidences of 30-day NACEs (6.3% vs. 21.5%, P < 0.001), any bleeding (2.4% vs. 12.8%, P = 0.001) and BARC 2-5 type bleeding (1.6% vs. 7.2%, P = 0.021) compared with the control regimen. The incidence of MACCEs (3.4% vs. 9.4%, P = 0.055) and stent thrombosis (0% vs. 1.1%, P = 0.229) were comparable between the two groups. Multivariate analysis showed that bivalirudin (OR: 0.245, 95% CI: 0.113-0.532, P < 0.001), transradial access (OR: 0.119, 95% CI: 0.067-0.211, P < 0.001), and statin (OR: 0.254, 95% CI: 0.08-0.807, P = 0.02) were independent protective factors for 30-day NACEs in female patients.

CONCLUSIONS

The use of bivalirudin during emergency PCI for AMI in female patients significantly reduced the bleeding risk with anticoagulation effects compared with heparin with or without tirofiban.

Gender differences in cardiovascular therapy: focus on antithrombotic therapy and percutaneous coronary intervention

The epidemiology of coronary artery disease (CAD) differs between women and men: female cardiac patients are older and have poorer risk profiles than their male counterparts. This results in a preferential exclusion of women from participation in clinical trials, reducing their power to detect differences in performance of cardiovascular therapies in women. In general, all the antiplatelet and anticoagulant medications used in cardiac patients are equally effective in men and women, although women tend to experience a higher relative benefit due to their poorer risk profile. In particular, women with CAD benefit the most from interventional treatment combined with modern antithrombotic drugs. No gender-related differences in the reduction of thromboembolic risk with more potent antithrombotic drugs have been reported. On the other hand, a clear trend to a higher incidence of bleeding complications has been consistently reported in women, which might be related to a more frequent over-dosage of antithrombotic treatment in women than in men. Women are therefore one of the subgroups that might benefit the most from careful dose adjustment of available antithrombotic drugs. However, the development of a gender-based dosage guideline remains an unmet need in cardiology.

Association of age and gender with risk for non-ST-elevation myocardial infarction

BACKGROUND

Age and gender associated risks for non-ST-elevation myocardial infarction (NSTEMI) at the population level are largely uncharacterized.

DESIGN

Nationwide, population (26,724,165 person-years) based eight-year registry-study in Finland.

METHODS

Gender- and age-associated frequency and incidence of NSTEMI were studied using a nationwide, population based registry of hospital admissions in patients aged ≥30 years during 2001-2008. Patients with NSTEMI as primary (88%), secondary (10%) or tertiary (2%) discharge diagnosis were included. Data was collected nationwide from all 22 hospitals with a coronary angiolaboratory.

RESULTS

The study period included 48,584 NSTEMI admissions of which 55.3% (95% confidence interval (CI) 54.6-56.0%) were of men and 44.7% (CI 44.1-45.3%) were of women, with age-adjusted relative risk of 1.86 (CI 1.60-2.16, p < 0.0001) for male gender. Female patients were significantly older than males (77.8 SD 10.2 vs. 70.2 SD 11.9 years, p < 0.0001). Standardized incidence rate of NSTEMI was 20.6 (CI 20.4-20.8)/10,000 person-years overall, 28.7 (CI 28.3-29.0)/10,000 in men and 15.0 (CI 14.7-15.2)/10,000 in women. Men had a 2.36-fold (CI 2.23-2.49; p < 0.0001) age-adjusted relative risk for NSTEMI compared with women, with highest risk difference in population under 40 years of age (relative risk 4.48; CI 3.10-6.48, p < 0.0001). Incidence increased with age by an estimated gender-adjusted increase rate of 61% (CI 59-62%; p < 0.0001) per five-year increase in age.

CONCLUSIONS

Men have a 2.4-fold overall risk for NSTEMI compared with women, with highest relative risk in young adults. Incidence rate of non-ST-elevation myocardial infarction increases by an estimated 61% per five-year increase in age.