Comparison of differences in outcome after percutaneous coronary intervention in men versus women <40 years of age

Prevalence of Cardiovascular Risk Factors in Women With Obstructive Coronary Disease Requiring Revascularization: A Meta-analysis

Background

Cardiovascular disease continues to be the primary cause of premature mortality in women, who previously have been overlooked in clinical trials. Several studies showed that women undergoing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) present more cardiovascular risk factors at baseline, develop more postprocedural complications, and have a higher mortality rate than men. The goal of this review is to analyze the difference between men and women in terms of the prevalence of individual cardiovascular risk factors.

Methods

A meta-analysis was conducted of original investigations with adult subjects who underwent surgical intervention or PCIs in which cardiovascular risk factors were evaluated, using the MEDLINE, Cochrane, Evidence-Based Medicine Reviews (EBMR), Ovid Embase, Google Scholar, and PubMed databases.

Results

Of the 4567 identified records found, 18 were retained for qualitative analysis. Prevalence of hypertension (CABG: 71% (95% confidence interval [CI] 64%, 78%]); PCI: (59% [95% CI 48%,70%]), and diabetes (CABG: 48% [95% CI 38%, 57%]); PCI 43% (95% CI 27%, 59%]) was high in women. Women who underwent either CABG or PCI had higher odds of having hypertension (CABG: odds ratio [OR] 1.92 [95% CI 1.47-2.50], P < 0.05); PCI: OR 1.86 [95% CI 1.76-1.97], P < 0.05]), and diabetes (CABG: OR 1.94 [95% CI 1.55-2.42], P < 0.05; PCI: OR 1.97 [95% CI 1.54-2.53], P < 0.05)). However, the prevalence of smoking among women, compared to men, was lower (CABG: 0.17 [95% CI 0.06-0.52], P < 0.05; PCI: 0.22 [95% CI 0.06-0.86], P < 0.03).

Conclusion

The review shows that women who underwent either surgical or percutaneous revascularization had higher odds of hypertension and diabetes, compared to men.

Risk Factors for Premature Coronary Heart Disease in Women Compared to Men: Systematic Review and Meta-Analysis

Background: We aimed to systematically examine literature on the prevalence of known modifiable and nonmodifiable risk factors for premature coronary heart disease (PCHD) in women compared with men. Materials and Methods: PubMed, CINAHL, Embase, and Web of Science databases were searched. Review protocol is registered in PROSPERO (CRD42020173216). Quality was assessed using the National Heart, Lung, and Blood Institute tool. Review Manager 5.3 was used for meta-analysis. Effect sizes were expressed as odds ratio (OR) and mean differences/standardized mean differences (SMD) with 95% confidence intervals (CIs) for categorical and continuous variables. Results: In this PCHD cohort (age <65 years), the mean age of presentation in women was 3 years older than men. Women had higher total cholesterol (SMD 0.11; 95% CI 0.00 to 0.23) and higher high-density lipoprotein cholesterol (SMD 0.49; 95% CI 0.29 to 0.69). Women were more likely to have hypertension (OR 1.51, 95% CI 1.42 to 1.60), diabetes mellitus (OR 1.78, 95% CI 1.55 to 2.04), obesity (OR 1.33, 95% CI 1.24 to 1.42), metabolic syndrome (OR 3.73, 95% CI 1.60 to 8.69), stroke (OR 1.63, 95% CI 1.51 to 1.77), peripheral vascular disorder (OR 1.67, 95% CI 1.43 to 1.96), and depression (OR 2.29, 95% CI 1.96 to 2.67). Women were less likely to be smokers (OR 0.60, 95% CI 0.55 to 0.66), have reported alcohol intake (OR 0.36, 95% CI 0.33 to 0.40), and reported use of illicit drug (OR 0.32, 95% CI 0.16 to 0.62). Conclusions: Risk factor profile in PCHD has a clear sex difference that supports early, aggressive, holistic, but sex-specific, approach to prevention.

Sex difference in clinical outcomes of Chinese patients with atrial fibrillation and coronary stenting according to age

OBJECTIVE

Sex differences in the clinical outcomes of patients with atrial fibrillation (AF) and coronary stenting should be assessed according to age.

METHODS

We analyzed the clinical data of all patients with nonvalvular AF who underwent coronary stenting between January 2010 and June 2015 in 12 hospitals of Beijing, China.

RESULTS

A total of 2,146 patients (71.8% men and 28.2% women) were included in the study. The mean age of the patients was 66.6±9.4 years. Women in this study were older and had higher prevalence of hypertension, diabetes, chronic kidney disease (CKD), and anemia. Smoking history was found to be higher in men, and women were less likely to be current smokers. The mean follow-up duration was 39.7 months. Women younger than 65 years had a remarkably higher mortality (11.2% vs. 5.3%, p=0.012) and a significantly lower rate of repeat revascularization (1.6% vs. 6.3%, p=0.034) than men. Female gender remained an independent predictor for all-cause mortality [hazard ratio (HR)=2.03, 95% confidence interval (CI): 1.09-3.79, p=0.025], along with heart failure (HR=3.64, 95% CI: 2.02-6.57, p<0.001) and CKD (HR=2.46, 95% CI: 1.09-5.57, p=0.031) after multivariate regression analysis. No significant difference was noted between men and women with regard to mortality, ischemic events, and major bleeding in elderly patients.

CONCLUSION

In Chinese patients younger than 65 years with AF and coronary stenting, female gender was independently associated with increased mortality; men were more likely to receive repeat revascularization possibly due to the current smoking. Whether it was a biological difference or a recognition disparity of the disease between men and women warrants further investigation.

Sex Differences in Outcomes Following Percutaneous Coronary Intervention According to Age

BACKGROUND

Women <50 years of age with coronary artery disease may represent a group at higher risk for recurrent ischemic events after percutaneous coronary intervention (PCI); however, no long-term, multicenter outcomes assessment exists in this population.

METHODS AND RESULTS

Using the National Heart, Lung, and Blood Institute Dynamic Registry, we evaluated the association of sex and age on cardiovascular-related outcomes in 10,963 patients (3797 women, 394 <50 years) undergoing PCI and followed for 5 years. Death, myocardial infarction, coronary artery bypass graft surgery, and repeat PCI were primary outcomes comprising major adverse cardiovascular events. Although procedural success rates were similar by sex, the cumulative rate of major adverse cardiovascular events at 1 year was higher in young women (27.8 versus 19.9%; P=0.003), driven largely by higher rates of repeat revascularizations for target vessel or target lesion failure (coronary artery bypass graft surgery: 8.9% versus 3.9%, P<0.001, adjusted hazard ratio 2.4, 95% confidence interval 1.5-4.0; PCI: 19.0% versus 13.0%, P=0.005, adjusted hazard ratio 1.6, 95% confidence interval 1.2-2.2). At 5 years, young women remained at higher risk for repeat procedures (coronary artery bypass graft surgery: 10.7% versus 6.8%, P=0.04, adjusted hazard ratio 1.71, 95% confidence interval 1.01-2.88; repeat PCI [target vessel]: 19.7% versus 11.8%, P=0.002, adjusted hazard ratio 1.8, 95% confidence interval 1.24-2.82). Compared with older women, younger women remained at increased risk of major adverse cardiovascular events, whereas all outcome rates were similar in older women and men.

CONCLUSIONS

Young women, despite having less severe angiographic coronary artery disease, have an increased risk of target vessel and target lesion failure. The causes of this difference deserve further investigation.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00005677.

Gender differences in in-hospital clinical outcomes after percutaneous coronary interventions: an insight from a Japanese multicenter registry

Background

Gender differences in clinical outcomes after percutaneous coronary intervention (PCI) among different age groups are controversial in the era of drug-eluting stents, especially among the Asian population who are at higher risk for bleeding complications.

Methods and Results

We analyzed data from 10,220 patients who underwent PCI procedures performed at 14 Japanese hospitals from September 2008 to April 2013. A total of 2,106 (20.6%) patients were women. Women were older (72.7±9.7 vs 66.6±10.8 years, p<0.001), and had a lower body mass index (23.4±4.0 vs 24.3±3.5, p<0.001), with a higher prevalence of hypertension (p<0.001), hyperlipidemia (p<0.001), insulin-dependent diabetes (p<0.001), renal failure (p<0.001), and heart failure (p<0.001) compared with men. Men tended to have more bifurcation lesions (p = 0.003) and chronic totally occluded lesions (p<0.001) than women. Crude overall complications (14.8% vs 9.5%, p<0.001) and the rate of bleeding complications (5.3% vs 2.8%, p<0.001) were significantly higher in women than in men. On multivariate analysis in the total cohort, female sex was an independent predictor of overall complications (OR, 1.47; 95% CI, 1.26–1.71; p<0.001) and bleeding complications (OR, 1.74; 95% CI, 1.36–2.24; p<0.001) after adjustment for confounding variables. A similar trend was observed across the middle-aged group (≥55 and <75 years) and old age group (≥75 years).

Conclusions

Women are at higher risk than men for post-procedural complications after PCI, regardless of age.

Impact of artificial plaque composition on drug transport

Drug-eluting stent (DES) implantation is a common treatment for atherosclerosis. The safety and efficacy of these devices will depend on the uptake and distribution of drug into the vessel wall. It is established that the composition of atherosclerotic vessels can vary dramatically with patients' age and gender. However, studies focused on elucidating and quantifying the impact of these variations on important drug transport properties, such as diffusion (D) and partition (k) coefficients, are limited. We have developed an improved tissue mimic or artificial plaque to probe the effect of varying concentrations of plaque constituents on drug transport in vitro. Based on these artificial plaques, we have quantified the impact of gelatin (hydrolyzed collagen) and lipid (cholesterol) concentration on D and k using two model drugs, tetracycline and fluvastatin. We found that for tetracycline, increasing the collagen concentration from 0.025 to 0.100 (w/w) resulted in a fivefold decrease in diffusivity, whereas there was no discernible impact on solubility. Increasing the lipid concentration up to 0.034 (w/w) resulted in only minor changes to transport properties of tetracycline. However, fluvastatin exhibited nearly a fivefold increase in k and 10-fold decrease in D with increased lipid concentration. These results were in reasonable agreement with existing models and exhibited behavior consistent with previous observations on drugs commonly used in DES applications. These observations suggest that variations in the chemical characteristics of atherosclerotic plaque can significantly alter the release rate and distribution of drug following DES implantation.

Gender gap in acute coronary heart disease: Myth or reality?

AIM

To investigate potential gender differences in the prevalence of cardiovascular risk factors, cardiovascular disease (CVD) management, and prognosis in acute coronary syndrome (ACS).

METHODS

A systematic literature search was performed through Medline using pre-specified keywords. An additional search was performed, focusing specifically on randomized controlled clinical trials in relation to therapeutic intervention and prognosis. In total, 92 relevant articles were found.

RESULTS

Women with CVD tended to have more hypertension and diabetes at the time of presentation, whereas men were more likely to smoke. Coronary angiography and revascularization by percutaneous coronary intervention were performed more often in men. Women were at a greater risk of short-term mortality and complications after revascularization. Interestingly, women under 40 years presenting with ACS were at highest risk of cardiovascular death compared with men of the same age, irrespective of risk factors. This disadvantage disappeared in older age. The long-term mortality risk of ACS was similar in men and women, and even in favor of women.

CONCLUSION

Mortality rates are higher among young women with ACS, but this difference tends to disappear with age, and long-term prognosis is even better among older women.

Cardiovascular risk in women: the impact of hormone replacement therapy and prospects for new therapeutic approaches

Cardiovascular disease (CVD) is the main cause of death in women. Observational studies of hormone replacement therapy (HT) and data from women with premature ovarian failure have provided support for the principle that estrogen confers protection against the development of CVD in premenopausal women. However, randomised, controlled trials investigating HT in postmenopausal women have failed to demonstrate a benefit of HT in the primary or secondary prevention of CVD. Nevertheless, HT may be effective if targeted at younger perimenopausal women. Research aimed at investigation of the cellular mechanisms of estrogen may result in the discovery of new therapeutic targets that may be able to harness the potential beneficial effects of estrogens in the cardiovascular system. An improved understanding of the distinct processes in the clinical presentation and progress of CVD in women will help develop new targets and enhance the use of current established drugs.

Current trends in coronary artery disease in women

PURPOSE OF REVIEW

There are some striking sex differences regarding presentation, symptoms and sign, diagnosis, and treatment of coronary artery disease. Historically, healthcare delivery to women has been plagued with treatment bias favoring men. This review will present relevant cardiovascular physiologic sex differences, current treatment options for coronary artery disease both surgical and medical, and clinical outcomes of such treatments.

RECENT FINDINGS

In the past, pharmacologic and interventional studies generally excluded women from their subjects. As a result, women have been traditionally treated based on the findings in their male counterparts. Recent studies examining sex differences in the treatment of coronary artery disease have given new insight into the hormonal and behavioral influences associated with coronary artery disease. Finally, these studies have drawn attention to possibly inadvertent discrepancies in the way men and women are treated for coronary artery disease.

SUMMARY

Despite significant advances in medical and surgical approaches to treat coronary artery disease, it remains and will continue to be the most important healthcare challenge of the 21st century. Whereas efforts are underway to encourage inclusion of more women in therapeutic trials, the educational process, particularly in medical school, needs to broadly address sex specific pathophysiology and treatment, rather than relying on sub-subspecialty training for optimizing healthcare delivery in women.

Comparison of results of percutaneous coronary intervention for non-ST-elevation acute myocardial infarction or unstable angina pectoris in men versus women

Previous randomized trials have addressed the impact of gender on outcomes, showing worse results in women assigned to invasive strategies compared with men with non-ST-elevation (NSTE) acute coronary syndrome (ACS). However, there is still a significant amount of controversy on strategies of treatment on the basis of gender. This study evaluated the impact of gender on treatment strategies and outcomes in patients with NSTE ACS in a high-volume, single-site tertiary center. We identified 1,197 consecutive patients with NSTE ACS (381 women, 816 men) who underwent percutaneous coronary intervention during their index hospitalizations. Patients were stratified by gender and baseline clinical and angiographic characteristics, and in-hospital and 9-month clinical outcomes were compared between the 2 groups. There were clear differences in baseline characteristics between men and women with ACS at presentation. Women were, on average, slightly older than men, with more hypertension and morbid obesity, but there were no differences in racial backgrounds or the prevalence of diabetes or dyslipidemia, nor were there treatment disparities in pharmacologic interventions. Women and men with ACS had similar rates of percutaneous coronary intervention on index admission. Women had a greater incidence of bleeding complications requiring blood transfusions. Overall, in-hospital and 9-month event-free survival were equivalent for the 2 genders. In conclusion, in this single-site observational study, patients with NSTE ACS who underwent angiography followed by percutaneous coronary intervention demonstrated no significant gender differences in treatment or in-hospital or 9-month event-free survival. From these results, interventional strategies should not be based on gender.

Gender differences in short-term cardiovascular outcomes after percutaneous coronary interventions

Recent studies have been inconsistent in demonstrating a decrease in the gender gap in short-term post-percutaneous coronary intervention (PCI) outcomes. We sought to determine gender differences in outcomes in younger and older patients who underwent PCI during the current stent era. We studied 4,768 elective PCI procedures performed at Emory University Hospital from 2001 to 2004. The baseline characteristics, periprocedural complications, angiographic success, procedural success, and major in-hospital complications (death, myocardial infarction, and emergency coronary artery bypass graft surgery) after PCI were compared between men and women. Women were more likely to be nonwhite and older, with a greater prevalence of hypertension and diabetes mellitus (all p <0.001) compared with men. After adjusting for baseline characteristics and coronary artery size, the incidence of coronary vascular injury complications was higher in women than in men, particularly in patients <or=55 years (odds ratio [OR] 2.74, 95% confidence interval [CI] 1.49 to 5.04). The difference was less when comparing women and men >55 years (OR 1.32, 95% CI 0.87 to 1.99, p = 0.047 for gender-age interaction). The adjusted odds of bleeding complications were also higher in women than in men (<or=55 years OR 5.39, 95% CI 2.26 to 12.8, >55 years OR 2.55, 95% CI 1.68 to 3.87, p = 0.121 for gender-age interaction). No significant gender differences were present in a combined end point of death, myocardial infarction, and emergency coronary artery bypass graft surgery. In conclusion, among patients who have undergone PCI, women, particularly younger women, are more likely than men to experience coronary vascular injury and bleeding complications unaccounted for by coronary artery size and other patient characteristics. No differences were found in major in-hospital complications by gender.

Impact of Age on the Outcomes of Women Following Percutaneous Coronary Intervention in the Bare-Metal Stent Era

AIM

Advanced age and female gender are both independent predictors of early and late mortality and adverse cardiac outcomes for patients undergoing balloon angioplasty. Elderly women are at particular risk. Stenting is now the standard of care in PCI. Whether elderly women remain at increased risk after PCI in the current stent era has not been examined widely.

METHODS

Prospective data were collected in 400 consecutive female patients undergoing PCI at a tertiary cardiac center (1999-2003). Follow-up was done at 1 month, 6 months, and 12 months by clinic visits, telephonic interviews, and reviewing hospital records. Follow-up was complete in 396 patients.

RESULTS

Compared to young women (<65 years old), elderly women (>65 years old) were less likely to smoke (15.7% vs 47.2%, P = 0.001), less likely to have diabetes (4.1% vs 8.5%, P = 0.05), and had more multivessel coronary artery disease. Usage of stent was high, similar in both groups. Hypertension, hypercholesterolemia, previous MI, vessels treated, abciximab usage, and access site bleeding were similar in both groups. Procedural success (96% vs 98%) and in-hospital and 1-year MACE (23.1% vs 25%) are similar in both groups.

CONCLUSION

Elderly women undergoing PCI have a distinct profile presenting with more multivessel disease, less smoking, and are less likely to have diabetes than younger women. In the current stent era, procedural success, in-hospital adverse cardiac events, and MACE at 1 year are similar in both groups. At 1 year, however, elderly women are less likely to have ischemia-driven TVR and recurrence of angina.

Impact of chronic oral anticoagulation on management and outcomes of patients with acute myocardial infarction: data from the RICO survey

OBJECTIVE

To determine the prevalence of chronic oral anticoagulant drug treatment (COA) among patients with acute myocardial infarction (AMI) and its impact on management and outcome.

METHODS

All patients with ST segment elevation AMI on the RICO (a French regional survey for AMI) database were included in this analysis. COA was defined as continuous use >or= 48 hours before AMI.

RESULTS

Among the 2112 patients with ST elevation myocardial infarction (STEMI), 93 (4%) patients were receiving COA. These patients were older and more likely to have a history of hypertension, diabetes and prior myocardial infarction than patients without COA. In addition, fewer patients who received COA underwent reperfusion therapy or received an antiplatelet agent (aspirin/thienopyridines). Moreover, patients receiving COA experienced a higher incidence of in-hospital major adverse events (death, recurrent myocardial infarction or major bleeding, p = 0.005). Multivariate analysis showed that only ejection fraction, current smoking and multiple vessel disease, but not COA, were independent predictive factors for major adverse events. In contrast, COA was an independent predictive factor for heart failure when adjusted for age, diabetes, creatinine clearance, reperfusion, heparin and glycoprotein IIb/IIIa inhibitors (odds ratio 2.06, CI 95% 1.23 to 3.43, p = 0.005).

CONCLUSION

In this population based registry, patients with STEMI with prior use of COA constituted a fairly large group (4%) with an overall higher baseline risk profile than that of patients without COA. Fewer in the COA group received reperfusion therapy or aggressive antithrombotic treatment and they experienced more adverse in-hospital outcomes. Thus, further studies are warranted to develop specific management strategies for this high risk group.

Diabetic cardiomyopathy: do women differ from men?

Although many aspects of cardiovascular disease are similar between women and men, it is becoming increasingly obvious that there are significant differences as well. Premenopausal women usually have a lower risk of cardiovascular diseases than age-matched men and postmenopausal women. However, the "female advantage" disappears once women are afflicted with diabetes mellitus. Heart diseases are twice as common in diabetic men and five times as common in diabetic women. It is believed that differences in sex hormones and intrinsic myocardial and endothelial functions between men and women may be responsible for this female "advantage" and "disadvantage" in normal and diabetic conditions. Most experimental and clinical studies on diabetes only included male subjects and failed to address this important gender difference in diabetic heart complications. Although female hearts may be better tolerated to stress (such as ischemia) insults than their male counterparts, female sex hormone such as estrogen may interact with certain risk factors under diabetes which may compromise the overall cardiac function. The benefit versus risk of estrogen replacement therapy on cardiac function and overall cardiovascular health in diabetes remains controversial. This review will focus on gender-related difference in diabetic heart complication--diabetic cardiomyopathy--and if gender differences in intrinsic myocardial contraction, polyol pathway metabolism, and advanced glycation endproduct formation and other neuroendocrinal regulatory mechanisms to the heart may contribute to disparity in diabetic cardiomyopathy between men and women.