Comparison of Long-Term Outcomes Following Coronary Revascularization in Men-vs-Women with Unprotected Left Main Disease

Percutaneous coronary intervention versus coronary artery bypass grafting in left main disease according to patients' sex: A meta-analysis

BACKGROUND

The role of sex in choosing between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for unprotected left main coronary artery (ULMCA) disease has gained interest.

METHODS

Randomized controlled trials and adjusted observational studies comparing PCI versus CABG in ULMCA patients with outcomes by sex were included. The primary endpoint was major adverse cardiovascular events (MACE), with secondary endpoints being all-cause mortality and repeated revascularization.

RESULTS

Ten studies (3 randomized, 7 observational) involving 22,141 ULMCA disease patients (13,411 PCI, 8730 CABG) with a median 5-year follow-up were included. Among males, PCI was associated with a higher risk of MACE (HR 1.18, 95% CI 1.01-1.38), while no significant difference was seen in females. However, moderator analysis showed no significant interaction between sex and revascularization strategy for MACE (p for interaction .422). No differences in all-cause mortality were observed between PCI and CABG for either sex. Repeated revascularization risk was significantly higher with PCI for both sexes (HR 3.51, 95% CI 2.21-5.59 in males and HR 4.20, 95% CI 2.57-6.87 in females).

CONCLUSIONS

In males with ULMCA disease, CABG was associated with a lower risk of MACE compared to PCI, while no significant differences were seen in females. The lack of a significant interaction between sex and revascularization strategy suggests that these findings may not reflect true sex-based effect modification. PCI was linked to a higher risk of repeated revascularization in both sexes compared to CABG.

TRIAL REGISTRATION

The protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (ID: CRD42024537726).

Italian Association of Hospital Cardiologists Position Paper 'Gender discrepancy: time to implement gender-based clinical management'

It has been well assessed that women have been widely under-represented in cardiovascular clinical trials. Moreover, a significant discrepancy in pharmacological and interventional strategies has been reported. Therefore, poor outcomes and more significant mortality have been shown in many diseases. Pharmacokinetic and pharmacodynamic differences in drug metabolism have also been described so that effectiveness could be different according to sex. However, awareness about the gender gap remains too scarce. Consequently, gender-specific guidelines are lacking, and the need for a sex-specific approach has become more evident in the last few years. This paper aims to evaluate different therapeutic approaches to managing the most common women's diseases.

The Appropriateness of Medical Devices Is Strongly Influenced by Sex and Gender

Until now, research has been performed mainly in men, with a low recruitment of women; consequentially, biological, physiological, and physio-pathological mechanisms are less understood in women. Obviously, without data obtained on women, it is impossible to apply the results of research appropriately to women. This issue also applies to medical devices (MDs), and numerous problems linked to scarce pre-market research and clinical trials on MDs were evidenced after their introduction to the market. Globally, some MDs are less efficient in women than in men and sometimes MDs are less safe for women than men, although recently there has been a small but significant decrease in the sex and gender gap. As an example, cardiac resynchronization defibrillators seem to produce more beneficial effects in women than in men. It is also important to remember that MDs can impact the health of healthcare providers and this could occur in a sex- and gender-dependent manner. Recently, MDs' complexity is rising, and to ensure their appropriate use they must have a sex-gender-sensitive approach. Unfortunately, the majority of physicians, healthcare providers, and developers of MDs still believe that the human population is only constituted by men. Therefore, to overcome the gender gap, a real collaboration between the inventors of MDs, health researchers, and health providers should be established to test MDs in female and male tissues, animals, and women.

Sex-based Differences in Percutaneous Coronary Intervention Outcomes in Patients With Ischemic Heart Disease

In high-income countries, ischaemic heart disease is the leading cause of death in women and men, accounting for more than 20% of deaths in both sexes. However, women are less likely to receive guideline-recommended percutaneous coronary intervention (PCI) than men. Women undergoing PCI have poorer unadjusted outcomes because they are older and have greater comorbidity than men, but uncertainty remains whether sex affects outcome after these differences in clinical characteristics are considered. In this paper, we review recent published evidence comparing outcomes between men and women undergoing PCI. We focus on the sex differences in PCI outcomes in different scenarios: acute coronary syndromes, stable angina and complex lesions, including the approach of left main coronary artery. We also review how gender is considered in recent guidelines and offer a common clinical scenario to illustrate the contemporary management strategies an interventional cardiologist should consider when performing PCI on a female patient.

Gender-related differences in clinical outcomes after either single or double left main bifurcation stenting

We sought to examine the impact of gender differences in clinical outcomes at 3 years also comparing the role of double versus single stenting approach for the treatment of coronary unprotected LM bifurcation lesions. We retrospectively analyzed both the procedural and medical data of patients referred to our hub center for complex LM bifurcation disease, treated using Crossover provisional stenting, T or T-and-Protrusion (TAP), Culotte, and Nano-inverted-T (NIT) techniques between January 1st, 2008 and May 1st 2018. The main outcome of the study was to evaluate the association between gender and target lesion failure (TLF) based on the different stenting technique used. Five hundred and sixty-seven patients (251 females, mean age 70.0 ± 10 years, mean Syntax score 31.6 ± 6.3) were evaluated. Crossover, T or TAP, culotte and NIT techniques were performed in 171 (30.1%), 61 (10.7%), 98 (17.2%) and 237 (41.8%) patients, respectively with no differences in baseline and peri-procedural items among gender. At a mean follow-up of 37.1 ± 10.8 months (range 22.1-39.3 moths), the overall TLF rate, cardiovascular mortality and stent thrombosis were 12.1%, 3.1% and 1.0%, respectively. Female gender was associated with an increased rate of major bleeding when treated with double stent strategy (p = 0.02). No gender difference in TLF was noted among gender, independently from the stenting approach used. Among patients with ULM bifurcation disease undergoing PCI, TLF rates were not different between genders at 3-year follow-up either using a single or double stent technique.