Sex-related Impact on Clinical Outcome of Everolimus-eluting Versus Bare-metal Stents in ST-segment Myocardial Infarction. Insights From the EXAMINATION Trial

Gender Differences in Treatment Delays, Management and Mortality among Patients with Acute Coronary Syndrome: A Systematic Review and Meta-analysis

BACKGROUND

We aimed to provide a comprehensive overview of existing gender differences in acute coronary syndrome (ACS), with respect to treatment delays, invasive management of ACS, and short and long-term mortality in patients with ACS.

METHODS

We defined 37 observational studies (OSs) and 21 randomized trials (RCTs) that best corresponded to our interests. OSs and RCTs were analyzed separately.

RESULTS

Women with ACS more often experienced delays in treatment compared to men (OR 1.43; 95% CI, 1.12-1.82) in RCTs. Female patients were less often treated invasively: RCTs (OR 0.87; 95% CI, 0.83-0.9), OSs: (OR 0.66; 95% CI, 0.63-0.68). Women had higher crude in-hospital mortality (OR 1.56; 95% CI, 1.53-1.59) and 30-day mortality (OR 1.71; 95% CI, 1.22-2.4) in OSs and (OR 2.74; 95% CI, 2.48-3.02) in RCTs. After adjustment for multiple covariates, gender difference was attenuated: in-hospital mortality (OR 1.19; 95% CI, 1.17-1.2), 30-day mortality (OR 1.18; 95% CI, 1.12-1.24) in OSs. Unadjusted long-term mortality in women was higher than in men (OR 1.41; 95% CI, 1.31-1.52) in RCTs and (OR 1.4; 95% CI, 1.3-1.5) in OSs.

CONCLUSION

Women with ACS experience a delay in time to treatment more often than men. They are also less likely to be treated invasively. Females have shown worse crude short-and long-term all-cause mortality compared to males. However, after adjustment for multiple covariates, a less significant gender difference has been observed. Considering the difference between crude and adjusted mortality, we deem it reasonable to conduct further investigations on gender-related influence of particular risk factors on the outcomes of ACS.

Drug-eluting stents in large coronary vessels improve both safety and efficacy compared with bare-metal stents in women: a pooled analysis of the BASKET-PROVE I and II trials

Background

Drug-eluting stents (DES) have proven superior to bare-metal stents (BMS) in terms of safety and efficacy. However, inference to the female subgroup has been limited by low enrolment rates of women in clinical trials. The objective of this study was to investigate the safety and efficacy of DES versus BMS in women and men.

Methods

In a pooled analysis of two all-comers randomised trials (Basel Stent Kosten-Effektivitäts Trial-Prospective Validation Examination (BASKET-PROVE) and BASKET-PROVE II) (n=4605), we examined safety and efficacy of DES versus BMS according to sex. Patients were followed 2 years for a composite endpoint of cardiac death, non-fatal myocardial infarction (MI) and clinically driven target-vessel revascularisation not related to MI.

Results

Among the 1076 women and 3529 men included in the analysis, 65.6% of the women and 67.2% of the men were randomised to receive DES. At baseline, men had more complex coronary artery disease than women. After 2 years, DES reduced rates of major adverse cardiac events (MACE) compared with BMS in both women (cumulative incidence, 6.1% vs 14.7%; adjusted HR 0.36 (95% CI 0.24 to 0.54)) and men (7.7 vs 12.1%, HR 0.62 (0.50 to 0.77)), although the reduction in MACE rates was more pronounced in women (adjusted p=0.02 for sex-stent interaction). Event rates were lower in DES for both safety and efficacy outcomes, with the largest effect seen for non-MI TVR, in both women (2.3 vs 9.2%, adjusted HR 0.24 (0.13 to 0.44)) and men (4.0 vs 7.8%, adjusted HR 0.48 (0.36 to 0.64)) (adjusted p=0.049 for sex-stent interaction).

Conclusions

In patients requiring stenting of large coronary arteries, DES were associated with improved safety in women and superior efficacy in both sexes as compared with BMS.