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

Acute Coronary Syndromes in Women: A Narrative Review of Sex-Specific Characteristics

Acute coronary syndromes (ACSs) encompass a spectrum of life-threatening cardiovascular conditions, including unstable angina (UA) and myocardial infarction. While significant progress has been made in the understanding and management of ACS over the years, it has become increasingly evident that sex-based differences play a pivotal role in the pathophysiology, presentation, and outcomes of these conditions. Despite this recognition, the majority of clinical research in the field has historically focused on male populations, leading to a significant knowledge gap in understanding the unique aspects of ACS in women. This review article aims to comprehensively explore and synthesize the current body of literature concerning the sex-specific characteristics of ACS, shedding light on the epidemiology, risk factors, clinical presentation, diagnostic challenges, treatment strategies, and prognosis in women. By elucidating the distinct aspects of ACS in women, this review intends to foster greater awareness and improved clinical management, ultimately contributing to enhanced cardiovascular care for female patients.

Mortality trends in women and men presenting with acute coronary syndrome: insights from a 20-year registry

BACKGROUND

Coronary artery disease (CAD) is the leading cause of mortality worldwide. The present study evaluated the impact of gender in patients hospitalized with acute coronary syndromes (ACS) over a 20-year period in Qatar.

METHODS

Data were collected retrospectively from the registry of the department of cardiology for all patients admitted with ACS during the study period (1991-2010) and were analyzed according to gender.

RESULTS

Among 16,736 patients who were admitted with ACS, 14262 (85%) were men and 2474 (15%) were women. Cardiovascular risk factors were more prevalent among women in comparison to men. On admission, women presented mainly with non-ST-elevation ACS and were more likely to be undertreated with β-blockers (BB), antiplatelet agents and reperfusion therapy in comparison to men. However, from 1999 through 2010, the use of aspirin, angiotensin-converting enzyme inhibitors and BB increased from 66% to 79%, 27% to 41% and 17% to 49%, respectively in women. In the same period, relative risk reduction for mortality was 64% in women and 51% in men. Across the 20-year period, the mortality rate decreased from 27% to 7% among the Middle Eastern Arab women. Multivariate logistic regression analysis showed that female gender was independent predictor of in-hospital mortality (odd ratio 1.51, 95% CI 1.27-1.79).

CONCLUSIONS

Women presenting with ACS are high-risk population and their in-hospital mortality remains higher for all age groups in comparison to men. Although, substantial improvement in the hospital outcome has been observed, guidelines adherence and improvement in the hospital care have not yet been optimized.

Age differences in long term outcomes of coronary patients treated with drug eluting stents at a tertiary medical center

We evaluate differences in outcomes in younger (<65 years) and older (≥65 years) patients for target lesion failure (TLF) at 2-year follow-up in an unselected consecutive series of patients treated with the everolimus- (EES) and paclitaxel-eluting (PES) stents at a tertiary medical center. 348 consecutive patients (younger 150; older 198) stented with the EES and PES were retrospectively analyzed. The primary endpoint was TLF (composite endpoint of cardiac death, non fatal myocardial infarction due to index vessel and target lesion revascularization (TLR)). At 2 years follow up, younger versus older patients had the following outcomes respectively: TLF 27.7% versus 25.5% (P = 0.71), TLR 24.8% versus 21.4% (P = 0.52), cardiac death 3.4% versus 2.5% (P = 0.75) and definite and probable stent thrombosis (2.0% versus 1.0%). Multivariate analysis showed that renal failure (odds ratio: 2.55, P = 0.045), number of stents per patient (odds ratio: 1.60, P = 0.001) and younger age (odds ratio: 0.97; P = 0.010), but not gender, diabetes or type of DES stent (EES versus PES) predicted TLF. We conclude that older age was not a predictor of TLF at 2-year follow-up after adjusting for renal insufficiency, number of stents used per patient, gender, diabetes and type of DES used.

Smoking status on outcomes after percutaneous coronary intervention

BACKGROUND

The effect of smoking on prognosis among patients undergoing percutaneous coronary intervention (PCI) is controversial, and data on the importance of smoking cessation or reductions were lacking.

HYPOTHESIS

Smoking cessation or reductions could reduce the risk of adverse outcomes in patient after PCI.

METHODS

There were 19 506 consecutive patients who had undergone successful PCI between April 2004 and January 2010 followed. Extensive data, including self-reported smoking habits, were obtained at baseline and during follow-up.

RESULTS

Compared with post-PCI quitters and persistent smokers, the nonsmokers and pre-PCI quitters were older and had a higher prevalence of comorbid factors such as hypertension and impaired left ventricle function. The adjusted hazard ratios for mortality were 2.52 (95% confidence interval [CI]: 1.92-3.30) for nonsmokers, 0.52 (95% CI: 0.32-0.84) for pre-PCI quitters, and 0.11 (95% CI: 0.06-0.22) for post-PCI quitters, compared to persistent smokers. With respect to additional revascularizations, a higher risk was observed among the quitters (1.70 [95% CI: 1.40-2.08] for pre-PCI quitters and 1.59 [95% CI: 1.36-1.85] for post-PCI quitters) as well as the nonsmokers (1.40 [95% CI: 1.20-1.64]). Among persistent smokers, each reduction of 5 cigarettes/day was associated with a 72% decline in mortality risk (P < 0.001) but did not reach statistical significant for repeated revascularizations (0.80 [95% CI: 0.46-1.37], P = 0.4132).

CONCLUSIONS

Despite a higher risk of revascularization, the cessation of smoking either before or after PCI is beneficial in all-cause mortality. The apparent smoker's paradox may be explained by the differences in baseline risk or the reduced sensitivity to adverse outcomes as well as the reluctance to seek medical help among smokers.

Gender differences among patients with acute coronary syndromes undergoing percutaneous coronary intervention in the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR)

BACKGROUND

Although prior studies have demonstrated disparities in the management and outcomes of women with acute coronary syndrome (ACS), there are limited large-scale contemporary data on gender differences in post-intervention outcomes in this population.

METHODS

We analyzed patients according to 2 ACS categories, unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) and ST-elevation myocardial infarction (STEMI) who had a percutaneous coronary intervention in the ACC-NCDR from January 1, 2004, to March 30, 2006. Of 199,690 patients, 55,691 women presented with UA/NSTEMI, and 12,335 women presented with STEMI. Clinical and angiographic characteristics, procedural and treatment patterns, and in-hospital outcomes were examined.

RESULTS

Women presented more often with UA/NSTEMI than men (82% of women vs 77% of men, P < .0001). Despite having greater comorbidities, women in both ACS categories had fewer high risk angiographic features than men. Women were less likely to receive aspirin or glycoprotein IIb/IIIa inhibitors, and were less often discharged on aspirin or statin. For in-hospital mortality, the adjusted odds ratio for men compared to women was similar (odds ratio 0.97, P = .5). Women had higher rates of cardiogenic shock, congestive heart failure, any bleeding, and any vascular complications. Importantly, rates of subacute stent thrombosis were less in women compared to men (0.43% vs 0.57%, P = .0003).

CONCLUSIONS

Although women had fewer high-risk angiographic features than men, they continue to have higher rates of in-hospital complications. This suggests the need for gender-tailored techniques to minimize post-intervention complications and maximize application of evidence-based antiplatelet therapies.

Predicting major adverse cardiac events after percutaneous coronary intervention: the Texas Heart Institute risk score

BACKGROUND

Many models have been devised in the past to predict adverse outcomes after PCI, but with rapid advancements in this field, a new risk-prediction model may be needed. The purpose of our study was to identify the clinical and angiographic variables associated with adverse cardiac events after percutaneous coronary intervention (PCI) and to construct a simple bedside tool for risk stratification of PCI patients.

METHODS

Using our institution's database, we analyzed data from 9,494 patients who underwent PCI between January 1, 1996, and December 31, 2002 (ie, during the bare-metal stent era). Predictors of major adverse cardiac events--death, myocardial infarction, stroke, and repeat revascularization by emergent coronary artery bypass grafting or PCI--were identified by multivariate logistic regression analysis using baseline clinical, angiographic, and procedural variables. A simple integer score was constructed by multiplying the beta coefficient for each variable by a constant and rounding the result to the nearest integer. The score was validated in 5,545 patients who underwent PCI between January 1, 2003, and December 31, 2006 (ie, during the drug-eluting stent era).

RESULTS

Multivariate regression analysis identified emergent procedure, urgent procedure, unstable angina, acute myocardial infarction, renal insufficiency, hypertension, congestive heart failure, peripheral vascular disease, type C lesion, presence of thrombus, and number of stents placed as independent predictors of adverse events after PCI. The model had good overall discrimination (area under the receiver operator characteristic curve 0.701), and the model fitted the validation cohort adequately.

CONCLUSIONS

Risk of complications after PCI can be assessed with this simple tool, which may permit comparisons between different operators as well as different hospitals.

Age-based clinical and angiographic outcomes after sirolimus-eluting stent implantation in patients with coronary artery disease

BACKGROUND

Advanced age independently predicts early and late mortality and major adverse cardiac events (MACE) after percutaneous coronary intervention (PCI). Randomized clinical trials indicate that sirolimus-eluting stent (SES) implantation reduces target lesion revascularization (TLR), but there are limited data on the impact of age on outcomes following SES implantation in patients with coronary artery disease (CAD) in real-world practice.

METHODS

A total of 333 CAD patients with 453 lesions were enrolled in this study. Subjects were divided into two groups according to age: a young group (< 65 years old, 244 patients with 369 lesions) and elderly group (= 65 years old, 89 patients with 113 lesions). Clinical follow-up and quantitative coronary angiography (QCA) were performed seven months after PCI.

RESULTS

Baseline clinical, demographic, angiographic, and procedural chararcteristics were similar in both groups, except that there were more female patients in the elderly group (21.3% vs 9.8%, P = 0.006). Primary success rate was similar in both groups (96.5% in young group vs 95.7% in elderly group, P > 0.05). During angiographic follow-up at 7 months, binary in-stent restenosis and in-segment restenosis rates were not significantly different between the two groups (4.7% vs 1.8%; 9.7% vs 8.8%, P > 0.05 respectively). Both sub-acute and late thrombosis rates were similar in the two groups (0.3% vs 0.9% and 1.2% vs 0.9%, P > 0.05 respectively). TLR was not significantly different between the two groups (6.5% vs 3.5%; P = 0.246). The rates of bleeding, stroke, angina rehospitalization during the follow-up period were also similar in both groups (P > 0.05 respectively).

CONCLUSION

Despite a high-risk clinical profile, coronary SES implantation can be safely and effectively performed in elderly patients with a similar procedural success rate, a low complication rate, and excellent 7-month outcomes.

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.