Comparison of immediate and long-term outcome of coronary angioplasty performed for unstable angina and rest pain in men and women

Sex differentiation with regard to coronary artery disease

Coronary artery disease was considered a male disease for many years. However, nowadays, coronary artery disease constitutes the leading cause of death in women, although there are a lot of gender-related differences regarding the presentation of acute myocardial infarction, its diagnosis, its treatment, short- and long-term mortality rates, and post-acute myocardial infarction complications. Generally, women have smaller and stiffer hearts and cardiac vessels, suffering a greater extent of atherosclerosis and endothelial and smooth muscle dysfunction. They are usually older than men and they have more comorbidities such as hypertension, renal impairment, and diabetes mellitus. Moreover, female coronary artery disease, the diagnosis of which is more complicated due to more false negative results of some diagnostic methods in women, is more often presented with atypical symptoms and women's symptoms of typical or atypical angina are more severe. Furthermore, women delay significantly more in seeking care and they are more frequently undertreated. Finally, women are associated with generally poorer in-hospital and long-term prognosis having almost two-fold higher early mortality and they are more prone to complications such as bleeding complications, shock, and heart failure, as well as to post-myocardial infarction depression and poorer physical function and mental health. In this review, we discuss these sex-related differences according to current literature.

Gender-based differences of percutaneous coronary intervention in the drug-eluting stent era

OBJECTIVES

The purpose of this study is to provide insights into percutaneous coronary intervention (PCI) performed in women in the United States by evaluating gender-based PCI-practice patterns and outcomes.

BACKGROUND

Limited "real world" contemporary data exist on how the introduction of DES has impacted PCI in women.

METHODS AND RESULTS

Patients (359 women, 807 men) with de novo coronary artery disease having PCI (1,166) were evaluated during the first year, since the introduction of DES in the United States market (May 1, 2003 to April 30, 2004). Women were more likely to be older, hypertensive, obese, diabetic, and have heart failure. Men were more likely to be smokers and have more vessels with obstructive coronary artery disease. PCI procedural success rates, number of vessels attempted, percentage DES utilization, and in-hospital major adverse cardiac events (MACE; death, new myocardial infarction, urgent revascularization) were similar for both genders. However, women had significantly higher unadjusted mortality (3.9% versus 1.6%, P = 0.01), cumulative vascular complications (12.0% versus 4.2%, P < 0.0001), and renal failure (2.5% versus 0.7%, P = 0.01). After adjustment for confounding variables, mortality was similar between genders, but a significant association with vascular complications and trend toward higher rates of renal failure persisted in women.

CONCLUSIONS

In this study of the modern era of PCI with DES utilization, in-hospital MACE is similar between men and women. However, the differences in baseline comorbidities and the proclivity for vascular and renal complications highlight the need for further investigation and improvements to optimize outcomes of PCI in women.

Gender-based outcomes after paclitaxel-eluting stent implantation in patients with coronary artery disease

OBJECTIVES

We sought to determine whether gender influences the results of paclitaxel-eluting stent implantation.

BACKGROUND

The TAXUS-IV trial demonstrated the safety and effectiveness of the slow-release, polymer-based, paclitaxel-eluting TAXUS stent compared to bare-metal stents in patients undergoing elective coronary intervention. Whether these results are generalizable to women is not known.

METHODS

A total of 1,314 patients with coronary lesions 10- to 28-mm long in 2.5- to 3.75-mm vessels were randomized to TAXUS stent versus bare-metal EXPRESS stents (Boston Scientific Corp., Natick, Massachusetts). Outcomes examined were stratified by gender.

RESULTS

A total of 662 patients (including 187 women) were assigned to the TAXUS stent, and 652 (180 women) received the control stent. Women were older than men, and had more hypertension, diabetes, renal insufficiency, unstable angina, and heart failure, but less smoking. Among patients receiving the TAXUS stent, women compared with men had higher unadjusted one-year rates of target lesion revascularization (TLR) (7.6% vs. 3.2%, p = 0.03), though female gender was not an independent predictor of TLR (odds ratio [OR] = 1.72 [95% confidence interval (CI) 0.68 to 4.37], p = 0.25). Moreover, restenosis rates were similar in men and women treated with the TAXUS stent (8.6% vs. 7.6%, respectively, p = 0.80), as was late loss (0.22 vs. 0.23 mm, p = 0.90). Compared to control stents, treatment with the TAXUS stent in women resulted in a significant reduction in nine-month restenosis (8.6% vs. 29.2%, p = 0.0001) and one-year TLR (7.6% vs. 14.9%, p = 0.02). The only independent predictor of freedom from restenosis in women was randomization to the TAXUS stent (OR = 0.28 [95% CI 0.11 to 0.74], p = 0.01).

CONCLUSIONS

The benefits of the paclitaxel-eluting stent in reducing clinical and angiographic restenosis are generalizable to women.

Outcomes of percutaneous and surgical revascularization in women

There are gender-related differences both in the natural history of coronary artery disease (CAD) and in the response to revascularization strategies of patients with CAD. This paper reviews the specific pathophysiology of CAD in women as it influences outcome and current interventional and surgical treatment modalities and outcomes for stable and unstable coronary artery syndromes.

Gender-related changes in the practice and outcomes of percutaneous coronary interventions in Northern New England from 1994 to 1999

OBJECTIVES

We sought to determine whether the changing practice of interventional cardiology has been associated with improved outcomes for women, and how these outcomes compare with those for men.

BACKGROUND

Previous work from the early 1990s suggested women are at a higher risk than men for adverse outcomes after percutaneous coronary interventions (PCIs). From 1994 to 1999 data were collected on 33,666 consecutive hospital admissions for a PCI in Northern New England. Multivariate models were used to adjust for differences in case-mix across year of procedure when comparing outcomes. Direct standardization was used to calculate adjusted rates.

RESULTS

From 1994 to 1999, the case-mix worsened for both women and men, although women had more co-morbidities than did men throughout the period. Stent use increased over time (>75% in 1999). Concomitantly, the need for emergency coronary artery bypass graft surgery (CABG) decreased significantly (p(trend) < or = 0.001; in 1999: 0.06% for women, 0.05% for men). Although the emergency CABG rates were higher for women at the beginning of the study, by the end, they were comparable (adjusted odds ratio 1.34, 95% confidence interval 0.76 to 2.38, p = 0.315). The myocardial infarction (MI) rates decreased over time for both women (by 29.7%, p(trend) = 0.378) and men (by 37.6%, p(trend) = 0.009) and did not differ by gender. The mortality rates did not decrease significantly over time and were not significantly different between the genders (mean 1.21% for women, 1.06% for men; p = 0.096).

CONCLUSIONS

Concurrent with the changing practice of PCI, and despite treating sicker patients, there have been important improvements in post-PCI CABG and MI rates for women, as well as for men. Unlike in earlier years, there are no longer significant differences in outcomes by gender.

Early angioplasty in acute coronary syndromes without persistent ST-segment elevation improves outcome but increases the need for six-month repeat revascularization: an analysis of the PURSUIT Trial. Platelet glycoprotein IIB/IIIA in Unstable angina: Receptor Suppression Using Integrilin Therapy

OBJECTIVES

We explored the effect of timing of percutaneous coronary intervention (PCI) in acute coronary syndromes (ACS) without persistent ST-segment elevation on the need for repeat revascularization, and we related this effect to other events.

BACKGROUND

Percutaneous coronary intervention is widely used to treat ACS without persistent ST-segment elevation. Moreover, restenosis and subsequent revascularization after PCI are more frequent in ACS than in stable angina. The optimal timing of PCI in ACS without persistent ST-segment elevation is unknown.

METHODS

In the Platelet glycoprotein IIB/IIIA in Unstable angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) database, patients were stratified by the time of PCI. In the PURSUIT trial, 9,461 patients received a platelet glycoprotein IIb/IIIa inhibitor, eptifibatide or placebo for 72 h. The investigators decided on other treatments.

RESULTS

A total of 2,430 patients underwent PCI within 30 days. Repeat revascularization (during 165 days) was notably higher for PCI within 24 h of enrollment (n = 620 [19%]) than for PCI at 24 to 72 h (n = 624 [16.7%]), 3 to 7 days (n = 614 [13.2%]), or 8 to 30 days (n = 561 [7.7%]; p < 0.001), regardless of eptifibatide use. This gradual reduction in the revascularization rate for later PCI was also observed after multivariate analysis correcting for baseline characteristics and with time as a continuous variable.

CONCLUSIONS

Percutaneous coronary intervention within 24 is associated with improved outcome (other analysis) but more repeat revascularization. Prospective analyses are needed to test the hypothesis that rapid PCI in ACS with a platelet glycoprotein IIb/IIIa receptor antagonist reduces myocardial infarction (and possibly death) and is therefore most suited for patients at highest risk of infarction, despite a higher need for repeat revascularization.

New-device angioplasty in women: clinical outcome and predictors in a 7,372-patient registry

BACKGROUND

Female gender has been identified as an independent predictor of early complications and mortality after conventional balloon angioplasty. To gain insight into the outcome of women after new-device angioplasty, we reviewed the early and late clinical outcome of 7,372 patients undergoing new-device angioplasty between 1991 and 1996 at the Washington Hospital Center.

METHODS

Patients (2,077 women and 5,295 men) with native coronary artery (82.5%) or saphenous vein graft lesions undergoing new-device angioplasty were included in the study. In-hospital and 1-year major adverse cardiac events (MACE), including death, myocardial infarction, and target lesion revascularization (TLR), were recorded and compared on the basis of gender. Multivariable logistic regression analysis was performed to identify predictors of in-hospital and late mortality, follow-up MACE, and TLR.

RESULTS

Women had more baseline comorbid risk factors and smaller reference vessel size compared with men. Women had a higher in-hospital cardiac mortality (1.39% vs 0.66%, P = 0.002), TLR (2.78% vs 1.81%, P = 0.008), and congestive heart failure (4.18% vs 2.29%, P < 0.001) compared with men. Overall in-hospital MACE tended to be higher among women (4.2% vs 3.3%, P = 0.074). Women had a higher 1-year mortality rate (4.39% vs 3.26%, P = 0.018), but a lower follow-up TLR (15.0% vs 18.1%, P = 0.001) and a lower overall MACE rate (29.2% vs 32.7%, P = 0.007) compared with men. Female gender was an independent predictor of in-hospital mortality (odds ratio 2.28, P = 0.02), but not late mortality.

CONCLUSIONS

Although female gender appears to carry an inherent risk of in-hospital mortality after new-device angioplasty, the procedural success and mortality rates are favorable compared with those associated with balloon angioplasty series. The long-term clinical outcome of women after new-device angioplasty is excellent. The use of new devices is a safe and effective alternative strategy for the treatment of women with ischemic coronary artery disease. Device-specific outcomes, including stents, will require further evaluation.

Comparison of event and procedure rates following percutaneous transluminal coronary angioplasty in patients with and without previous coronary artery bypass graft surgery [the ROSETTA (Routine versus Selective Exercise Treadmill Testing after Angioplasty) Registry]

To compare 6-month post-percutaneous transluminal coronary angioplasty (PTCA) outcomes and cardiac procedure use among patients with and without prior coronary artery bypass graft (CABG) surgery, we examined 791 patients who were enrolled in the Routine versus Selective Exercise Treadmill Testing after Angioplasty (ROSETTA) Registry. The ROSETTA Registry is a prospective, multicenter registry that examines the use of functional testing after successful PTCA. Most patients were men (76%, mean age 61 +/- 11 years) who underwent single-vessel PTCA (85%) with stent implantation (58%). Baseline and procedural characteristics differed between patients with a prior CABG (n = 131) and patients with no prior CABG (n = 660), including Canadian Cardiovascular Society angina class III to IV (60% vs 49%, respectively, p = 0.03) and stenosis involving the proximal left anterior descending coronary artery (10% vs 22%, p = 0.004). Event rates among patients with prior CABG were higher than among patients with no prior CABG, including unstable angina (19% vs 11%, p = 0.02), myocardial infarction (2% vs 1%, p = 0.2), death (4% vs 2%, p = 0.08), and composite clinical events (22% vs 12%, p = 0.003). Furthermore, patients with prior CABG had higher rates of follow-up cardiac procedures, including angiography (24% vs 14%, p = 0.008) and PTCA (13% vs 7%, p = 0.04), but not repeat CABG (2% vs 3%, p = 0.8). A multivariate analysis that included baseline clinical and procedural characteristics demonstrated that prior CABG was a significant independent predictor of clinical events and cardiac procedure use (odds ratio 2.3, 95% confidence interval 1.5 to 3.5, p = 0.0001). Within the prior CABG group, patients with a PTCA of a bypass graft had a higher composite clinical event rate than patients with a PTCA of a native vessel (32% vs 17%, p = 0.05). In contrast, patients with a PTCA of a native vessel had event rates similar to those of patients with no prior CABG (17% vs 12%, p = 0.2). Thus, post-CABG patients have an increased risk of developing a cardiac event or needing a follow-up cardiac procedure during the 6 months after PTCA.

Six-month outcomes of percutaneous transluminal coronary angioplasty in hypertensive patients: results from the ROSETTA registry. Routine Versus Selective Exercise Treadmill Testing After Angioplasty

PURPOSE

Hypertension is an important risk factor for coronary artery disease. However, the impact of hypertension on the outcomes of patients undergoing percutaneous transluminal coronary angioplasty (PTCA) is unknown. Our purpose was to evaluate the association between hypertension and adverse outcomes and repeat cardiac procedures during the 6-month period after PTCA.

METHODS

We studied 791 patients who were enrolled in the Routine Versus Selective Exercise Treadmill Testing After Angioplasty (ROSETTA) registry. This registry is a prospective multicenter study examining the use of functional testing after a successful PTCA.

RESULTS

We compared 411 hypertensive patients (mean age 60.1 +/- 10 years, 31.1% female) with 380 normotensive patients (mean age 59.1 +/- 12 years, 16.2% female). Patients with hypertension had a higher 6-month rate of composite clinical events (unstable angina, myocardial infarction, death) than did normotensive patients (16.5% vs 10.5%, P =.017). In addition, there was a trend for hypertensive patients to have higher rates of cardiac procedures (angiography, repeat PTCA, coronary artery bypass graft surgery) compared with normotensive patients (19.8% vs 14.9%, P =.074). However, functional testing after PTCA was lower among hypertensive subjects (44.4% vs 54.0%, P =.008). Among the 411 hypertensive patients, a regression analysis showed that several variables were independently associated with increased 6-month adverse event rates, including pre-PTCA Killip class III-IV (odds ratio [OR] 5.7, 95% CI 1.7-19.0), Canadian Cardiovascular Society angina class III-IV (OR 2.1, 95% CI 1.1-4.2), unstable angina as the reason for PTCA (OR 2.3, 95% CI 1.2-4.3), peripheral vascular disease (OR 3.2, 95% CI 1.5-6.4), PTCA of a bypass graft (OR 3.1, 95% CI 1.2-7.6), and calcium antagonist usage at admission for the index PTCA (OR 1.9, 95% CI 1.1-3.4).

CONCLUSIONS

During the 6-month period after a successful PTCA, patients with hypertension have significantly higher adverse event rates than do those without hypertension. Several clinical variables may help identify which hypertensive patients are at higher risk for clinical events.

Effect of gender on fast-track recovery after coronary artery bypass graft surgery

OBJECTIVE

To examine the effects of gender on time to extubation after coronary artery bypass graft (CABG) surgery and intensive care unit and hospital length of stay.

DESIGN

Retrospective study comparing outcomes as related to gender.

SETTING

Tertiary care university teaching hospital.

PARTICIPANTS

Consecutive patients (n = 561; 376 men, 185 women) undergoing CABG surgery between January 1995 and December 1997.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Early extubation was possible in 74% of men versus 64% of women (p = 0.03); length of stay was < or =5 days in 60% of men versus 48% of women (p = 0.008); overall postoperative length of stay was 5.7 days for men versus 6.5 days for women (p = 0.003); morbidity and mortality were not significantly different between groups.

CONCLUSION

Women undergoing CABG surgery with a standardized fast-track protocol have longer intubation times, intensive care unit length of stay, and hospital length of stay than their male counterparts.

Trends in success rate after percutaneous transluminal coronary angioplasty in men and women with coronary artery disease

Women with coronary artery disease are less likely to undergo percutaneous transluminal coronary angioplasty (PTCA) because of the potential referral bias in favor of men with coronary artery disease in the use of invasive diagnostic procedures and interventions. This difference may represent a sex bias in the delivery of medical care. The apparent sex difference in short-term success of PTCA seen in the early 1980s has not persisted in subsequent studies. The higher in-hospital mortality rate, if any, in women compared with men after PTCA is related more to the severity of their underlying disease rather than sex alone. In addition, women have a better long-term PTCA success rate. PTCA should not be withheld in women who are considered appropriate anatomic candidates for fear of reduced success or increased major complications.