In the Journals

5-year PCI outcomes worse for women than men

Ioanna Kosmidou

In a pooled analysis of individual patient data from 21 trials, at 5 years after undergoing PCI, women had higher risk for MACE and ischemia-driven target lesion revascularization compared with men.

Ioanna Kosmidou, MD, PhD, staff cardiologist and assistant clinical professor of medicine at NewYork-Presbyterian Hospital/Columbia University Irving Medical Center and medical director of electrophysiology services at the Cardiovascular Research Foundation, and colleagues assessed the association between sex and MACE, defined as cardiac death, MI or ischemia-driven TLR, at 5 years.

The researchers analyzed 32,877 patients (28% women) from 21 contemporary PCI trials.

Compared with men, women were older, had higher BMI, were more likely to have hypertension or diabetes, were less likely to have had prior PCI or surgical revascularization, had smaller reference vessel diameter and had shorter lesion lengths (P < .0001 for all), according to the researchers.

Sex differences

In an unadjusted analysis, compared with men, women had higher rates of MACE (18.9% vs. 17.7%; P = .003), all-cause mortality (10.4% vs. 8.7%; P = .0008), cardiac mortality (4.9% vs. 4%; P = .003) and ischemia-driven TLR (10.9% vs. 10.2%; P = .02).

In a multivariable analysis, female sex predicted MACE (adjusted HR = 1.14; 95% CI, 1.01-1.3), MI (aHR = 1.25; 95% CI, 1.02-1.54) and ischemia-driven TLR (aHR = 1.23; 95% CI, 1.05-1.44), but not all-cause mortality (aHR = 0.91; 95% CI, 0.75-1.09) or cardiac mortality (aHR = 0.97; 95% CI, 0.73-1.29).

The low inclusion rate of women in randomized trials, as observed in the current pooled analysis, has resulted in device-based techniques being optimized for men,” Kosmidou and colleagues wrote. “The extent to which procedural factors, such as less rigorous lesion preparation, suboptimal treatment of smaller vessels or more conservative antithrombotic

therapy in women contribute to the worse prognosis in the female population deserves further study.”

Women remain undertreated

Michelle L. O’Donoghue
Amy A. Sarma

In a related editorial, Michelle L. O’Donoghue, MD, PhD, associate physician in cardiovascular medicine at Brigham and Women’s Hospital, associate professor of medicine at Harvard Medical School and senior investigator in the TIMI Study Group, and Amy A. Sarma, MD, cardiologist in the Corrigan Women’s Heart Health Center at Massachusetts General Hospital and instructor in medicine at Harvard Medical School, wrote: “The higher incidence of ischemia-driven target lesion revascularization after accounting for angiographic factors raises interesting questions about potential sex differences in the underlying pathobiology of stent restenosis or procedural differences, including lesion preparation or post-stent optimization at the time of PCI.”

However, they wrote, “Because none of the trials included in the analysis were randomized comparisons of PCI vs. medical management, one must not conclude from the current findings that women derive less benefit from PCI than men. This point is worth emphasizing, because it has been repeatedly shown that women remain under-evaluated and undertreated in the setting of stable ischemic heart disease and ACS when compared with men.” – by Erik Swain

Disclosures: The study was investigator-initiated and sponsored in part by Abbott. Kosmidou and Sarma report no relevant financial disclosures. O’Donoghue reports she has received research grants from Amgen, AstraZeneca, Eisai, GlaxoSmithKline, Janssen, Medimmune, Merck and The Medicines Company and has served as a consultant for Amgen, AstraZeneca, Janssen and Novartis. Please see the study for all other authors’ relevant financial disclosures.

Ioanna Kosmidou

In a pooled analysis of individual patient data from 21 trials, at 5 years after undergoing PCI, women had higher risk for MACE and ischemia-driven target lesion revascularization compared with men.

Ioanna Kosmidou, MD, PhD, staff cardiologist and assistant clinical professor of medicine at NewYork-Presbyterian Hospital/Columbia University Irving Medical Center and medical director of electrophysiology services at the Cardiovascular Research Foundation, and colleagues assessed the association between sex and MACE, defined as cardiac death, MI or ischemia-driven TLR, at 5 years.

The researchers analyzed 32,877 patients (28% women) from 21 contemporary PCI trials.

Compared with men, women were older, had higher BMI, were more likely to have hypertension or diabetes, were less likely to have had prior PCI or surgical revascularization, had smaller reference vessel diameter and had shorter lesion lengths (P < .0001 for all), according to the researchers.

Sex differences

In an unadjusted analysis, compared with men, women had higher rates of MACE (18.9% vs. 17.7%; P = .003), all-cause mortality (10.4% vs. 8.7%; P = .0008), cardiac mortality (4.9% vs. 4%; P = .003) and ischemia-driven TLR (10.9% vs. 10.2%; P = .02).

In a multivariable analysis, female sex predicted MACE (adjusted HR = 1.14; 95% CI, 1.01-1.3), MI (aHR = 1.25; 95% CI, 1.02-1.54) and ischemia-driven TLR (aHR = 1.23; 95% CI, 1.05-1.44), but not all-cause mortality (aHR = 0.91; 95% CI, 0.75-1.09) or cardiac mortality (aHR = 0.97; 95% CI, 0.73-1.29).

The low inclusion rate of women in randomized trials, as observed in the current pooled analysis, has resulted in device-based techniques being optimized for men,” Kosmidou and colleagues wrote. “The extent to which procedural factors, such as less rigorous lesion preparation, suboptimal treatment of smaller vessels or more conservative antithrombotic

therapy in women contribute to the worse prognosis in the female population deserves further study.”

Women remain undertreated

Michelle L. O’Donoghue
Amy A. Sarma

In a related editorial, Michelle L. O’Donoghue, MD, PhD, associate physician in cardiovascular medicine at Brigham and Women’s Hospital, associate professor of medicine at Harvard Medical School and senior investigator in the TIMI Study Group, and Amy A. Sarma, MD, cardiologist in the Corrigan Women’s Heart Health Center at Massachusetts General Hospital and instructor in medicine at Harvard Medical School, wrote: “The higher incidence of ischemia-driven target lesion revascularization after accounting for angiographic factors raises interesting questions about potential sex differences in the underlying pathobiology of stent restenosis or procedural differences, including lesion preparation or post-stent optimization at the time of PCI.”

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However, they wrote, “Because none of the trials included in the analysis were randomized comparisons of PCI vs. medical management, one must not conclude from the current findings that women derive less benefit from PCI than men. This point is worth emphasizing, because it has been repeatedly shown that women remain under-evaluated and undertreated in the setting of stable ischemic heart disease and ACS when compared with men.” – by Erik Swain

Disclosures: The study was investigator-initiated and sponsored in part by Abbott. Kosmidou and Sarma report no relevant financial disclosures. O’Donoghue reports she has received research grants from Amgen, AstraZeneca, Eisai, GlaxoSmithKline, Janssen, Medimmune, Merck and The Medicines Company and has served as a consultant for Amgen, AstraZeneca, Janssen and Novartis. Please see the study for all other authors’ relevant financial disclosures.