Short- and medium-term outcome differences in women and men after primary percutaneous transluminal mechanical revascularization for acute myocardial infarction

Effects of clopidogrel vs. prasugrel vs. ticagrelor on endothelial function, inflammatory parameters, and platelet function in patients with acute coronary syndrome undergoing coronary artery stenting: a randomized, blinded, parallel study

AIMS

In a randomized, parallel, blinded study, we investigate the impact of clopidogrel, prasugrel, or ticagrelor on peripheral endothelial function in patients undergoing stenting for an acute coronary syndrome.

METHODS AND RESULTS

The primary endpoint of the study was the change in endothelium-dependent flow-mediated dilation (FMD) following stenting. A total of 90 patients (age 62 ± 9 years, 81 males, 22 diabetics, 49 non-ST elevation myocardial infarctions) were enrolled. There were no significant differences among groups in any clinical parameter. Acutely before stenting, all three drugs improved FMD without differences between groups (P = 0.73). Stenting blunted FMD in the clopidogrel and ticagrelor group (both P < 0.01), but not in the prasugrel group. During follow-up, prasugrel was superior to clopidogrel [mean difference 2.13, 95% confidence interval (CI) 0.68-3.58; P = 0.0047] and ticagrelor (mean difference 1.57, 95% CI 0.31-2.83; P = 0.0155), but this difference was limited to patients who received the study therapy 2 h before stenting. Ticagrelor was not significantly superior to clopidogrel (mean difference 0.55, 95% CI -0.73 to 1.82; P = 0.39). No significant differences were seen among groups for low-flow-mediated dilation. Plasma interleukin (IL)-6 (P = 0.02 and P = 0.01, respectively) and platelet aggregation reactivity in response to adenosine diphosphate (P = 0.002 and P = 0.035) were lower in the prasugrel compared to clopidogrel and ticagrelor group.

CONCLUSION

As compared to ticagrelor and clopidogrel, therapy with prasugrel in patients undergoing stenting for an acute coronary syndrome is associated with improved endothelial function, stronger platelet inhibition, and reduced IL-6 levels, all of which may have prognostic implications. This effect was lost in patients who received the study medication immediately after stenting.

EUDRACT-NO

2011-005305-73.

Interventions for ST Elevation Myocardial Infarction in Women

The management of ST-segment elevation myocardial infarction (STEMI) has significantly advanced from supportive care to reperfusion therapies with thrombolytics and percutaneous coronary revascularization techniques. These advances have improved the outcomes of patients with STEMI. Although cardiovascular disease is the leading cause of death in both men and women, the minority of patients in trials studying the impact of these therapies on outcomes are women. Multiple studies have shown that men and women do not have equivalent outcomes after STEMI. This article reviews the treatment options for STEMI and the outcomes of women after treatment with reperfusion therapies.

[Percutaneous coronary angioplasty in women: clinical, procedural and prognostic features]

AbstractX Les résultats de l′angioplastie transluminale (ATL) des coronaires chez la femme ont été pendant de nombreuses années controversés et longtemps considérés comme moins favorable que chez l′homme. Le but de notre travail était d’évaluer les caractéristiques de l'angioplastie coronaire chez la femme, ainsi que les résultats immédiats et à moyen terme et de les comparer à ceux chez l'homme.

Nous avons comparé 200 patients dont 100 femmes, ayant bénéficié d'une angioplastie coronaire, colligés au service de cardiologie de l'hôpital Hédi Chaker de Sfax entre 2002 et 2007.

Les femmes étaient significativement plus âgées que les hommes. La comparaison de la fréquence des facteurs de risque d'athérosclérose chez les deux sexes, a permis de noter une co-morbidité franchement plus importante chez la femme, avec une différence statiquement significative. L'ATL a été plus motivée chez la femme devant un angor stable sévère (p<0,05) et un SCA ST- (p=NS). Les femmes avaient plus d'atteinte polytronculaire (p<0,05), d'atteintes des segments moyens et distaux (p<0,05) et plus des lésions serrées (p=NS), longues et calcifiées (p<0,05). 259 stents ont été déployés, un stenting direct était plus fréquent dans la population féminine (p<0,05). Le diamètre des artères féminines, assimilé à celui du stent et/ou ballon utilisé, a été significativement moins important que celui des hommes. La longueur des stents et/ou ballon utilisés, ainsi que les pressions de larguage des stents ont été plus importantes chez la population féminine (p<0,05). Le succès angiographique global a été obtenu chez 94% de la population générale, sans différence significative entre les deux sexes. Les évènements cardiaques majeurs (MACE) hospitaliers ont été plus fréquents chez la femme (p=0,05). Après un suivi moyen de 31 mois, le taux de MACE global a été significativement plus important chez la femme (39% vs. 28%, p<0,05), portant surtout sur la mortalité globale (13% vs. 3%, p<0,05). Le taux de resténose a été comparable chez les deux sexes.

L'angioplastie coronaire constitue actuellement un moyen thérapeutique efficace et sur chez la femme, au prix de complications plus fréquentes.

Sex differences in percutaneous coronary interventions

Cardiovascular disease is the leading cause of mortality in women, and women have a higher cardiovascular mortality and morbidity associated with the treatment of cardiovascular disease compared to men. Percutaneous coronary intervention (PCI) is an important therapy for women with coronary artery disease particularly in acute coronary syndromes; however, only 33% of all PCIs are performed in women. The purpose of this review is to evaluate the evidence for PCI in women and demonstrate the unique aspects of therapy in regard to sex.

Mortality differences between men and women after percutaneous coronary interventions. A 25-year, single-center experience

OBJECTIVES

Our aim was to examine whether gender-based differences in mortality after percutaneous coronary interventions (PCIs) have changed in the past 25 years.

BACKGROUND

Women with coronary artery disease have a higher risk of adverse outcomes after PCIs than do men. Recent temporal trends in short-term and long-term mortality in women after PCIs are unknown.

METHODS

We performed a retrospective cohort study of 18,885 consecutive, unique patients who underwent PCIs between 1979 and 1995 (early group, n = 7,904, 28% women) and between 1996 and 2004 (recent group, n = 10,981, 31% women). Thirty-day and long-term mortality were compared by gender.

RESULTS

Compared with men, women undergoing PCIs were older and more likely to have diabetes mellitus, hypertension, or hypercholesterolemia. Overall, PCI was successful in 89% of women and 90% of men. In the recent group, 30-day mortality was significantly reduced compared with that in the early group in women (2.9% vs. 4.4%, p = 0.002) and men (2.2% vs. 2.8%, p = 0.04). However, long-term survival was similar between the early and recent groups among both men and women. After adjustment for risk factors, there was no difference between men and women from 1994 onward for either 30-day or long-term outcomes.

CONCLUSIONS

The 30-day mortality after PCI in men and women has decreased in the past 25 years. After accounting for baseline risks, no differences in short-term or long-term mortality were observed between men and women.

Mortality differences between men and women after percutaneous coronary interventions. A 25-year, single-center experience

OBJECTIVES

Our aim was to examine whether gender-based differences in mortality after percutaneous coronary interventions (PCIs) have changed in the past 25 years.

BACKGROUND

Women with coronary artery disease have a higher risk of adverse outcomes after PCIs than do men. Recent temporal trends in short-term and long-term mortality in women after PCIs are unknown.

METHODS

We performed a retrospective cohort study of 18,885 consecutive, unique patients who underwent PCIs between 1979 and 1995 (early group, n = 7,904, 28% women) and between 1996 and 2004 (recent group, n = 10,981, 31% women). Thirty-day and long-term mortality were compared by gender.

RESULTS

Compared with men, women undergoing PCIs were older and more likely to have diabetes mellitus, hypertension, or hypercholesterolemia. Overall, PCI was successful in 89% of women and 90% of men. In the recent group, 30-day mortality was significantly reduced compared with that in the early group in women (2.9% vs. 4.4%, p = 0.002) and men (2.2% vs. 2.8%, p = 0.04). However, long-term survival was similar between the early and recent groups among both men and women. After adjustment for risk factors, there was no difference between men and women from 1994 onward for either 30-day or long-term outcomes.

CONCLUSIONS

The 30-day mortality after PCI in men and women has decreased in the past 25 years. After accounting for baseline risks, no differences in short-term or long-term mortality were observed between men and women.

Impact of gender on in-hospital mortality of patients with acute myocardial infarction undergoing percutaneous coronary intervention: an evaluation of the TAMIS-II data

OBJECT

It is a matter of concern that women have higher in-hospital mortality rates than men with percutaneous coronary intervention (PCI), however, it is not yet clear whether significant gender differences exist. We studied the influence of gender on the characteristics and in-hospital mortality among patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI).

METHODS

We used data from 15 acute care hospitals included in the sample from the Tokai Acute Myocardial Infarction Study II (TAMIS-II), a prospective study of all patients admitted to these hospitals from 2001 to 2003 with a diagnosis of AMI. We abstracted the baseline and procedural characteristics from detailed chart reviews which included not only physician notes but also nursing notes, and a questionnaire which included baseline characteristics, procedural course and in-hospital mortality. Multivariate analysis was performed, controlling for age and other variables which were found to be significantly different between men and women by chi-square test or unpaired t test.

PATIENTS

A total of 566 women and 2,048 men were included in the present study.

RESULTS

There were gender differences in age, comorbid conditions, smoking status, body mass index, activities of daily livings, heart failure on presentation, duration of stay, angiographic data, transfer to ICU/CCU, and thrombolytic drugs. In univariate analysis, women had a higher in-hospital mortality rate than did men; however, this gender difference disappeared after adjustment for age and other variables.

CONCLUSION

Our study demonstrated that women with AMI who undergo PCI do not have a higher in-hospital mortality rate than men.

Coronary revascularisation in women

Coronary heart disease is the leading cause of death in men and women worldwide. It is still considered a disease of men and there has been little recognition of its importance in women. Gender differences exist in acute and chronic ischaemia in terms of clinical manifestations, investigations and treatment. There are clear gender differences in coronary revascularisation with a higher mortality seen in women. At the time a woman presents with coronary artery disease she is older and has more co-morbid factors. Furthermore, women have smaller coronary arteries making them more difficult to revascularise. In recent years there has been a general trend towards improved outcomes in women undergoing both surgical and percutaneous coronary intervention. The increasing use of drug eluting stents and adjunctive medical treatment as well as the use of off-pump bypass surgery needs further evaluation in terms of gender differences. This article reviews the current literature on coronary revascularisation in women.

Differences in in-hospital mortality between men and women with acute myocardial infarction undergoing percutaneous coronary intervention in Japan: Tokai Acute Myocardial Infarction Study (TAMIS)

BACKGROUND

It is a matter of concern that women have higher in-hospital mortality rates than men with percutaneous coronary intervention (PCI); however, it is not yet clear whether significant sex differences exist. This study aimed to determine if there are sex differences in the characteristics and in-hospital mortality among patients with acute myocardial infarction (AMI) undergoing PCI in Japan.

METHODS

We used data from 13 acute care hospitals in the Tokai region (central Japan) included in the sample from the TAMIS, a retrospective study of all patients admitted to these hospitals from 1995 to 1997 with a diagnosis of AMI. We abstracted the baseline and procedural characteristics from detailed chart reviews which included not only physician notes but also nursing notes, and a questionnaire included baseline characteristics, procedural course, and in-hospital mortality. Multivariate analysis was performed, controlling for age and other variables which were found to be significantly different between men and women by chi2 test or Mann-Whitney U test.

RESULTS

In TAMIS, we had a total of 2020 subjects. A total of 303 women and 1033 men undergoing PCI were included in the present study. There were sex differences in age, comorbid conditions, smoking status, activities of daily living, and heart failure on presentation. In univariate analysis, women had a higher in-hospital mortality rate than men; however, this sex difference disappeared after multivariable adjustment.

CONCLUSIONS

Our study demonstrates that women with AMI who undergo PCI do not have a significantly higher in-hospital mortality rate than men in Japan; additional larger-scale studies are needed to confirm these results.

Ischemic and bleeding outcomes in women treated with bivalirudin during percutaneous coronary intervention: a subgroup analysis of the Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events (REPLACE)-2 trial

BACKGROUND

Outcomes in women undergoing percutaneous coronary intervention (PCI) in the contemporary era are poorly defined. The REPLACE-2 trial demonstrated that bivalirudin with provisional glycoprotein IIb/IIIa (GpIIb-IIIa) blockade is noninferior to heparin with planned GpIIb-IIIa blockade during PCI, with regard to ischemic and bleeding end points.

OBJECTIVES

The aim of this study was to define sex-based clinical ischemic and bleeding outcomes from the REPLACE-2 trial.

METHODS

A retrospective sex-based subgroup analysis of the REPLACE-2 trial comparing clinical ischemic and inhospital bleeding end points was conducted.

RESULTS

Compared with men in REPLACE-2, women were older, had more diabetes, congestive heart failure and hypertension, and less prior revascularization and myocardial infarction. Female sex was a univariate predictor of death and bleeding complications. Among women treated with either bivalirudin or heparin, there was no significant difference in the individual or composite ischemic end points of death, myocardial infarction, or urgent revascularization at 30 days or 6 months. Protocol-defined major bleeding, minor bleeding, and access site bleeding were less frequent with bivalirudin compared with heparin. Multivariable modeling found no significant interactions between sexes, with the composite ischemic end point, major bleeding, or 1-year mortality.

CONCLUSIONS

Women remain at higher risk for poorer outcomes with contemporary PCI, likely because of comorbidities. Bivalirudin with provisional GpIIb-IIIa confers similar protection against ischemic end points compared with heparin and planned GpIIb-IIIa blockade and significantly reduces the inherent bleeding risk of women undergoing contemporary PCI.

Coronary Revascularization in Women

Coronary revascularization procedures have less salutary outcomes for women than for their male peers. Procedural bleeding complications, among others, warrant pathophysiologic assessment; limitation of such complications can improve clinical outcomes for women.

Impact of female sex on outcome after percutaneous coronary intervention

BACKGROUND

Prior reports have suggested that women have increased mortality compared to men following percutaneous coronary intervention (PCI). It remains unclear if this difference is secondary to sex or other confounding variables.

METHODS

We sought to examine the characteristics and outcomes of 18039 consecutive women and men undergoing PCI at The Cleveland Clinic Foundation from 1992-2002.

RESULTS

Procedural success rates were similar in both sexes, but the female cohort had a greater incidence of access site hematoma (5% vs. 2%, P < .0001) and blood product transfusion (12% vs. 4%, P < .0001) following PCI. The rate of myocardial infarction (MI) at 1 year was slightly higher among females (10% vs. 9%, P = .004), but revascularization rates were not significantly different between sexes. One-year mortality was also higher in the female cohort (7% vs. 5%, P < .0001). After adjustment in a multivariate model, the Cox proportional hazard ratio for mortality in females was 1.01 (95% CI 0.93-1.11, P = .78). The hazard ratio for the combined endpoint of death or MI was 1.05 (95% CI 0.97-1.13, P = .23).

CONCLUSIONS

After adjustment for differences in comorbidities, the risk for long-term mortality is not significantly different between sexes following PCI. However, there is a greater incidence of post-procedural bleeding complications among women.

Coronary heart disease: the female heart is vulnerable

During the past decade, an overall theme has emerged, validating the exploration of gender-based differences in coronary heart disease (CHD) as a basis for clinical strategies to improve outcomes for women. Underrepresentation of women in most of CHD and lack of gender-specific reporting in many clinical trials continue to limit the available knowledge and evidence-based medicine needed to devise optimal managements for women with CHD. Control of conventional coronary risk factors provides comparable cardioprotection for men and women. Current evidence fails to show cardiac protection from menopausal hormone therapy. Clinical presentations of coronary heart disease (CHD) and management strategies differ between the sexes. Underutilization of proven beneficial therapies is a contributor to less-favorable outcomes in women. The contemporary increased application of appropriate diagnostic, therapeutic, and interventional managements has favorably altered the prognosis for women, particularly when the data are adjusted for baseline characteristics. Better education of women during office visits, earlier and more aggressive control of coronary risk factors, and a greater index of suspicion regarding chest pain and its appropriate evaluation may help to reverse the trend of late referral and late intervention. Research indicates that behavioral changes on the part of women and reshaping of practice patterns by their health care providers may dramatically reduce the number of women disabled and killed by CHD each year.

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.