Gender differences in the outcome of cardiac interventions

Abstract

I. The actual data base on the decision-making process of indication for revascularization reveals that angiographic severity of coronary artery disease (CAD) is the primary determinant of referral to coronary interventional procedures. Several recent studies demonstrated that after an acute myocardial infarction, women undergo cardiac catheterization to a lesser extent than men. Data of the MITI study and of the Cooperative Cardiovascular Project suggested that during acute treatment of myocardial infarction a somewhat less aggressive therapy is performed in women as compared to men. II. With respect to sex-related differences in the early and late outcome after elective PCI, the main problem is the small, limited amount of data due to the lack of randomized clinical studies including a larger number of women. The vast majority of data was obtained in patients with PTCA and stents. All the older studies and registers until 1993 revealed a three times higher periprocedural complication rate and in-hospital mortality in women. In recent studies such as BARI, after successful PCI women have an excellent long-term prognosis comparable or even better than in men. III.1. Several studies on the effect of interventional strategies in patients with unstable angina or non-ST elevation myocardial infarction NSTEMI) revealed superiority of an early invasive versus a more conservative, noninvasive approach. However, the data of the FRISC II and RITA-3 trials indicated that an early intervention strategy resulted in a beneficial effect only in men which was not seen in women. On the other hand, two studies (e.g., the TACTICS-TIMI- 18 study) showed an improved outcome of women with acute coronary syndrome after early invasive therapy. III.2. In numerous investigations, a higher early mortality after acute ST elevation myocardial infarction (STEMI) has been observed in women compared to men. Although placebo-controlled randomized trials of thrombolytic therapy have demonstrated a 25-30% reduction in early mortality, in-hospital survival has remained consistently lower for women than men after thrombolytic reperfusion. -- In our clinic, prospective studies on clinical events during the early phase (30 days) and during long-term follow-up for 4 years after direct (primary) PTCA for acute STEMI were performed in women. Data were obtained in 204 consecutive and unselected women; results in women were compared with those of 577 consecutive and unselected men who had undergone direct angiography/primary PTCA for acute STEMI in the same time span. PTCA of the infarct-related artery was equally successful in both sexes (women 95%, men 94%). In the group of patients with acute STEMI who had been treated with primary infarct PTCA, no difference of early (30 days) mortality was detected in women versus men. Total cumulative mortality during 4 years of follow-up was 12.5%, 14.5%, 18% and 23% in women, respectively, versus 9%, 10.5%, 12% and 15%, respectively, in men. The general trend for a higher postdischarge mortality in women became apparent after 3 years and reached significance after 4 years. After multivariate analysis, female gender was no independent risk factor of increased mortality. Thus, direct (primary) coronary angiography and PCI eliminate significant gender-specific differences in survival early after acute myocardial infarction. Long-term follow-up (4 years) also revealed no sex-related differences in mortality and cardiac morbidity after direct (primary) PCI for acute ST elevation myocardial infarction.