Sex-related differences in fractional flow reserve-guided treatment

Abstract

Background: Sex-specific differences affect the evaluation, treatment, and prognosis of coronary artery disease. We tested the hypothesis that long-term outcomes of fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) are different between women and men.

Methods and results: Consecutive 1090 patients, referred for PCI and undergoing FFR measurements at the Mayo Clinic between October 2002 and December 2009, were included in this registry study. Clinical events were compared between the sexes during a median follow-up of 50.9 months. Of all patients, women had higher FFR adjusted by visual coronary stenosis than men (P=0.03). The Kaplan-Meier percent of major adverse cardiac events at 5 years was 35% in women and 38% in men (P=0.54). Interestingly, in patients undergoing PCI with an FFR <0.75, the incidence of death or myocardial infarction was significantly higher in women than in men (hazard ratio, 2.16; 95% confidence interval, 1.04-4.51; P=0.04). Moreover, compared with patients with FFR >0.80, deferral of PCI for those with FFR between 0.75 and 0.80 was associated with an increased rate of major adverse cardiac events, particularly death or myocardial infarction in women (hazard ratio, 3.25; 95% confidence interval, 1.56-6.74; P=0.002) and revascularization in men (hazard ratio, 2.66; 95% confidence interval, 1.66-4.54; P<0.001).

Conclusions: Long-term outcome differs between women and men undergoing FFR-guided PCI. Our data suggest that the sex-based treatment strategy is necessary to further optimize prognosis of patients with coronary artery disease.

Keywords: fractional flow reserve, myocardial; percutaneous coronary intervention; sex.

Figure 1. Comparison of fractional flow reserve between women and men

In women and men with <60%, 60%-69%, 70%-79%, 80%-89% and ≥90% stenoses, the median FFR were 0.90 and 0.89, 0.85 and 0.84, 0.79 and 0.77, 0.78 and 0.76, 0.84 and 0.79, respectively. After adjustment for covariates, FFR values were significantly higher in women than in men only for lesion with 60-69% diameter stenosis (mean: 0.021, P=0.03) and 70-79% (mean: 0.039, P=0.002) diameter stenosis. The edges of the blue boxes are the 25th and 75th percentiles (Q1, Q3) respectively; the lines inside the blue boxes represent the median values; the blue diamonds on the plot are the means; the upper and lower bars outside the blue boxes represent the maximum and minimum values, the green diamonds represent the adjusted means of FFR, respectively. FFR = fractional flow reserve intervention; F = female; M = male

Figure 2. Major adverse cardiac events during follow up

Unadjusted Kaplan-Meier curves during a 5-year follow-up for major adverse cardiac events. FFR = fractional flow reserve; MI = myocardial infarction; PCI = percutaneous coronary intervention

Figure 3. Risk of outcome events in women and men

The chart shows hazard ratios (dot) and 95% CIs (horizontal lines) for outcome events. CI = confidence interval; FFR = fractional flow reserve; HR = hazard ratio; MACE =major adverse cardiac event; PCI = percutaneous coronary intervention