Differences in sex-related bleeding and outcomes after percutaneous coronary intervention: Insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) registry

Othman, Hussein; Khambatta, Sherezade; Seth, Milan; LaLonde, Thomas; Rosman, Howard; Gurm, Hitinder S.; Mehta, Rajendra H.

doi:10.1016/j.ahj.2014.07.012

Cited by 26 publications

(19 citation statements)

References 20 publications

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“…Women included were more likely to present with stable angina/atypical chest pain, were more likely to be hypertensive and have peripheral vascular disease, and less likely to have prior CABG. In another study using the Blue Cross Blue Shield of Michigan registry, women undergoing PCI were less likely to have their procedure performed via RAA (9.5% in women, 11% in men; statistical significance not reported) . Similarly, women in this registry had more comorbidities, and were less likely to have prior CABG.…”

Section: Discussionmentioning

confidence: 84%

“…Bleeding and vascular access complications remain the most common early complications postprocedure and are associated with a threefold increased risk of mortality and major adverse cardiovascular events . Observational studies have demonstrated that post‐PCI bleeding is more common in women even after controlling for bleeding risk factors, and is associated with a greater mortality when compared to men with bleeding . In the modern PCI era, radial access, smaller sheath size, and use of ultrasound guided vascular access have reduced the risk of bleeding complications.…”

Section: Introductionmentioning

confidence: 99%

“…Randomized controlled trials have demonstrated that RAA can be used to safely perform PCI and is associated with lower bleeding risk and vascular complications compared to traditional femoral access . RAA is considered to be a component of a “bleeding avoidance” strategy that may also include ultrasound guided arterial cannulation, and avoidance of GPIIb/IIIa inhibitors . The use of RAA has been steadily increasing as operators become more comfortable with this technique with some studies reporting 50% radial access use .…”

Section: Introductionmentioning

confidence: 99%

“…5,6 RAA is considered to be a component of a "bleeding avoidance" strategy that may also include ultrasound guided arterial cannulation, and avoidance of GPIIb/IIIa inhibitors. 3 The use of RAA has been steadily increasing as operators become more comfortable with this technique with some studies reporting 50% radial access use. 7,8 However, in some studies, RAA is used less in women compared to men, 7,9 and women are more likely to have access site crossover with an initial RAA approach.…”

mentioning

confidence: 99%

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Radial artery access is under‐utilized in women undergoing PCI despite potential benefits: Mayo Clinic PCI Registry

Chester

Mina

Lewis

et al. 2019

Cathet Cardio Intervent

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Background Women may benefit from radial artery access (RAA) for percutaneous coronary interventions (PCI) due to a higher risk of bleeding compared to men; however, RAA may be underutilized in women. We sought to determine the frequency and predictors of RAA use in patients undergoing PCI. Methods We studied 21,123 (29.0% female) participants in the Mayo Clinic PCI Registry from January 1, 2006–December 31, 2016. Data were analyzed as a cohort and by time tertiles. Frequency of RAA versus femoral access and bleeding events were recorded. Logistic regression was used to identify predictors of RAA. Results In the overall cohort, women compared to men were older (69.6 ± 12.6 vs. 65.6 ± 11.9; p < .001), more likely to present with acute coronary syndrome (82.0% in women vs. 80.0% in men; p = .0008) and had more comorbidities. RAA increased from tertile one (3.5% for women vs. 4.0% for men; p = .3) through tertile three (46.8% for women vs. 50.3% for men; p = .01), but remained lower in women. In multivariable analysis, female sex is associated with 22% less RAA use (OR 0.78, 95% CI 0.72–0.84; p < .0001). Women compared to men experienced more bleeding (6.3 vs. 3.0%; p < .0001) but bleeding was less likely in RAA (OR 0.45, 95% CI 0.36–0.56; p < .0001). Conclusion Women undergoing PCI are less likely to receive RAA compared to men despite having a higher risk of bleeding. This trend persists despite increase in RAA use. Given the potential benefit of RAA in women, sex should be considered in patient selection for RAA.

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Section: Discussionmentioning

confidence: 84%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

mentioning

confidence: 99%

See 2 more Smart Citations

Radial artery access is under‐utilized in women undergoing PCI despite potential benefits: Mayo Clinic PCI Registry

Chester

Mina

Lewis

et al. 2019

Cathet Cardio Intervent

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“…It is a matter of fact that women have a higher bleeding tendency14 15 and are more likely to be transfused than men 11–1316–21 The latter phenomenon, together with the occurrence of perioperative blood loss and anaemia, may worsen their postoperative outcome.…”

Section: Introductionmentioning

confidence: 99%

Gender disparities in red blood cell transfusion in elective surgery: a post hoc multicentre cohort study

et al. 2016

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ObjectivesA post hoc gender comparison of transfusion-related modifiable risk factors among patients undergoing elective surgery.Settings23 Austrian centres randomly selected and stratified by region and level of care.ParticipantsWe consecutively enrolled in total 6530 patients (3465 women and 3065 men); 1491 underwent coronary artery bypass graft (CABG) surgery, 2570 primary unilateral total hip replacement (THR) and 2469 primary unilateral total knee replacement (TKR).Main outcome measuresPrimary outcome measures were the number of allogeneic and autologous red blood cell (RBC) units transfused (postoperative day 5 included) and differences in intraoperative and postoperative transfusion rate between men and women. Secondary outcomes included perioperative blood loss in transfused and non-transfused patients, volume of RBCs transfused, perioperative haemoglobin values and circulating red blood volume on postoperative day 5.ResultsIn all surgical groups, the transfusion rate was significantly higher in women than in men (CABG 81 vs 49%, THR 46 vs 24% and TKR 37 vs 23%). In transfused patients, the absolute blood loss was higher among men in all surgical categories while the relative blood loss was higher among women in the CABG group (52.8 vs 47.8%) but comparable in orthopaedic surgery. The relative RBC volume transfused was significantly higher among women in all categories (CABG 40.0 vs 22.3; TKR 25.2 vs 20.2; THR 26.4 vs 20.8%). On postoperative day 5, the relative haemoglobin values and the relative circulating RBC volume were higher in women in all surgical categories.ConclusionsThe higher transfusion rate and volume in women when compared with men in elective surgery can be explained by clinicians applying the same absolute transfusion thresholds irrespective of a patient's gender. This, together with the common use of a liberal transfusion strategy, leads to further overtransfusion in women.

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Sex Differences Among Patients With High Risk Receiving Ticagrelor With or Without Aspirin After Percutaneous Coronary Intervention

et al. 2021

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IMPORTANCE Shortened dual antiplatelet therapy followed by potent P2Y12 receptor inhibitor monotherapy reduces bleeding without increasing ischemic events after percutaneous coronary intervention (PCI).OBJECTIVE To explore sex differences and evaluate the association of sex with outcomes among patients treated with ticagrelor monotherapy vs ticagrelor plus aspirin. DESIGN, SETTING, AND PARTICIPANTSThis was a prespecified secondary analysis of TWILIGHT, an investigator-initiated, placebo-controlled randomized clinical trial conducted at 187 sites across 11 countries. Study participants included patients who underwent successful PCI with drug-eluting stents, were planned for discharge with ticagrelor plus aspirin, and who had at least 1 clinical and at least 1 angiographic feature associated with high risk of ischemic or bleeding events. Data were analyzed from May to July 2020.INTERVENTIONS At 3 months after PCI, patients adherent to ticagrelor and aspirin without major adverse event were randomized to either aspirin or placebo for an additional 12 months along with ticagrelor. MAIN OUTCOMES AND MEASURESThe primary end point was Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding at 12 months after randomization. The primary ischemic end point was a composite of death, myocardial infarction, or stroke. RESULTSOf 9006 enrolled patients, 7119 underwent randomization (mean [SD] age, 63.9 [10.2] years; 5421 [76.1%] men). Women were older (mean [SD] age, 65.5 [9.6] years in women vs 63.4 [10.3] years in men) with higher prevalence of chronic kidney disease (347 women [21.2%] vs 764 men [14.7%]). The primary bleeding end point occurred more often in women than men (hazard ratio [HR], 1.32; 95% CI, 1.06-1.64; P = .01). After multivariate adjustment, incremental bleeding risk associated with female sex was no longer significant (adjusted HR, 1.20; 95% CI, 0.95-1.52; P = .12). Ischemic end points were similar between sexes. Ticagrelor plus placebo vs ticagrelor plus aspirin was associated with lower risk of BARC type 2, 3, or 5 bleeding in women (adjusted HR, 0.62; 95% CI, 0.42-0.92; P = .02) and men (adjusted HR, 0.57; 95% CI, 0.44-0.73; P < .001; P for interaction = .69). Ischemic end points were similar between treatment groups in both sexes.CONCLUSIONS AND RELEVANCE These findings suggest that the higher bleeding risk in women compared with men was mostly attributable to baseline differences, whereas ischemic events were similar between sexes. In this high-risk PCI population, the benefits of early aspirin withdrawal with continuation of ticagrelor were generally comparable in women and men.

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Differences in sex-related bleeding and outcomes after percutaneous coronary intervention: Insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) registry

Cited by 26 publications

References 20 publications

Radial artery access is under‐utilized in women undergoing PCI despite potential benefits: Mayo Clinic PCI Registry

Radial artery access is under‐utilized in women undergoing PCI despite potential benefits: Mayo Clinic PCI Registry

Gender disparities in red blood cell transfusion in elective surgery: a post hoc multicentre cohort study

Sex Differences Among Patients With High Risk Receiving Ticagrelor With or Without Aspirin After Percutaneous Coronary Intervention

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