Percutaneous Coronary Intervention and Adjunctive Pharmacotherapy in Women

Abstract

Abstract-More than 1.2 million percutaneous coronary interventions are performed annually in the United States, with only an estimated 33% performed in women, despite the established benefits of percutaneous coronary intervention and adjunctive pharmacotherapy in reducing fatal and nonfatal ischemic complications in acute myocardial infarction and high-risk acute coronary syndromes. This statement reviews sex-specific data on the safety and efficacy of contemporary interventional therapies in women. 1 Despite the fact that more women than men die from cardiovascular disease in the United States, and despite the established benefits of PCI in reducing fatal and nonfatal ischemic complications in patients with acute myocardial infarction and high-risk acute coronary syndromes, only an estimated 33% of annual PCIs are performed in women. [1][2][3][4] In addition, women experience greater delays 5 to intervention and are referred for diagnostic catheterization less frequently than are men. 6 -8 Although suggested reasons for referral differences have included women's older age at presentation, greater risk profile, and increased risk for an adverse procedural outcome, as well as differences in symptoms and pain perception between men and women and lower predictive accuracy of noninvasive testing in women, some evidence suggests a potential sex and race bias. 9 In contrast, once women are referred for cardiac catheterization, revascularization rates and practices are similar to those in men. 10 -12 Recent advances in angioplasty equipment and technique have improved options for patients with smaller coronary and peripheral (access) arteries. In addition, the increased use of stents and adjunctive pharmacotherapy has improved outcomes in both women and men. Nevertheless, women continue to represent 15% to 38% of the population in studies of PCI, and still relatively few sex-or race-specific data exist.The purpose of this statement is to review what is known and not known about PCI in women and to put published data in context with contemporary coronary intervention. It is not the intention of the writing group to give specific treatment recommendations but rather to compile and collate the available sex-specific data on the safety and efficacy of interventional therapies in women. Tables 1 and 3 provide summaries of the findings in women drawn from this literature review, as well as recommendations from previously published American College of Cardiology/American Heart Association (ACC/AHA) guidelines. MethodsThe information in this statement was compiled by systematic literature review. By searching MEDLINE from JanuaryThe American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perc...

Is There Gender Bias in Critical Care?

“…As Beery noted nearly 20 years ago, 30 aspects of gender bias have long been recognized in referrals of women with coronary artery disease (CAD) for diagnostic and therapeutic procedures such as angioplasty, 31 coronary revascularization, implantable cardioverter defibrillators (ICDs), and heart transplants, at least partially explaining why women are older, sicker, and suffer from more comorbidities by the time they receive these therapies and why their outcomes are worse than men's. When the European Institute of Women's Health 32 issues a comparable summary regarding women with heart disease being older when first hospitalized, more prone to risk, receiving inferior treatments, and having more complications and worse outcomes than men in India, China, and western Asia, it is clear that the issue of women not receiving equitable medical services for heart disease has not progressed in 2 decades, but may be more widely recognized today.…”

“…35 Despite these ominous circumstances, women with acute MI less frequently undergo reperfusion and revascularization 31 and, when they do receive revascularization, their outcomes are significantly worse compared to men, an event not fully accounted for by the smaller size of their coronary vessels. As a result, although age and detrimental cardiovascular profiles in women with CAD may contribute to these findings, some studies conclude that the female gender itself constitutes an independent predictor of morbidity and mortality.…”

“…As a result, although age and detrimental cardiovascular profiles in women with CAD may contribute to these findings, some studies conclude that the female gender itself constitutes an independent predictor of morbidity and mortality. 31,36,37 Some aspects of patient management for acute MI vary with gender. Nguyen 38 found that although there was no evidence of gender bias in either the pharmacologic therapies (aspirin, β-blockers, ACE inhibitors, angiotensin-receptor blockers) administered or in the use of coronary revascularization once patients were diagnosed with acute MI, there was evidence of gender bias in the referral of patients for coronary angiography, where women were 46% less likely than men to undergo investigative coronary angiography and that for revascularization, women were more likely to receive percutaneous intervention (PCI), whereas men were more likely to have coronary artery bypass grafting.…”

Coronary Revascularization in Women

“…Bleeding complications, a previous concern in women, were reduced with less aggressive anticoagulation regimens. 8 The previously mentioned Michigan (BMC2) registry also evaluated gender differences among STEMI and primary PCI in over 8000 patients from 2003 to 2008. 9 Twenty-nine percent of the patients were female.…”

Analysis of Myocardial Infarction Time Course in Women Compared With Men in Upper Silesia Population in 30 Day Follow-Up

“…However, revascularization is less frequently performed in women. 9,10) Our study is an analysis of gender influence on the management of acute coronary syndrome and the outcome of this treatment defined by the occurrence of major adverse cardiac events (reocclusion, death, stroke) in 30 day followup in Upper Silesia (an industrial region). The statistics prove how serious a problem acute coronary syndromes are in this part of Poland.…”