Angioplasty Outcomes in Women

Summarized by Robert W. Griffith, MD
June 28, 2002 (Reviewed: June 29, 2004)

Introduction

In the previous decade, it was shown that women undergoing coronary angioplasty had higher in-hospital mortality and worse overall outcome than men. It was assumed that advanced age and greater co-morbidity were largely responsible. By 1998, however, the situation with respect to in-hospital mortality and 5-year survival had changed, with women having similar results as men. The authors of the study summarized here wanted to examine gender differences in patients having contemporary percutaneous coronary intervention (PCI), as reported in a large US registry.

Method

The US National Heart, Lung, and Blood Institute (NHLBI)-funded Dynamic Registry was used. This registry includes 15 clinical centers and a coordinating center. Data were collected from over 2,000 patients over 8 months in 1997 and 1998, and the baseline characteristics and outcomes of percutaneous transluminal coronary angioplasty (PCTA) compared between the sexes; then the data for the women were compared with those of women from the same clinical centers in 1985-1986 and 1993-1994.

The mass of data analyzed included demographics, medical history, risk factors, angiographic results before and after PCTA, left ventricular ejection fraction, and procedural "success" estimates. Outcomes measured included in-hospital complications (deaths, infarction, emergency coronary bypass graft surgery (CABG), and any other adverse events. At one year, the vital status was assessed, as well as the presence of angina, medications being taken, and occurrence of infarction, repeat PCI, or CABG.

Results

Of the 2,524 patients registered, 895 (35%) were women. At baseline, the women were significantly older, more likely to be black, and more likely to have unstable angina, diabetes, hypertension and previous congestive heart failure. On the other hand, they were less likely to be smokers, have multiple-vessel lesions, significant lesions, and total occlusions.

Two procedural complications - major entry site complications and bleeding requiring transfusion - were commoner in women than in men; otherwise, there were no gender differences in the PCI procedures.

Immediate outcomes were mostly similar in men and women: in-hospital death (1.3% vs. 2.2%), infarction (2.3% vs. 3.0%, and CABG (1.4% vs. 1.3%). There were no significant differences between the results for each sex.

After one year, mortality and the combined events death-or-infarct-or-CABG were greater for women than for men (6.5% vs. 4.3%, p=0.02, and 18.3% vs. 14.4%, p=0.03, respectively). However, Cox regression analyses were done adjusting for those baseline characteristics that were different in men and women (see above); these analyses showed that gender was not a significant predictor of death or combined death-or-infarct (relative risks 1.26 and 1.14, respectively, with 95% CI's 0.85, 1.87, and 0.86, 1.50, respectively).

The combined events death-or-infarct-or-CABG at one year were significantly more frequent at one year in women than in men, even after adjustment for baseline characteristics, but there was no difference during the first 90 days after the procedure.

The women from the Dynamic registry, when compared with those from similar groups in 1985-1986 and 1993-1994, were found to be older, and had more comorbidity, diabetes, hypertension, hypercholesterolemia, calcified lesions, and multi-vessel disease than those from the earlier registries. However, their in-hospital mortality was the similar, and their combined events death-or-infarct-or-CABG were significantly less (6.0% vs. 11.6%, p</=0.001). At one year, adjusted mortality figures showed the Dynamic registry women to have a relative risk significantly lower than the 1985-1986 registry women (RR=0.51, 95% CI 0.29, 0.90).

Comment

This study confirms the 'persistent and well-recognized' differences between men and women undergoing PCI. This is largely because women present clinically with coronary artery disease 10 to 20 years later than men do, and they continue to be older when they need revascularization procedures. Women's smaller body frames correlate with smaller coronary artery diameters, but recent improvements in technique have produced improved outcomes with smaller vessels.

In the 1985-1986 registry, in-hospital death rates were ten-fold higher in women than in men. This dramatic difference has dwindled to virtually no difference 12 years later, as this study shows. As the authors of the study claim, 'women in need of coronary revascularization who are candidates for a PCI should be referred for the procedure with the expectation of an excellent outcome, which is no longer associated with undue risk'.

Source

• Improved outcomes for women undergoing contemporary percutaneous coronary intervention. AK. Jacobs, JM. Johnston, A. Haviland,  et al., J Am Coll Cardiol, 2002, vol. 39, pp. 1608--1614

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