Sex Differences in the Drug-Eluting Stent Era

Abstract

Over the past several years, there has been increasing focus on obtaining sex-specific data in the cardiovascular area. This is particularly important, given that cardiovascular disease remains the greatest cause of death in women, and unlike men, the mortality rates do not seem to be declining in recent years (1). Many have attributed this finding to difficulties in recognizing symptoms; delay in diagnosis; under-use of recommended diagnostic tests and therapies in women (2-4); as well as anatomic, physiological, and genetic differences. See page 301Several studies have confirmed that women who present with coronary disease are older and have more comorbidities, including diabetes, hypertension, and heart failure, compared with men (3-7). Moreover, women with acute coronary syndromes or myocardial infarction have an increased risk of mortality that is not consistently eliminated after adjustments for comorbidities (3-9). Women who undergo coronary artery bypass grafting (CABG) are less likely to receive a mammary graft and have more incomplete revascularization, greater bleeding, and mortality, compared with men (10).The good news is that outcomes after coronary revascularization are improving. A single-center study noted better 30-day and 1-year outcomes among women undergoing percutaneous coronary interventions (PCI) after the year 2000 (11). A national registry reported that sex was no longer predictive of major adverse cardiac events in the era of stenting (12). Drug-eluting stents (DES) seem to be equally effective at reducing restenosis and improving outcomes in both men and women (13)(14)(15)(16)(17)(18)(19). In fact, secondgeneration DES might be particularly well-suited for the small tortuous coronary arteries found in some women, given their lower profile, more enhanced deliverability, and thinner strut designs.In this issue of JACC: Cardiovascular Interventions, Stefanini et al. (20) described their pooled data on more than 5,000 patients enrolled in 3 prospective randomized DES trials. Their study is unique in that patients were not highly selected, use of second-and third-generation DES was unrestricted, and 2-year follow-up was available. Although women experienced a higher mortality at 30 days, by 2 years, adjusted mortality was similar (odds ratio: 0.99, 95% confidence interval: 0.63 to 1.56, p ϭ 0.97), as was target vessel revascularization. Among the patients who underwent protocol-driven angiographic follow-up, late loss and restenosis rates were similar among men and women (despite smaller vessels and more diabetes in women).Results of the Stefanini et al. study (20) and others (13-19) suggest that DES have leveled the playing field between men and women undergoing PCI. Many studies have shown that acute angiographic success, late restenosis, and clinical outcomes are now similar between men and women, despite advanced age and more comorbidities in the latter. These results are likely due to improvements in catheters and more flexible stent designs. Conversely, other investigators continue to...

Short- and Long-Term Outcomes of Coronary Stenting in Women Versus Men

“…Prior small pooled trial studies assessing DES use have yielded similar trends toward long-term outcomes by sex. 12,13,39,40 The DES benefit in our study may reflect a bias toward a preferential use of BMS in higher-risk or sicker patients, which cannot be directly addressed in our data set. Furthermore, variables associated with stent selection such as upcoming surgery, compliance with antiplatelet therapy, and quantification of bleeding risk are not routinely collected in most registries.…”

Chronic Coronary Syndromes in Women

“…In patients undergoing percutaneous coronary interventions with implantation of drugeluting stents, sex is not an independent predictor of major adverse cardiovascular events. 56,57 In fact, second-and thirdgeneration drug-eluting stents are equally effective at improving outcomes in women and men with similarly low target-vessel revascularization rates during follow-up, 58 likely due to their low profile, thin strut designs that may enhance stent deliverability in small, tortuous coronary arteries found in some women. 56 Moreover, routine use of radial access can eliminate femoral access site complications that occur more frequently in women than in men.…”

“…56,57 In fact, second-and thirdgeneration drug-eluting stents are equally effective at improving outcomes in women and men with similarly low target-vessel revascularization rates during follow-up, 58 likely due to their low profile, thin strut designs that may enhance stent deliverability in small, tortuous coronary arteries found in some women. 56 Moreover, routine use of radial access can eliminate femoral access site complications that occur more frequently in women than in men. 59 Women who undergo coronary artery bypass grafting have more incomplete revascularization, bleeding complications, and greater hospital and long-term mortality compared with men.…”