Before and After PCI, Women Have Poorer Health Status Than Men

Despite seeing improvements in health status comparable to those of men following nonprimary PCI, women are more likely to continue to have angina and to have poorer overall health, both before and after their procedures, according to a post hoc analysis of the CPORT-E trial.

The findings held up even after adjustment for clinical and procedural characteristics, authors note.

Health status—which includes things like physical limitation and quality of life (QoL)—is an important outcome of PCI, and understanding differences in health status outcomes is key to closing any gaps, said lead study author Pranoti G. Hiremath, MD (Johns Hopkins School of Medicine, Baltimore, MD).

Freedom from angina was 34% less likely in women compared with men at 6 weeks and 32% less likely than men at 9 months,” Hiremath et al note in their paper.

The study of 6,851 women and 12,016 men used scores from the Seattle Angina Questionnaire (SAQ) to assess health status before PCI and at regular intervals thereafter. While women’s overall scores improved, they did not do so to the same degree as men.

“Interestingly, for the domain of health status called ‘treatment satisfaction,’ we found that even though women had increased angina, reduced physical limitation, and reduced quality of life in comparison to men, they actually had similar treatment satisfaction as men, meaning they were satisfied with their care overall. That was the only equivalent component of disease-specific health status that we found,” Hiremath told TCTMD. Additionally, at baseline, women had worse symptoms and greater comorbidities than men, which she said could suggest that providers have a higher threshold for referring women for invasive procedures, or could highlight differences in the symptom threshold of female patients seeking care.

In an editorial accompanying the study, Sonya N. Burgess , PhD, MBChB (Nepean Hospital, Sydney, Australia), says the analysis is in keeping with several contemporary high-quality studies that have reported significant inequities between men and women after PCI from a variety of risk cohorts, despite careful multivariate risk analysis.

Burgess says the study, published online ahead of print in Circulation: Cardiovascular Interventions, serves as a reminder of how much more needs to be done to close the gender gap for women with cardiovascular disease “and is a call to action to keep working toward better evidence-based solutions and to more consistent and equitable management strategies.”

More Bleeding, Less DAPT and Statins for Women

CPORT-E was a large US-based trial that enrolled PCI patients from 60 centers with or without on-site cardiac surgery between August 2006 and March 2011. Health status was assessed with the SAQ at baseline, 6 weeks, and 9 months. Compared with men, women were older, more frequently Black, and had higher rates of baseline comorbidities (heart failure, hypertension, diabetes, prior stroke or peripheral vascular disease, and family history of CVD). Fewer women than men had a prior MI, PCI, or CABG.

The proportion of women reporting angina-free status increased from 26.2% at baseline to 71.6% at 6 weeks, further increasing to 78.1% at 9 months (P < 0.001 for all comparisons). Similarly, the proportion of men reporting angina-free status rose from 29.8% at baseline to 78.7% at 6 weeks, further increasing to 83.0% at 9 months (P < 0.001 for all comparisons). Following adjustment for clinical and procedural characteristics and baseline SAQ summary score, women had a lower SAQ summary score than men at 6 weeks and 9 months (P < 0.001 for both).

[The study is] a call to action to keep working toward better evidence-based solutions and to more consistent and equitable management strategies. Sonya Burgess

There were no sex-based differences in all-cause mortality or in rates of MACE. However, women were more likely than men to experience bleeding (8.5% vs 3.7%) and to require vascular repair (1.6% vs 1.1%), as well as repeat diagnostic catheterization (16.4% vs 12.4%; P < 0.001 for all). The poorer health status for women versus men also was seen in patient subsets with no bleeding complications, with DES placement only, and with single-vessel disease.

Looking at medical therapy after PCI, Hiremath and colleagues found that women were less likely than men to be prescribed statins at discharge, 6 weeks, or 9 months. Additionally, dual antiplatelet therapy (DAPT) was prescribed less often in women than men (93% vs 94.5%), as were aspirin (95% vs 96.6%) and statins (84.5% vs 88.1%; P < 0.001 for all).

“If someone is not prescribed a statin, they may be more likely to have progression of disease after their PCI. So that was actually a contributing factor, potentially,” Hiremath said. In the paper, she and her colleagues also suggest that biological differences in CAD pathophysiology, as well as differences in pain perception may play roles in the sex-based differences in health status observed following PCI.

“Few studies have done what we need, which is to focus on coronary artery disease pathophysiology that is disproportionately higher in women, such as microvascular dysfunction and coronary-based spasm,” Hiremath added. “It's really time to close the gender gap and bring women to the forefront of clinical investigation in coronary artery disease and cardiology overall.”

Burgess notes that data such as these point to the importance of treating all patients in accordance with accepted guidelines and aiming for “more consistent referral and treatment thresholds, better use of radial access, potent P2Y12 inhibitors, referral to cardiac rehab, statin therapy, and more aggressive management of cardiac risk factors particularly hypertension and body mass index.”

A final piece of the puzzle with regard to the observed sex differences may be related to the gender of the physician treating the patient, with Burgess noting that data support the theory that women with MI who are treated by women have better outcomes.

To TCTMD, Hiremath said while more work needs to be done to achieve equity for women with CVD, particularly in optimizing medical therapy equitably, the study is reassuring overall of “a great health status benefit of PCI in women with coronary artery disease.”