Female-Specific Data Lacking for Myocardial Revascularization: SCAI

A new consensus statement shines a light on areas where additional evidence for women in needed, Alexandra Lansky says.

Female-Specific Data Lacking for Myocardial Revascularization: SCAI

When it comes to myocardial revascularization in women, there are still a lot of unknowns stemming from a lack of data, and the Society for Cardiovascular Angiography and Interventions (SCAI) hopes to accelerate research on the issue by identifying the gaps in knowledge in a new consensus statement.

Women, particularly those who are younger and who have STEMI or cardiogenic shock, tend to receive less-aggressive treatment than do men, and that’s thought to contribute to worse outcomes, Alexandra Lansky, MD (Yale University School of Medicine, New Haven, CT), chair of the document’s writing group, told TCTMD.

Moreover, women have historically been underrepresented in clinical studies and as a result, practice guidelines don’t contain sex-specific information, Lansky said.

This consensus statement, published online last week in the Journal of the Society for Cardiovascular Angiography and Interventions, highlights what is and is not known about myocardial revascularization in the female population in a format mirroring guideline documents.

While the guidelines give us broad recommendations across men and women, our consensus homes in on the knowns and the gaps in evidence, so we can make informed decisions on best treatment options for women,” Lansky said. There are already ongoing efforts to build additional evidence around revascularization in women, “and we hope to encourage more,” she added.

The document reviews the existing sex-specific literature and identifies gaps related to the epidemiology of ischemic heart disease; various diagnostic tools used to guide procedures; revascularization across the spectrum of coronary disease; considerations in specific patient populations; device and lesion considerations during percutaneous revascularization; and vascular access and health status outcomes in women.

Some of the areas identified as lacking information include the true prevalence of obstructive and nonobstructive CAD in women presenting with MI, potential sex differences when various diagnostic tools are used to guide procedures, and the choice of CABG or PCI for women across multiple conditions.

Providing an example of a scenario in need of additional data, Lansky noted that the latest US guidelines on myocardial revascularization—published in December—recommend either PCI or CABG in patients with left main or three-vessel disease and lower SYNTAX scores. Women only made up 20% to 25% of the patients included in the trials informing that guidance, however, and there is some evidence that female patients would actually do better with CABG. “Whether that’s true or not is not entirely clear, but we do need more randomized data for our female patients so we can understand [how to get] the best treatment recommendations and best outcome,” Lansky said.

How women with STEMI and shock are managed is another area in need of attention, she pointed out, noting that female patients often don’t get adequate treatment. “One of the strong recommendations of this consensus is to better define pathways of care for females where delays or too often not offering standard treatments is known to worsen outcomes.”

But it’s not all negative, Lansky said, citing evidence around the use of intravascular lithotripsy that indicates women fare better than men, with fewer complications. “We hope to inform and change practice for treating calcified lesions with safer approaches whenever possible,” she said.

In a broader sense, the consensus document is a “call to action” for expedited access to care for all patients. “It brings attention to differences in outcomes between men and women, to the disparities in access to care, and to the underrepresentation [of women] in clinical studies,” said Lansky.

When it comes to how this statement might be used, the authors note that “in many clinical scenarios, the level of evidence supporting clinical decisions in women is poor due to insufficient data,” but add that “clinicians can use the observations highlighted in this document to guide practice.”

“Until further investigation in women is performed, interventional cardiologists should continue to apply relevant randomized trial evidence to inform clinical judgment and best practices in women undergoing PCI,” they advise.

In an accompanying editorial, Birgit Vogel, MD (Icahn School of Medicine at Mount Sinai, New York, NY), and colleagues note in a report published last year by a Lancet commission on women and CVD, ischemic heart disease was one of the areas in which sex-related disparities in diagnosis and care were particularly relevant.

“Substantial differences between women and men with ischemic heart disease in pathophysiology, clinical presentation, risk factor patterns, quality of care, and outcomes have been increasingly recognized,” they write. “Therefore, sex-specific considerations in myocardial revascularization as a cornerstone of the treatment for ischemic heart disease are of particular interest.”

On that background, “this expert consensus statement is a powerful reminder of how little robust evidence exists on ischemic heart disease and myocardial revascularization in women,” Vogel et al say. “It is, furthermore, a call to action to urgently build the evidence base for sex-specific recommendations, where appropriate, and improve care for women with cardiovascular disease.”

Todd Neale is the Associate News Editor for TCTMD and a Senior Medical Journalist. He got his start in journalism at …

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  • Lansky reports no relevant conflicts of interest.