Higher Long-term Mortality for Women Undergoing Primary PCI

Although women who undergo percutaneous coronary intervention (PCI) tend to have more serious cardiovascular risk factors, their long-term rates of cardiac events are similar to those of men. However, an important exception is women with ST-segment elevation myocardial infarction (STEMI), who suffer increased long-term mortality compared with their male counterparts, according to a small observational study published online January 3, 2011, ahead of print in the American Journal of Cardiology.

Investigators led by Fabrizio D’Ascenzo, MD, of the University of Turin (Turin, Italy), looked at 833 consecutive patients who had undergone PCI at their center between July 2002 and December 2004, comparing the male (n = 623) and female (n = 210) cohorts.

After a median follow-up of 60 months, there were trends toward a lower rate of the primary outcome (MACE; composite of all-cause death, nonfatal MI, and TVR) and higher mortality for women but no differences in the incidence of MI, TVR, or stent thrombosis (table 1).

Table 1. Long-term Outcomes

 

Women
(n = 210)

Men
(n = 623)

P Value

MACE

42.3%

48.8%

0.090

All-Cause Death

21.2%

15.4%

0.090

MI

7.9%

9.0%

0.952

TVR

19.2%

17.6%

0.652

Definite or Probable Stent Thrombosis

1.3%

1.8%

0.435


However, when patients were stratified according to admission diagnosis, women with STEMI had higher mortality than men (table 2).

Table 2. Interaction Between Admission Diagnosis and Long-term Mortality

 

Women
(Mortality)

Men
(Mortality)

P Value

STEMI

20.0%

8.1%

0.029

Unstable Angina/

NSTEMI

20.5%

16.6%

0.421

StableAngina/
Silent Ischemia

22.2%

16.0%

0.508


In an e-mail communication with TCTMD, Dr. D’Ascenzo said that the results are generalizable to patients in regions with similar health care systems. However, he acknowledged, the study did have some limitations, including its observational design and nonrandomized nature, making it strictly hypothesis-generating.

Referral Bias Against Women?

In the paper, the researchers suggested that in women with STEMI, the mortality disadvantage could be due to presenting with atypical symptoms leading to longer door-to-needle times compared with their male counterparts. In addition, a referral bias against women involving both clinical presentation and initial management—sometimes called the Yentl syndrome—has been reported, they observe

“In our study, [and] as reported by other large European registries, women were less likely to undergo reperfusion or to receive adjunctive therapies,” the researchers write. “Thus, it could be argued that the low use of drug-eluting stents and anti-glycoprotein IIb/IIIa agents in the female patients contributed to their worse outcomes.”

“Great care in diagnosis, in hemodynamic interventions, and in clinical strategies should be offered to female patients, who carry a cardiovascular risk burden as high as those of men,” Dr. D’Ascenzo said in his e-mail. “In our opinion, the present study should increase awareness [of gender differences] and attention towards female patients, to avoid this so-called Yentl syndrome.”

The authors comment that although the association between gender and mortality has received increased attention in recent years, it is still poorly understood.

“Contrasting results are reported in the literature,” Dr. D’Ascenzo said. “[However,] from these data and from the present work, women still have worse long-term outcomes when presenting with STEMI. Thus, strict adherence to evidence[-based] practice strategies should be adopted when treating acute care patients.”

Study Details

Despite the fact that the women were older (70 ± 9 years vs. 63 ± 8 years; P < 0.0001), and had higher rates of diabetes (42.2% vs. 23.6%; P < 0.01) and hypertension (82.3% vs. 73.7%; P = 0.006), men more often reported having undergone prior revascularization.

During angiography and angioplasty, men were more frequently found to have chronic total occlusion and small vessels, while women received fewer DES and stent lengths were shorter. In addition, women were less likely to have received glycoprotein IIb/IIIa inhibitors.

 


Source:
D’Ascenzo F, Gonella A, Quadri G, et al. Comparison of mortality rates in women versus men presenting with ST-segment elevation myocardial infarction. Am J Cardiol. 2011:Epub ahead of print.

 

 

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Disclosures
  • Dr. D’Ascenzo makes no statement regarding conflicts of interest.

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