What's Good for the Gander is Now Good for the Goose
Abstract & Commentary
By Jonathan Abrams, MD, Professor of Medicine, Division of Cardiology, University of New Mexico, Albuquerque. Dr. Abrams serves on the speaker's bureau for Merck, Pfizer, and Parke-Davis.
Sources: Singh M, et al. Mortality differences between men and women after percutaneous coronary interventions. J Am Coll Cardiol. 2008;51:2313-2320; Wilson RF, Raveendran G. What's good for the gander is now good for the goose. J Am Coll Cardiol. 2008;51:2321-2322.
It has long been believed, with considerable substantiation, that women have poorer results of percutaneous interventions (PCI) than men, with higher morbidity and mortality rates. The present report signals a change in this paradigm. A PCI registry from the Mayo Clinic extending from 1996-2004 was analyzed for outcomes in women vs men. Furthermore, recent results are compared to those of many years ago (1979-1995). A Mayo Clinic registry of PCI was used in this report of a total patient base of almost 19,000 consecutive PCI. The 18,885 patients were divided into two eras, 1979-1995 (early group) and 1996-2004 (recent group). The early group consisted of 7900 patients, 28% women; the recent group consisted of 11,000 patients, 31% women. Procedural success was defined as a coronary artery lumen reduction of less than 50%, without Q wave MI, CABG, or hospital deaths. Follow-up occurred at six and 12 months, and then on a yearly basis. The primary endpoints were 30-day and long-term mortality rates.
Results: During both time periods, women had more severe symptoms of CAD, more heart failure, more ACS, more severe angina, and higher age. Furthermore, morbid conditions were greater in women, including diabetes and hypertension, and there was less CABG or PCI in women at baseline. A striking increase in evidence-based therapy for secondary prevention was noted in the recent group, as compared to the older group. Stenting and glycoprotein IIb/IIIa were similar in men and women. Although more symptomatic with angina, women had a lower prevalence of multi-vessel disease, thrombosis and ACC/AHA type C lesions. Procedural success, early and late, was excellent and comparable between men and women at 90%, with improvement noted in the recent time period. Thirty-day mortality in women was 4.4%, and 2.8% in men in the early cohorts, much improved compared to 2.9% and 2.2%, respectively in recent years. Also, 30-day mortality was significantly decreased in women in the early group (p = 0.002) and men (p = 0.4). Follow-up was excellent, with data collected through September 2005. Nearly 92% of the patients participated in the annual follow-up, with median duration of 13 years (range 11-17 years) in the recent group. Women had a slightly lower survival then men, but survival was similar between the two time periods in both cohorts. Probability of survival at 5 years in the early and recent groups was 79% and 81% for women vs 83% and 83% in men, respectively. Excluding patients who died or who had less then a 30-day follow-up, women demonstrated a significant unadjusted higher mortality at 30 days and one year over long-term follow-up. However, after adjustment for risk factors in the early group, the mortality rates were not significantly different between men and women at 30 days and long term. The authors concluded that 30-day mortality for men and women after PCI has decreased in the last decade, and there is now no difference in short- or long-term mortality between men and women.
Commentary
The authors observed that long-term outcomes of PCI in women and men have improved over the past quarter century, even though women had a higher-risk profile. After adjustment for risk factors, 30-day and long-term mortality rates were similar in men and women, with a 25-year time frame failing to show any gender-related disparity in improved outcomes after PCI. The authors refer to a number of earlier studies, including the NHLBI registry, clearly indicating gender differences, with higher complication rates in women. More recent studies have shown improvement in hospital complications, equaling that of men, and improvement of clinical outcomes in women noted in elective PCI as well as for acute coronary syndromes. The authors speculate that the improvement noted in both genders is likely related to improved technologies and operator experience, better education, and adherence to evidence-based medications. The authors state that "the higher in-hospital mortality in women is likely multi-factorial and maybe likely due to an increased risk profile, such as ACS and higher prevalence of comorbid conditions." Utilization of evidence-based medications have been substantially higher in recent years, similar between men and women, and related to decreased mortality. The use of evidence-based therapies in the male group was noted to be higher than in other reports, suggesting that "such disparities highlight underutilization of evidence-based therapies in women in the real world vs the results obtained at a single center referral hospital."
An editorial accompanying this paper briefly reviews older reports of a gender gap in the past that is no longer present. Some studies have shown less appropriate use of PCI in women in stable and unstable situations, with failure to perform PCI in one-third of patients who would benefit from revascularization. Thus, the early use of PCI showed major differences between men and women. Younger women in the past have been shown to have worse outcomes then men, although equivalent outcomes at age 70 or older. The difference between early and late mortality in PCI in the early group for women showed a decline of 4.4 to 2.9% in recent experience. Higher morbidities and acute and worse outcomes have been noted for women in the past. These editorialists concur that there are "very similar adjusted outcomes from PCI in women." They note that women have smaller coronary arteries, with poorer outcomes after CABG. They suggest that stenting, more commonly done now, might be the primary reason for outcome improvement in women.
The concluding sentence of the editorial brings up an unresolved issue that has been fueled by the current COURAGE data suggesting that many coronary interventions can be safely avoided in selected stable patients with CAD. There are a multiplicity of reasons why morbidity and mortality in women have improved during the past 25 years. More than likely, it is not due to a single issue, but is related to improved techniques, stenting, greater use of protective drugs, better operator experience and skills, and improved anticoagulation strategies. Since the early data for women were so striking with respect to increased morbidity and mortality, there probably has been decreased enthusiasm for PCI in women, although women have a higher prevalence of acute coronary syndromes, including STEMI, then men, and more women have angina. In any case, this is a good news story, supporting the suggestion that we no longer need to worry about gender in consideration of revascularization, and that we should be pleased that the interventional community has been able to perform PCI with increasing effectiveness and decreasing risk in women. Whether many or most hospitals can achieve the excellence of the Mayo Clinic is uncertain. Finally, use of risk factor medications are an important, but not the sole, reason for this positive data, for which the cardiology community should be congratulated.
It has long been believed, with considerable substantiation, that women have poorer results of percutaneous interventions (PCI) than men, with higher morbidity and mortality rates.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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