Sex-based differences in clinical and angiographic outcomes after primary angioplasty or stenting for acute myocardial infarction

doi:10.1016/S0002-9149(00)01360-6

The American Journal of Cardiology

Volume 87, Issue 3, 1 February 2001, Pages 289-293

https://doi.org/10.1016/S0002-9149(00)01360-6 Get rights and content

Abstract

A paucity of data exists on the importance of gender in contributing to the mortality rate after primary angioplasty, although it is has been shown that women with acute myocardial infarction (AMI) are less likely than men to undergo reperfusion treatments. This study analyzes gender-related differences in 6-month clinical and angiographic outcomes in nonselected patients with AMI who underwent primary angioplasty or stenting. We compared clinical and angiographic outcomes of 230 women and 789 men who underwent primary angioplasty or stenting from January 1995 to August 1999. The women were older than the men, and had a greater incidence of diabetes and cardiogenic shock. The 6-month mortality rate was 12% in women and 7% in men (p = 0.028). Nonfatal reinfarction occurred in 3% of the women and in 1% of the men (p = 0.010). There were no differences in repeat target vessel revascularization rates. After multivariate analysis, gender did not emerge as a significant variable in relation to 6-month mortality or to the combined end point of death, reinfarction, and repeat target vessel revascularization. Both women and men with stented infarct arteries had lower restenosis rates (29% and 26%, respectively) than patients without stents (52% and 39%, repectively). The results of outcome analysis in nonselected patients suggest that sex is not an independent predictor of mortality after primary angioplasty for AMI, and that the benefit of primary stenting is similar in men and women.

Section snippets

Patients and treatment protocol

Since 1995, primary PTCA has been the systematic treatment for all patients with AMI, without any restriction based on age, sex, or clinical status on presentation. The exclusion criteria included (1) previous fibrinolytic treatment, and (2) inabilty to provide informed consent. Angiographic criteria for exclusion from intervention included (1) diameter stenosis of the infarct-related artery (IRA) <70%, and (2) inability to identify the IRA. From January 1995 to March 1997, a strategy of

Patients

From January 1995 to August 1999, 1,037 patients with AMI were admitted to our hospital. Of these, 11 patients (9 men and 2 women) refused primary PTCA, and 7 patients (5 men and 2 women) with cardiogenic shock died before primary PTCA attempt. Thus, altogether, 1,019 patients with AMI underwent primary PTCA. Of the 1,019 patients in the study, 789 (77%) were men and 230 (23%) were women. Baseline clinical and angiographic characteristics are summarized in Table 1. Women were older than men;

Patient population

The high incidence of very elderly patients and of cardiogenic shock are the most relevant demographic characteristics of this population, and result from application of a systematic primary PTCA strategy without any restriction based on age or clinical status on presentation. Moreover, very few treated patients (20%) are referred to our center from community hospitals, and these patients are generally at high risk and with contraindication to fibrinolytic treatment; this small group also

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Atrioventricular mechanical coupling and major adverse cardiac events in female patients following acute ST elevation myocardial infarction
2020, International Journal of Cardiology
Sex-specific outcome data following myocardial infarction (MI) are inconclusive with some evidence suggesting association of female sex and increased major adverse cardiac events (MACE). Since mechanistic principles remain elusive, we aimed to quantify the underlying phenotype using cardiovascular magnetic resonance (CMR) quantitative deformation imaging and tissue characterisation.
In total, 795 ST-elevation MI patients underwent post-interventional CMR imaging. Feature-tracking (CMR-FT) was performed in a blinded core-laboratory. Left ventricular function was quantified using ejection fraction (LVEF) and global longitudinal/circumferential/radial strains (GLS/GCS/GRS). Left atrial function was assessed by reservoir (εs), conduit (εe) and booster-pump strains (εa). Tissue characterisation included infarct size, microvascular obstruction and area at risk. Primary endpoint was the occurrence of MACE within 1 year.
Female sex was associated with increased MACE (HR 1.96, 95% CI 1.13–3.42, p = 0.017) but not independently of baseline confounders (p = 0.526) with women being older, more often diabetic and hypertensive (p < 0.001) and of higher Killip-class (p = 0.010). Tissue characterisation was similar between sexes. Women showed impaired atrial (εs p = 0.011, εe p < 0.001) but increased systolic ventricular mechanics (GLS p = 0.001, LVEF p = 0.048). While atrial and ventricular function predicted MACE in men only LV GLS and GCS were associated with MACE in women irrespective of confounders (GLS p = 0.036, GCS p = 0.04).
In men ventricular systolic contractility is impaired and volume assessments precisely stratify elevated risks. In contrast, women experience reduced atrial but increased ventricular systolic strain. This may reflect ventricular diastolic failure with systolic compensation, which is independently associated with MACE adding incremental value to sex-specific prognosis evaluation.
Short and long-term mortality in women and men undergoing primary angioplasty: A comprehensive meta-analysis
2015, International Journal of Cardiology
Citation Excerpt :
Analysis using fixed effect model yielded similar results (Supplemental Table S3). Twenty six studies [5,6,8,9,18–21,24–31,42,47,49–54,56,57] (n = 51,656) reported sex-specific crude long-term mortality rates. Women had higher long-term mortality than men [12.4% vs 8.0%, p < 0.001; RR: 1.60, 95% CI: 1.46–1.76, p < 0.001] (Supplemental Fig. S3).
Women with acute myocardial infarction are treated less aggressively than men and have a higher mortality. It is possible that these sex-related differences in outcome are a result of differences in baseline risk and management.
We undertook a meta-analysis to study the differences in mortality among women and men with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (P-PCI). Studies reporting sex-specific crude mortality rates and/or adjusted effect estimates in STEMI patients undergoing P-PCI were identified. Among 48 studies, involving 103,895 patients, (26,556 women and 77,337 men), the crude in-hospital [pooled relative risk (RR): 1.94, 95% confidence interval (CI): 1.74–2.16, p < 0.001; 23 studies (n = 43,872)], 30-day [RR: 1.76, 95% CI: 1.50–2.07, p < 0.001; 20 studies (n = 43,279)], and long-term [RR: 1.60, 95% CI: 1.46–1.76, p < 0.001; 26 studies (n = 51,656)] mortality was significantly higher in women compared to men. When meta-analysis using adjusted effect estimates from individual studies was performed, in-hospital [RR: 1.31, 95% CI: 1.08–1.65, p = 0.007; 14 studies (n = 33,380)] and 30-day mortality [RR: 1.19, 95% CI: 1.01–1.39, p = 0.03; 14 studies (n = 28,564)] remained significant while long-term mortality [RR: 1.01, 95% CI: 0.93–1.11, p = 0.75; 20 studies (n = 52,492)] was no longer different between women and men.
Sex-based differences exist in short and long-term mortality among patients with STEMI undergoing P-PCI. However, these differences were markedly attenuated following adjustment for clinical differences and/or hospital course. Despite adjustment, short-term mortality remains higher in women than men, while long-term mortality was no longer significantly different.
Sex-related differences in patients with ST-elevation myocardial infarction undergoing primary PCI: A long-term mortality study
2015, Cardiovascular Revascularization Medicine
Citation Excerpt :
Several studies have shown that women exhibit higher rates of mortality and worse risk profiles [4–20]. Conversely, in some series, differences in mortality rates were no longer present after adjustment for age and other risk factors [5,8,11,12,14,16]. Moreover, only a limited number of studies reported medium or long term mortality results [4,6,11,18,21–23].
To assess sex differences in clinical presentation, in-hospital and long-term outcome in ST-elevated myocardial infarction (STEMI) patients undergoing primary PCI (PPCI).
Several studies have shown higher rates of mortality in women. These differences are not always confirmed after adjusting for confounding variables.
From January 2007 to December 2011, 325 consecutive patients (23.1% females and 76.9% males) were prospectively treated and retrospectively analyzed. Primary outcome was in-hospital and long-term mortality.
Women were older (71.8 ± 11.7 vs. 62.5 ± 12.6 years; p < 0.0001), presented more renal failure (45.3% vs. 20.8%; p < 0.0001) and severe haemodynamic impairment (9.3% vs. 3.6%; p = 0.04). In-hospital overall mortality (14.7% vs. 4.8%; p = 0.003) and cardiac death (12% vs. 2%; p = 0.002) were significantly higher in women. The multivariate analysis identified age (OR 1.07; 95% CI: 1.01–1.13), resuscitated cardiac arrest (CCA) and cardiogenic shock (CS) (OR 15.31; 95% CI: 4.30–61.75), renal failure (OR 0.20; 95% CI: 0.06–0.68), but not sex (OR 1.49; 95% CI: 0.53–4.22) as independent prognostic factors of in-hospital mortality. During a median follow-up of 46.5 months (IQR range 32.7–63.1 months), long-term overall mortality (24.2% vs. 11.0%; p = 0.007) and cardiac death (4.8% vs. 1.7%; p = 0.02) were significantly higher in women. The multivariate analysis identified age (HR 1.06; 95% CI: 1.02–1.11), previous AMI (HR 3.9; 95% CI: 1.63–9.35), renal failure (HR 5.21; 95% CI: 2.12–12.85), technical success (HR 0.35; 95% CI: 0.14–0.84) but not sex (HR 0.90; 95% CI: 0.42–1.94) as independent prognostic factors of long-term mortality.
Worse clinical presentation rather than sex may explain the excess of mortality in women with STEMI undergoing PPCI.
Gender differences in left ventricular function following percutaneous coronary intervention for first anterior wall ST-segment elevation myocardial infarction
2014, American Journal of Cardiology
Little is known regarding gender differences in left ventricular (LV) function after anterior wall ST-segment elevation myocardial infarction (STEMI), despite it being a major determinant of patients' morbidity and mortality. We therefore sought to investigate the impact of gender on LV function after primary percutaneous coronary intervention (PCI) for first anterior wall STEMI. Seven hundred eighty-nine consecutive patients (625 men) with first anterior STEMI were included in the analysis. All patients underwent an echocardiographic study within 48 hours of PCI. Women were older and more likely to have diabetes, hypertension, chronic renal failure, and a higher Killip score. Women had prolonged ischemic time, which was driven by prolonged symptom-to-presentation time (2.75 [interquartile range 1.5 to 4] vs 2 [interquartile range 1 to 3.5] hours, p = 0.005). A higher percentage of women had moderate or worse LV dysfunction (LV ejection fraction <40%; 61.6% vs 48%, p = 0.002). In a univariable analysis female gender was associated with moderate or worse LV function (p = 0.002). However, after accounting for variable baseline risk profiles between the 2 groups using multivariable and propensity score techniques, ischemic time >3.5 hours, leukocytosis, and pre-PCI Thrombolysis In Myocardial Infarction flow grade <2 were independent predictors of moderate or worse LV dysfunction, whereas female gender was not. Data on LV function recovery at 6 months, which were available for 45% of female and male patients with moderate or worse LV dysfunction early after PCI, showed no significant gender related difference in LV function recovery. In conclusion, women undergoing PCI for the first event of anterior STEMI demonstrate worse LV function than that of men, which might be partially attributed to delay in presentation. Hence greater efforts should be devoted to increasing women's awareness of cardiac symptoms during the prehospital course of STEMI.
Gender-related differences in outcome after BMS or DES implantation in patients with ST-segment elevation myocardial infarction treated by primary angioplasty: Insights from the DESERT cooperation
2013, Atherosclerosis
Several studies have found that among patients with ST-segment elevation myocardial infarction (STEMI) treated by thrombolysis, female sex is associated with a worse outcome. However, still controversial is the prognostic impact of gender in primary angioplasty, especially in the era of drug-eluting stents (DES). Therefore, the aim of this study was to investigate sex-related differences in clinical outcome in patients with STEMI treated with primary angioplasty with Bare-Metal Stent (BMS) or DES.
Our population is represented by 6298 STEMI patients undergoing primary angioplasty and stent implantation included in the DESERT database. Follow-up data were collected from 3 to 6 years after primary angioplasty.
Female gender was observed in 1466 (23.2%) out of 6298 STEMI patients. Women were older (65.3 ± 12.4 vs 59.3 ± 11.4 years, p < 0.001), with higher prevalence of diabetes (18.6% vs 14.5%, p < 0.001), hypertension (52.4% vs 41.4%, p < 0.001), slightly longer ischemia time (272 ± 247 vs 258 ± 220 min, p = 0.06). No difference was observed in terms of angiographic and procedural characteristics. Follow-up data were available at a mean of 1201 ± 441 days. At long-term follow-up female gender was associated with a significantly higher rate of death (11.7% vs 8.5%, HR [95% CI] = 1.45 [1.18–1.78], p < 0.001), while no difference was observed in terms of reinfarction (HR [95% CI] = 1.14 [0.89–1.45], p = 0.3), ST (HR [95% CI] = 1.12 [0.85–1.48], p = 0.4), with similar temporal distribution (acute, subacute, late and very late) between male and female patients, and no difference in TVR (HR [95% CI] = 1.11 [0.95–1.3], p = 0.2, p = 0.2). These results were confirmed in both patients receiving BMS or DES. The impact of female gender on mortality disappeared after correction for baseline confounding factors (HR [95% CI] = 0.88 [0.71–1.09], p = 0.25).
This study shows that in patients with STEMI treated by primary angioplasty, female gender is associated with higher mortality rate in comparison with men, and this is mainly due to their higher clinical and angiographic risk profiles. In fact, female sex did not emerge as an independent predictor of mortality.
Relation of gender to infarct size in patients with ST-segment elevation myocardial infarction undergoing primary angioplasty
2013, American Journal of Cardiology
Previous reports have shown that female gender is associated with impaired outcomes among patients with ST-segment elevation myocardial infarction (STEMI) treated by thrombolysis, mainly owing to a worst risk profile (more diabetes, more advanced age, and higher Killip class at presentation) compared to men. Still contrasting are data on the effect of gender on the outcome in patients with STEMI undergoing primary angioplasty. In particular, it is still unclear whether a larger infarct size might contribute to the explanation of the worse outcome in women. Therefore, the aim of the present study was to investigate gender-related differences in infarct size as evaluated by myocardial scintigraphy in a large cohort of patients with STEMI undergoing primary percutaneous coronary intervention. We included 830 patients with STEMI undergoing primary percutaneous coronary intervention. The infarct size was evaluated at 30 days using technetium-99m-sestamibi. A logistic regression analysis was performed to determine the relation between gender and infarct size (as percentage of patients above the median) after correction for baseline confounding factors. We also evaluated the presence of a potential age–gender interaction. A total of 183 patients (20.8%) were women. Female gender was associated with more advanced age and a greater prevalence of hypertension; previous infarction and smoking were more frequently observed in men. Female gender was associated with a smaller infarct size (p <0.001) that was confirmed after correction for baseline confounding factors (adjusted odds ratio 0.48, 95% confidence interval 0.33–0.7, p <0.001). No age–gender interaction was observed (p = 0.13). In conclusion, the results of the present study have shown that despite the presence of high-risk features at presentation, female gender was associated with a smaller infarct size than that in men, without any interaction between age and gender.

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Sex-based differences in clinical and angiographic outcomes after primary angioplasty or stenting for acute myocardial infarction

Abstract

Section snippets

Patients and treatment protocol

Patients

Patient population

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Am Heart J

Am J Cardiol

Am Heart J

Sex differences in mortality after myocardial infarctionis there evidence for an increased risk for women?

Circulation