Stent or Surgery: What is Best for a Woman ?

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Stent or SurgeryWhat is Best for a Woman ?

• Dr R H Stables
• Cardiothoracic Centre LiverpoolUK

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Conflict of Interest

• I am (or at one time was) a man

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Understanding the Problem
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Cardiovascular Disease - The Facts

• 3 million UK residents have coronary disease
• Effective treatment and prevention strategies
  exist
• Kills 3 times as many women as cancer
• Causes one quarter of all early death

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Medical Advice Not Consistently Helpful
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Background Coronary Artery Disease in Women

• Initial presentation at an older age
• Natural history of disease process
• Systematic failure of early recognition
• More frequent acute event presentations
• More advanced patterns of disease
• Risk factor profiles - Increased co-morbidity
• Smaller body surface area
• Coronary vessels of smaller calibre

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Background Coronary Artery Disease in Women

• Female patients under-represented in clinical
  trials
• Major cardiovascular drug classes
• Revascularisation
• Compounds problems with generalisation of trials
• Undermines the evidence base
• May lead to use of inappropriate treatments
• Increases reliance on observational studies
• Compromised by bias (recognised or covert)

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Coronary Artery Bypass Surgery

• Surgical results - improved over the last 20
  years
• Majority of additional risk explained by
• Age and more advanced disease patterns
• Conventional risk factors and co-morbidity
• Excess, unexplained gender risk persists
• EUROSCORE surgical risk calculations

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EUROSCORE Surgical Risk Calculator

• 60 Years Stable angina Good LV No Risks
• Logistic Mortality Male 0.94 Female 1.3
• 60 Years Unstable angina Poor LV No Risks
• Logistic Mortality Male 4.77 Female 6.51

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CABG in Female Patients

• Smaller coronary arteries - technical
  difficulties
• Also affects choice of graft conduit
• Less IMA pedicle grafting
• Smaller radial arteries
• Younger patients may be particularly affected

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CABG in the Younger Female Patient
Circulation 20021051176-1181
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Greater Mortality Difference in Younger Patients
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CABG in Female Patients

• Smaller coronary arteries - technical
  difficulties
• Also affects choice of graft conduit
• Less IMA pedicle grafting
• Smaller radial arteries
• Younger patients may be particularly affected
• Higher rates of surgical morbidity

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Surgical Morbidity in Female Patients
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PCI in the Female Patient

• No additional mortality - beyond conventional
  risk
• May be associated with an increased MACCE rate
• NWQIP risk model for in-hospital MACCE
• Odds ratio 1.58 (1.08 - 2.33, p 0.019)

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PCI in the Female Patient

• Observational studies suggest ? BMS restenosis
• Seems odd - smaller vessels, more diabetes
• ? Protective effect of oestrogen
• Selection bias
• At time of revascularisation
• Quality of follow-up
• Willingness to re-intervene
• DES efficacy confirmed in female patients

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PCI in the Female Patient

• Increased vascular complications
• Most marked with big sheathes / adjunctive kit
• Smaller peripheral vessels
• More frequent peripheral vascular disease
• Reduced availability of the radial (small size?)
• CTC Liverpool 2005 4 operators All PCI
• Radial access access for procedure
• Male 94 Female 90.4

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PCI v CABG Randomised Studies

• SYNTAX awaited
• Previous generation trials - limited female
  numbers
• ARTS Females 23
• SoS Females 21
• Higher risk profile eg SoS
• Age gt 65 Male 37 Female 53
• Unstable presn Male 19 Female 26
• NYHA III / IV Male 26 Female 66

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Substudy From The Stent or Surgery Trial (SoS)
Am J Cardiol 200493404-409
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PCI v CABG SoS Substudy

• No male - female differences in
• LIMA grafts
• Total number of grafts created
• Number of PCI lesions attempted
• Number of PCI lesions revascularised
• Stent rates
• No statistical power for mortality or MACE
• Analysis of angina symptoms and QoL

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QoL Outcomes
PCI
CABG
CABG gives more gain than PCI - except at 1 year
in women
Magnitude of improvement in QoL compared to
baseline
Both improve with revasc BUTMen get more
improvement than women
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Conclusions

• Revascularisation procedures in women are
• Being performed in increasing numbers
• Have better outcomes than historic controls
• CABG and PCI outcomes less good than in males
• Not fully explained by natural history and risk
• Scope for advances in therapy to close gap
• Urgent need to improve evidence base - research
• PCI attractive option - anatomy dependent
• Only when high quality revasc is possible

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Questions and Discussion