Stent or Surgery:

What is Best for a Woman ?

Dr R H Stables

Cardiothoracic Centre Liverpool

UK

Conflict of Interest

• I am (or at one time was) a man

Understanding the Problem

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

Medical Advice: Not Consistently Helpful

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

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)

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

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%

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

CABG in the Younger Female Patient

Circulation 2002;105:1176-1181

Greater Mortality Difference in Younger Patients

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’

Surgical Morbidity in Female Patients

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)

Heart 2006; 92: 658-63Heart 2006; 92: 658-63

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

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%

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 > 65 Male 37% Female 53%

• Unstable presn Male 19% Female 26%

• NYHA III / IV Male 26% Female 66%

Substudy From The ‘Stent or Surgery’ Trial (SoS)

Am J Cardiol 2004;93:404-409

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

QoL Outcomes

Magnitude of improvement in QoL compared to baseline

PCI CABG

Both improve with revasc BUTMen get more improvement than women

CABG gives more gain than PCI - except at 1 year in women

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

Questions and Discussion