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Is Primary Angioplasty Equally Effective in Both Men and Women ? . Keith Dawkins MD FRCP FACC Southampton University Hospital UK. Conflicts of Interest. Research Grant Support Boston Scientific Corporation Advisory Board/Consultant Abbott Vascular Boston Scientific Corporation

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slide1
Is Primary Angioplasty Equally Effective in Both Men and Women ?

Keith Dawkins MD FRCP FACC

Southampton University Hospital

UK

conflicts of interest
Conflicts of Interest
  • Research Grant Support
    • Boston Scientific Corporation
  • Advisory Board/Consultant
    • Abbott Vascular
    • Boston Scientific Corporation
    • Conor Medsystems
    • Eli Lilly
    • Medtronic
    • Nycomed
women in cardiology england wales n ireland rcp census
Women in CardiologyEngland, Wales & N. Ireland (RCP Census)

Consultant Cardiologists (n)

Heart 2005;91:283-289

slide8
Establish mentors for women in cardiology
  • Encourage flexible training
  • Establish more part-time posts
  • Improve access for women to popular specialities (e.g. coronary intervention)
  • Refuse to tolerate sexism or gender based discrimination in the work place
slide9
Old

Eur Heart J 2000;21:1135-1140

slide11
Women are poorly represented in cardiology
  • Women with cardiac disease are under investigated and under treated
  • Most cardiologists are men
  • All men are bastards…

Are we following the flock…?

deaths by cause women 2004
Injuries & Poisoning (3%)

Respiratory Disease (14%)

All Other Causes (22%)

Other Ca (14%)

Colorectal

Ca (2%)

Breast Ca (4%)

CHD (15%)

Lung Ca (4%)

Other CVD (9%)

CVA (12%)

Deaths by Cause (Women) 2004

Office of National Statistics (2005)

Scotland General Register Office (2005)

Northern Ireland General Register Office (2005)

age standardised coronary events women 35 64 yrs monica project
UK Glasgow

UK Belfast

0 50 100 150 200 250 300

Coronary Events/100,000 population

Age-Standardised Coronary Events (Women 35-64 yrs) MONICA Project

Lancet 1999;353:1547-1557

acute myocardial infarction isis 3
Acute Myocardial Infarction (ISIS-3)

p<0.001

Percent (%)

Age at Presentation

NEJM 1998;338:8-14

ami cumulative mortality day 0 35
AMI: Cumulative Mortality (Day 0-35)

15 -

10 -

5 -

0 -

14.8%

Women (n=6,600)

9.1%

Mortality (%)

Men (n=26,480)

CI: 1.73 [1.61-1.86]

0 7 14 21 28 35

Days after Study Entry

NEJM 1998;338:8-14

slide18
Complications of acute myocardial infarction

Papillary Muscle Rupture

VSD

LV Rupture

infarct vessel patency and mortality gusto i angiographic trial
Infarct Vessel Patency and MortalityGUSTO-I angiographic trial

Mortality at 30 days (%)

TIMI-0

TIMI-1

TIMI-2

TIMI-3

Infarct vessel patency at 90 minutes

Circ 1998;97:1549-1556

long term survival after randomisation to streptokinase influence of myocardial blood flow
12 years

5 years

p=0.005

p=0.023

Mortality (%)

TIMI-0/1

TIMI-2

TIMI-3

Infarct vessel patency at 3-4 weeks

Long-term survival after randomisation to Streptokinase: influence of myocardial blood flow

JACC 1999;34:62-69

slide21
x
  • Small numbers
  • No gender matched controls
  • Post hoc
  • Sub-analysis
  • Underpowered etc

AHJ 2004;147:133-139

effect of door to balloon time on mortality nrmi 3 4 n 29 222
12 -

10 -

8 -

6 -

4 -

2 -

0

No Risk Factors

In-Hospital Mortality (%)

≤90

>90-120

>120-150

>150

Door-to-Balloon Time (mins)

Effect of Door-to-Balloon Time on Mortality: NRMI 3-4 (n=29,222)

JACC 2006;47:2180-2186

slide23
12 -

10 -

8 -

6 -

4 -

2 -

0

No Risk Factors

≥1 Risk Factors

In-Hospital Mortality (%)

≤90

>90-120

>120-150

>150

Door-to-Balloon Time (mins)

Effect of Door-to-Balloon Time on Mortality: NRMI 3-4 (n=29,222)

JACC 2006;47:2180-2186

stemi nirmi 3 4 gender prelevance n 29 222
STEMI (NIRMI 3-4)Gender Prelevance (n=29,222)

70.9%

Prelevance (n)

29.1%

Male

Female

JACC 2006;47:2180-2186

stemi nirmi 3 4 gender differences n 29 222
108

p<0.0001

p<0.0001

6.9%

100

Mortality (%)

Door-to-Balloon Time (mins)

3.6%

Male

Female

Male

Female

STEMI (NIRMI 3-4)Gender Differences (n=29,222)

JACC 2006;47:2180-2186

ppci relationship between door to balloon time and gender
PPCI: Relationship between Door-to-Balloon time and Gender

p=0.05

p=0.05

9.9%

7.3%

Percentage (%)

6.5%

3.9%

>2 hours

≤2 hours

Female

Female

Male

Male

JAMA 2000;283:2941-2947

slide27
Sex-Based Differences in Early Mortality of

Patients undergoing Primary Angioplasty for First Acute Myocardial Infarction

Circ 2001;104:3034-3038

prognosis after myocardial infarction
Prognosis after Myocardial Infarction
  • Prognosis may be worse in women per se
  • Women are older at the time of presentation
  • Women may have more co-morbidity (e.g. shock, hypertension, obesity, renal impairment, diabetes)
  • Women present later and delay seeking medical attention
  • Women are under investigated
  • Women are under treated (less lysis, PCI or CABG)
slide29
Physicians recommendations for Cardiac

Catheterization: Effects of Race and Gender

NEJM 1999;340:618-626

gender differences in revascularisation rates following ami
p<0.001

p<0.001

14.5%

32%

9.6%

Mortality (%)

Revascularisation Rate (%)

20%

Male

Female

Male

Female

Gender Differences in Revascularisation Rates following AMI

AJC 2006;97:1722-1726

admission patterns and revascularisation rates following ami
p<0.001

p<0.001

60%

54%

52%

45%

Patients admitted HREV +ve (%)

Revasc Rate in HREV +ve hospitals (%)

Male

Female

Male

Female

Admission Patterns and Revascularisation Rates following AMI

AJC 2006;97:1722-1726

slide33
Men Fare Better

Women Fare Better

All Patients

Patients in HREV +ve

Patients in HREV –ve

Patients REV +ve

Patients REV -ve

0 0.5 1.0 1.5 1.75

Odds Ratio [95% CI]

Age-adjusted in-hospital mortality with STEMI

Men vs. Women

AJC 2006;97:1722-1726

slide34
Failure of perfusion with thrombolytics

alone…

RCA occlusion

LAD occlusion

coronary reperfusion fibrinolysis vs percutaneous intervention
Fibrinolysis

PCI

>90% Availability

100%

50%

0%

10% Availability

<50% Treated

5% Reocclusion

54% TIMI 3

0.1% CVA

10% Reocclusion

25% Late

Occlusion

1%

CVA

>90% Treated

>90% TIMI 3

Coronary ReperfusionFibrinolysis vs. Percutaneous Intervention

Heart 2002;88:298-305

stemi ppci vs thrombolysis short term outcome
p<0.0001

p=0.0002

p=0.0003

p<0.0001

p=0.0004

Frequency (%)

Non-fatal

AMI

Stroke

Death

(Non-shock)

Combined

Death

STEMI (PPCI vs. Thrombolysis)Short-term Outcome

Gender?

Lancet 2003;361:13-20

clinical benefits of abciximab is independent of gender epic epilog epistent meta analysis n 6 595
Death, MI, TVR (30 Day)

Bleeding with Abciximab

p<0.001

p<0.001

p<0.001

Major Bleed

Minor Bleed

12.7%

11.3%

Event Rate (%)

Patients %)

6.5%

5.8%

Female

Male

Female

Male

Abciximab

Placebo

Clinical Benefits of Abciximab is Independent of GenderEPIC, EPILOG, EPISTENT meta-analysis (n=6,595)

JACC 2000;36:381-386

cadillac gender based outcomes
STEMI <12 hrs, No shock (N=2,681)

Angiographic Criteria fulfilled

N=2,082

(73% men, 27% women)

Randomise

Primary PCI

+ Abciximab

(N=528)

Men = 391

Women = 137

Multilink Stent

+ Abciximab

(N=524)

Men = 388

Women = 136

Primary PCI

(N=518)

Men = 370

Women = 148

Multilink Stent

(N=512)

Men = 371

Women = 141

CADILLAC: Gender based Outcomes

Circ 2005;111:1611-1618

slide40
CADILLAC: Baseline Variables

Circ 2005;111:1611-1618

conclusions aha scientific statement
Conclusions: AHA Scientific Statement
  • There is a rising mortality burden in women with CVD
  • PCI is performed less frequently and with greater delays in women
  • Better understanding of this disparity should be a priority
  • RCTs should be developed to specifically assess gender-based, ethnic and racial results of interventional therapy with appropriately matched controls

Circ 2005;111:940-953

conclusions
Conclusions:
  • Mortality from STEMI is higher in women
  • Women present later for PPCI
  • PPCI is performed less frequently in women
  • Outcomes following PPCI are less favourable in women
  • Complications of PPCI are higher in women
  • Present gender specific data are inadequate
slide45
X

X

Time for the Ladies to stop selling themselves short…

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