Impact of gender on clinical outcomes after mTOR-inhibitor drug-eluting stent implantation in patients with first manifestation of ischaemic heart disease
Restricted accessResearch articleFirst published online October, 2012
Impact of gender on clinical outcomes after mTOR-inhibitor drug-eluting stent implantation in patients with first manifestation of ischaemic heart disease
Background: Women have a worse outcome than men after percutaneous coronary intervention (PCI). However, in the drug-eluting stent (DES) era, limited data are available about the impact of gender-related differences on clinical outcome. Furthermore, many series have also included patients previously treated by coronary-artery bypass grafts or PCI, which may bias the evaluation of DES-related clinical events at follow up. We aimed to assess the impact of gender on clinical outcomes in a consecutive series of patients at first manifestation of coronary artery disease (CAD) undergoing PCI with mTOR-inhibitor DES.
Methods and results: A total of 138 consecutive patients (age 64 ± 13 years, female gender 29%) undergoing successful mTOR-inhibitor DES implantation [sirolimus-eluting stent (SES); zotarolimus-eluting stent (ZES); and everolimus-eluting stent (EES)] for the treatment of stable chronic angina or an acute coronary syndrome, as their first clinical manifestation of CAD, were prospectively enrolled between February 2008 and May 2009. Major adverse cardiac events (MACE), defined as a combination of cardiac death, myocardial infarction (MI), and clinically driven target lesion revascularization (TVR) at 12-month follow up, constituted the endpoint of the study. Fifty-one (37%) patients received SES; 46 (33%) patients received ZES; and 41 (30%) patients received EES. At follow up, 21 (15%) patients experienced a MACE. Three (2%) patients had cardiac death, five (4%) had MI, while 13 (9%) patients underwent clinically driven TVR. MACE occurred more frequently in females than males [10 (25%) vs. 11 (11%), p = 0.05]. At Cox regression analysis, the only independent predictors of MACE were female gender and implantation of more than one stent [hazard ratio (HR) 3.70, 95% confidence interval (CI) 1.46–9.36, p = 0.006; HR 1.26, 95% CI 0.99–2.74, p = 0.01, respectively].
Conclusions: In conclusion, our finding suggests that women may have a worse outcome as compared with men after mTOR-inhibitor DES implantation.
RosamondWFlegalKFridayGFurieKGoAGreenlundK. Heart disease and stroke statistics – 2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation2007; 115(5): e69–e171.
2.
LenzenMJBoersmaEBertrandMEMaierWMorisCPiscioneF. Management and outcome of patients with established coronary artery disease: the Euro Heart Survey on coronary revascularization. Eur Heart J2005; 26(12): 1169–1179.
3.
PriceJFFowkesFG. Risk factors and the sex differential in coronary artery disease. Epidemiology1997; 8(5): 584–591.
4.
MakKHKarkJDChiaKSSimLLFoongBHDingZP. Ethnic variations in female vulnerability after an acute coronary event. Heart2004; 90(6): 621–626.
5.
JousilahtiPVartiainenETuomilehtoJPuskaP. Sex, age, cardiovascular risk factors, and coronary heart disease: a prospective follow-up study of 14786 middle-aged men and women in Finland. Circulation1999; 99(9): 1165–1172.
6.
CampbellDJ. Why do men and women differ in their risk of myocardial infarction?Eur Heart J2008; 29(7): 835–836.
7.
SrinivasVSGargSNegassaABangJYMonradES. Persistent sex difference in hospital outcome following percutaneous coronary intervention: results from the New York State reporting system. J Invasive Cardiol2007; 19(6): 265–268.
8.
JacobsAK. Coronary revascularization in women in 2003. Sex revisited. Circulation2003; 107(3): 375–377.
9.
GreenbergMAMuellerHS. Why the excess mortality in women after PTCA?Circulation1993; 87(3): 1030–1032.
10.
KesleySFJamesMHolubkovALCowleyMJDetreKM. Results of percutaneous transluminal coronary angioplasty in women. 1985–1986 National Heart, Lung, and Blood Institute’s Coronary Angioplasty Registry. Circulation1993; 87(3): 720–727.
11.
MalenkaDJO’ConnerGTQuintonHWennbergDRobbJFShubrooksS. Differences in outcomes between women and men associated with percutaneous transluminal coronary angioplasty. A regional prospective study of 13,061 procedures. Circulation1996; 94(9Suppl): II99–II104.
12.
EllisSGRoubinGSKingSBDouglasJSJrWeintraubWSThomasRG. Angiographic and clinical predictors of acute closure after native vessel coronary angioplasty. Circulation1988; 77(2): 372–379.
13.
EllisSGMylerRKKingSBDouglasJSJrTopolEJShawRE. Causes and correlates of death after unsupported coronary angioplasty: implications for use of angioplasty and advanced support techniques in high risk settings. Am J Cardiol1991; 68(15): 1447–1451.
14.
LanskyAJNgVGMutluHCristeaEGuiranJBMideiM. Gender-based evaluation of the XIENCE V everolimus-eluting coronary stent system: clinical and angiographic results from the spirit III randomized trial. Catheter Cardiovasc Interv2009; 74(5): 719–727.
15.
VainaSVoudrisVMoriceMCDe BruyneBColomboAMacayaC. Effect of gender differences on early and mid-term clinical outcome after percutaneous or surgical coronary revascularisation in patients with multivessel coronary artery disease: insights from ARTS I and ARTS II. EuroIntervention2009; 4(4): 492–501.
16.
SolinasENikolskyELanskyAJKirtaneAJMoriceMCPopmaJJ. Gender-specific outcomes after sirolimus-eluting stent implantation. J Am Coll Cardiol2007; 50(22): 2111–2116.
17.
LanskyAJCostaRAMooneyMMideiMGLuiHKStricklandW. Gender-based outcomes after paclitaxel-eluting stent implantation in patients with coronary artery disease. J Am Coll Cardiol2005; 45(8): 1180–1185.
18.
OnumaYKukrejaNDaemenJGarcia-GarciaHMGonzaloNChengJM. Impact of sex on 3-year outcome after percutaneous coronary intervention using bare-metal and drug-eluting stents in previously untreated coronary artery disease: insights from the RESEARCH (Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital) and T-SEARCH (Taxus-Stent Evaluated at Rotterdam Cardiology Hospital) Registries. JACC Cardiovasc Interven2009; 2(7): 603–610.
19.
SerruysPWKutrykMJOngAT. Coronary-artery stents. N Engl J Med2006; 354(5): 483–495.
20.
MoriceMCSerruysPWSousaJEFajadetJBan HayashiEPerinM. A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med2002; 346(23): 1773–1780.
21.
JacobsAK. Coronary intervention in 2009: are women no different than men?Circulation Cardiovasc Interven2009; 2(1): 69–78.
22.
SinghMRihalCSGershBJRogerVLBellMRLennonRJ. Mortality differences between men and women after percutaneous coronary interventions. A 25-year, single-center experience. J Am Coll Cardiol2008; 51(24): 2313–2320.
23.
SolinasENikolskyELanskyAJKirtaneAJMoriceMCPopmaJJ. Gender-specific outcomes after sirolimus-eluting stent implantation. J Am Coll Cardiol2007; 50(22): 2111–2116.
24.
AbbottJDVlachosHASelzerFSharafBLHolperEGlaserR. Gender-based outcomes in percutaneous coronary intervention with drug-eluting stents (from the National Heart, Lung, and Blood Institute Dynamic Registry). Am J Cardiol2007; 99(5): 626–631.
25.
JacobsAKJohnstonJMHavilandABrooksMMKelseySFHolmesDRJr. Improved outcomes for women undergoing contemporary percutaneous coronary intervention. A report from the National Heart, Lung, and Blood Institute Dynamic Registry. J Am Coll Cardiol2002; 39(10): 1608–1614.
26.
MalenkaDJWennbergDEQuintonHAO'RourkeDJMcGrathPDShubrooksSJ. Gender related changes in the practice and outcomes of percutaneous coronary interventions in northern New England from 1994 to 1999. J Am Coll Cardiol2002; 40(12): 2092–2101.
27.
Lloyd-JonesDAdamsRJBrownTMCarnethonMDaiSDe SimoneG. Heart disease and stroke statistics-2010 update: a report from the American Heart Association. Circulation2010; 121(7): e46–e215.
28.
AjaniUAFordESMcGuireLC. Distribution of lifestyle and emerging risk factors by 10-year risk for coronary heart disease. Eur J Cardiovasc Prev Rehabil2006; 13(5): 745–752.
29.
Kones R. Recent advances in the management of chronic stable angina I: approach to the patient, diagnosis, pathophysiology, risk stratification, and gender disparities. Vasc Health Risk Manag 2010; 6: 635–656.
30.
CantorWJMillerJMHellkampASKramerJMPetersonEDHasselbladV. Role of target vessel size and body surface area on outcomes after percutaneous coronary interventions in women. Am Heart J2002; 144(2): 297–302.
31.
DoyleFDe La HarpeDMcGeeHShelleyEConroyR. Gender differences in the presentation and management of acute coronary syndromes: a national sample of 1365 admissions. Eur J Cardiovasc Prev Rehabil2005; 12(4): 376–579.
32.
PepineCJKerenskyRALambertCRSmithKMvon MeringGOSopkoG. Some thoughts on the vasculaopathy of women with ischemic heart disease. J Am Coll Cardiol2006; 47(3Suppl): S30–S35.
33.
MikkolaTTurunenPAvelaKOrpanaAViinikkaLYlikorkalaO. 17 beta-estradiol stimulates prostacyclin, but not endothelin-1, production in human vascular endothelial cells. J Clin Endocrinol Metab1995; 80(6): 1832–1836.
34.
ChenSJLiHDurandJOparilSChenYF. Estrogen reduces myointimal proliferation after balloon injury of rat carotid artery. Circulation1996; 93(3): 577–584.
35.
BorczukACvan HoevenKHFactorSM. Review and hypothesis: the eosinophil and peripartum heart disease (myocarditis and coronary artery dissection)–coincidence or pathogenetic significance?Cardiovasc Res1997; 33(3): 523–527.
36.
NiccoliGSchiavinoDBelloniFFerranteGLa TorreGConteM. Pre-intervention eosinophil cationic protein serum levels predict clinical outcomes following implantation of drug-eluting stents. Eur Heart J2009; 30(11): 1340–1347.
37.
HammermeisterKEDeRouenTADodgeHT. Variables predictive of survival in patients with coronary disease. Selection by univariate and multivariate analyses from the clinical, electrocardiographic, exercise, arteriographic, and quantitative angiographic evaluations. Circulation1979; 59(3): 421–430.
38.
MarkDBNelsonCLCaliffRMHarrellFEJrLeeKLJonesRH. Continuing evolution of therapy for coronary artery disease. Initial results from the era of coronary angioplasty. Circulation1994; 89(5): 2015–2025.
39.
BautersCHubertEPratABougrimiKVan BelleEMcFaddenEP. Predictors of restenosis after coronary stent implantation. J Am Coll Cardiol1998; 31(6): 1291–1298.
40.
LindahlBVengePWallentinL. Relation between troponin T and the risk of subsequent cardiac events in unstable coronary artery disease. The FRISC study group. Circulation1996; 93(9): 1651–1657.
41.
OhmanEMArmstrongPWChristensonRHGrangerCBKatusHAHammCW. Cardiac troponin T levels for risk stratification in acute myocardial ischemia. GUSTO IIA Investigators. N Engl J Med1996; 335(18): 1333–1341.
42.
GuptaRBirnbaumYUretskyBF. The renal patient with coronary artery disease: current concepts and dilemmas. J Am Coll Cardiol2004; 44(7): 1343–1353.
43.
SarnakMJLeveyASSchoolwerthACCoreshJCulletonBHammLL. Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Circulation2003; 108(17): 2154–2169.
44.
JungersPMassyZAKhoaTNFumeronCLabrunieMLacourB. Incidence and risk factors of atherosclerotic cardiovascular accidents in predialysis chronic renal failure patients: a prospective study. Nephrol Dial Transplant1997; 12(12): 2597–2602.
